HEALTH ECONOMICS

Health Econ. (2012)

Published online in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/hec.2849

HEALTH ECONOMICS LETTER

EMERGENCY ADMISSIONS AND ELECTIVE SURGERY

WAITING TIMES

MELIYANNI JOHAR, GLENN STEWART JONES and ELIZABETH SAVAGE*

Economics Discipline Group, University of Technology, Sydney, Australia

ABSTRACT
An average patient waits between 2 and 3 months for an elective procedure in Australian public hospitals. Approximately
60% of all admissions occur through an emergency department, and bed competition from emergency admission provides
one path by which waiting times for elective procedures may be lengthened. In this article, we investigated the extent to
which public hospital waiting times are affected by the volume of emergency admissions and whether there is a differential
impact by elective patient payment status. The latter has equity implications if the potential health cost associated with
delayed treatment falls on public patients with lower ability to pay. Using annual data from public hospitals in the state
of New South Wales, we found that, for a given available bed capacity, a one standard deviation increase in a hospital’s
emergency admissions lengthens waiting times by 19 days on average. However, paying (private) patients experience no
delay overall. In fact, for some procedures, higher levels of emergency admissions are associated with lower private patient
waiting times. Copyright © 2012 John Wiley & Sons, Ltd.

Received 7 February 2011; Revised 30 April 2012; Accepted 8 May 2012

KEY WORDS: emergency admissions; elective waiting times; public hospitals; equity

1. INTRODUCTION

Long waiting times are a major concern in countries where hospital treatment is free and waiting lists are used to
ration the demand for elective procedures. In 2000, the UK government introduced target waiting times and sanc-
tions for poorly performing hospitals. In Australia, public hospitals also report their waiting times performance in
aggregate and by clinical urgency. The latest government report reveals that more than 10% of patients admitted
for elective procedures spent at least 237 days on the waiting list, 5% of patients waited more than 12 months and
16% of patients were not admitted within clinically recommended time (Australian Institute of Health and Welfare
(AIHW), 2008). Such long waiting times can be partly explained by patients’ conditions (Johar et al., 2011), but
they can also be caused by bed competition in the treating hospital. In particular, when a hospital has an emergency
department (ED), elective patients have to compete with admissions from the ED for available beds. The objective
of this study is to investigate the extent to which elective procedure waiting times are affected by the volume of
emergency admissions and to determine the patient groups affected by delayed treatment.
In 2009, there were approximately 4.5 million admissions in Australian public hospitals, of which 58% origi-
nated in an ED (Australian Institute of Health and Welfare, 2009). Emergency admissions have grown steadily,
putting greater pressure on public hospitals; in the 4 years between 2001 and 2005, emergency admissions grew
by 24% and within the next 2 years they grew by a further 10%. Under the principle of treatment based on clinical
needs, emergency patients are given priority. As a result, for a given number of beds, we expect admissions from
emergency to postpone the admission of elective procedure patients, who, by definition, are less urgent. However,

*Correspondence to: Economics Discipline Group, University of Technology, Sydney, Broadway, NSW 2007, Australia. E-mail: elizabeth.
savage@uts.edu.au

Copyright © 2012 John Wiley & Sons, Ltd.

 M. JOHAR ET AL.

there is scant empirical evidence confirming the extent to which this occurs, and more importantly, quantifying the
extent of the resultant delays suffered by elective procedure patients. Although most elective patients do not have
life-threatening conditions, delayed treatment is not costless. It may prolong suffering, decrease earning capacity
and cause deterioration of quality of life (Hodge et al., 2007; Oudhoff et al., 2007). The bulk of the existing liter-
ature on the interaction between emergency and elective activities consists of simulation-based studies reported in
the health operations management literature. These studies predict how, given a capacity constraint and scheduling
principle, the admission of emergency patients affects waiting times and cancellations of elective surgery patients
(Vassilacopoulos, 1985; Bagust et al., 1999; Harper, 2002; VanBerkel and Blake, 2007; Sobolev et al., 2008).
Other studies are qualitative, discussing the competing uses of hospital beds (Richardson and Mountain, 2009).
In Australia, public hospitals treat both public (nonpaying) patients and private (paying) patients who have
choice of doctor. Private patients make up approximately 13% of all elective admissions. Given that public
hospitals operate with fixed budgets for public patients, they have an incentive to generate extra revenue by
increasing private admissions. This raises the interesting question of whether the effect of emergency admissions
on elective waiting times differs by patient payment status. Johar and Savage (2010) found that private patients in
public hospitals are given admission priority; the average waiting time of private patients can be a third that of com-
parable public patients. Unequal treatment by payment status challenges the equity goal of the Australian public
health system. The principles governing funding of public hospitals are defined in the Australian Health Care
Agreements1 between the Commonwealth and each state. Principle 7 requires that all public hospital services to
private patients should be provided on the same basis as for public patients. Access to public hospital care should
be on the basis of clinical need, not payment status. The implementation of this principle relies on an urgency clas-
sification system recommending clinically appropriate maximum waiting times (30, 90 or 365 days) to guide the
prioritisation of patients on the waiting lists. In this study, we explore the differential impact of ED admissions on
the treatment delays of public and private elective patients. In estimating the impacts of emergency admissions, we
control for hospital characteristics and the characteristics of patients in the hospital.
We have in mind a model in which hospitals form an expectation of the volume of emergency admissions and
use elective patient waiting times to adjust total admissions to available bed capacity. This may also allow hospitals
to meet ED performance indicators.2 There are likely to be reputation effects for poorly performing hospitals and
significant health risks associated with delaying an emergency admission. Higher bed allocations to emergency
patients come at the cost of delayed admission of elective patients. Public hospital allocation decisions require
them to resolve the trade-off between performance and financial incentives. Because of the funding arrangements
for public hospitals, there are financial incentives for hospitals to admit private patients. There is also an incentive
to reserve beds for private patients to satisfy the admitting rights of the hospital’s salaried and visiting medical
specialists. As a result, we expect that higher emergency admissions extend the waiting times of public elective
patients relative to private elective patients. Because planned procedures vary in their urgency, we expect to
observe larger delays for public elective patients who are waiting for nonurgent procedures.

2. DATA

We have patient-level data on completed admissions between the period 1/07/2004 and 30/06/2005 from 221
public facilities in the state of New South Wales (NSW), the most populous state of Australia. The facilities are
categorised into hospital groups (‘peer groups’): principal referral hospitals; specialist women’s and children’s
hospitals; large, medium and small hospitals; and other acute and other nonacute hospitals. Our analysis
focuses on 108 facilities that have both a waiting list and an ED.3

1
http://www.health.gov.au/internet/main/publishing.nsf/content/B02C99D554742175CA256F18004FC7A6/$File/New%20South%20%
20Wales.pdf
2
Waiting times in emergency departments are one key performance indicator used by the NSW Department of Health.
3
We exclude rehabilitation units and psychiatric hospitals for which the relationship between emergency department and waiting lists is
quite distinct.

Copyright © 2012 John Wiley & Sons, Ltd. Health Econ. (2012)
DOI: 10.1002/hec
 EMERGENCY ADMISSIONS AND ELECTIVE SURGERY WAITING TIMES

For each hospital, we calculated the total number of emergency admissions during the year and the mean
elective surgery waiting time for planned admissions overall and by payment status. The mean waiting time
is derived for the 296 350 public patients and 51 992 private patients who were admitted in the period of the
data. This large sample ensures the representativeness of the sample mean to the hospitalised population mean.
We also obtained hospital-specific characteristics such as hospital group, average available beds, location (city,
inner region, outer region or remote/very remote) and patient health profile (age, same day admission, urgency
category, number of diagnoses). Differences in the characteristics of hospitals may attract patients with differ-
ent health profiles, so we included these hospital characteristics as control variables to hold these effects con-
stant in the estimation of the effect of emergency admissions on waiting time.
We conducted analysis at the two levels: hospital and hospital procedure. At the hospital-procedure level,
there are multiple observations for each hospital by procedure group. Hospitals may vary in the manner they
allocate beds, and an increase in emergency admissions may affect admissions of some elective procedures less
than others. There are 20 broad categories of procedures in the Australian Classification of Health Interventions
(4th Edition).4 Some admitted patients have no procedure (e.g. monitoring). We treat this as an additional cat-
egory. On average, each hospital has 13 procedures with a mode of 19. Our final sample size is 1372 hospital
procedures. We calculate the patient profile for each hospital-procedure observation.
Table I presents summary statistics at the hospital level. The mean waiting time for all patients is 70 days.
Private patients have substantially shorter waiting times than public patients (37 compared with 74 days). The
average number of emergency admissions in a year is 6440 with wide variation across hospitals.

3. RESULTS

3.1. Hospital level analysis

The results of linear regressions of mean hospital waiting time on emergency admissions and other control variables
are reported in Table II.5 The sample sizes vary because in some hospitals there is no variation by patient status.
We found that emergency admissions lengthen the overall hospital waiting time. Holding the number of beds
constant, the model predicts an increase in elective surgery waiting time of 19 days for a one standard devia-
tion increase in emergency admissions (7826 per year). Distinguishing patients by payment status, we found
that the waiting times of private patients are unaffected by emergency admissions. This result is consistent
with our conjecture that the financial incentives associated with private patients protect them from delays
due to emergency admissions.
Hospital characteristics have different effects on the waiting time of public and private patients. This result
highlights the importance of controlling for these characteristics. Increasing the number of available beds
lowers the average waiting time, especially for public patients. Hospitals in regional areas have shorter waiting
times on average compared with hospitals in the city. This suggests that city hospitals may face greater pressure
than regional hospitals in terms of coping with demand, but the difference is not statistically significant. There
are differential effects by hospital group. Principal referral (major teaching) hospitals have longer waiting times
than other types of hospital, except for large hospitals. This may be explained by the greater number of proce-
dures that principal referral hospitals perform. These hospitals also tend to treat more complex cases, which
may be more difficult to schedule. Patient age profile matters for private patients: average waiting times are
lower the higher the proportion of younger and older patients in the hospital. For public patients, waiting times
are longer the higher the proportion of least urgent and same day patients.

4
http://www.aihw.gov.au/procedures-data-cubes/
5
This specification assumes emergency admissions and waiting times are in an equilibrium state. Stable monthly average waiting time and
emergency admissions over the period of our data support this assumption. We explored lagged effects using monthly variation and found
that the correlation between waiting times and emergency admissions is stable irrespective of lags. Detailed results are available on request.

Copyright © 2012 John Wiley & Sons, Ltd. Health Econ. (2012)
DOI: 10.1002/hec
 M. JOHAR ET AL.

Table I. Summary statistics

n Mean SD Min Max

Waiting time all admissions 108 69.538 46.100 0 218.510
Waiting time public admissions 107 74.043 47.384 0 221.451
Waiting time private admissions 100 36.903 24.147 0 156.368
Emergency admissions 108 6440 7826 10 33 123
Hospital group: principal referral 108 0.204 0.405 0 1
Hospital group: specialist women and children 108 0.019 0.135 0 1
Hospital group: large 108 0.148 0.357 0 1
Hospital group: medium 108 0.352 0.480 0 1
Hospital group: small 108 0.250 0.435 0 1
Hospital group: other 108 0.028 0.165 0 1
Major city 108 0.287 0.454 0 1
Inner region 108 0.343 0.477 0 1
Outer region 108 0.352 0.480 0 1
Remote/very remote 108 0.019 0.135 0 1
% Patients age <20 years 108 0.095 0.140 0 1
% Patients age 20–39 years 108 0.164 0.088 0 0.418
% Patients age 40–59 years 108 0.242 0.088 0 0.550
% Patients age 60–69 years 108 0.170 0.072 0 0.573
% Patients age 70–79 years 108 0.197 0.080 0 0.452
% Patients age 80+ years 108 0.132 0.111 0 0.667
% Same day planned admissions 108 0.242 0.287 0 0.997
% Patients with 7-day urgency 108 0.082 0.105 0 0.605
% Patients with 30-day urgency 108 0.173 0.131 0 1
% Patients with 90-day urgency 108 0.210 0.164 0 0.783
% Patients with 365-day urgency 108 0.169 0.154 0 0.851
No. diagnoses 108 2.826 0.706 1.471 4.667

For location, we are using the Australian Bureau of Statistics’ Accessibility/Remoteness Index of Australia (ARIA) classification. The
distribution of hospitals under this classification may be different to that in the AIHW reports, which use ARIA+ classification. Mean
waiting time can be zero because planned procedures can be same-day procedures (e.g. imaging services, noninvasive procedures).

3.2. Hospital-procedure level analysis

The results of linear regressions of mean hospital-procedure waiting time on ED admissions and other control
variables are reported in Table III.6 The last four columns report the mean waiting time by procedure, the
number of emergency admissions and the numbers of elective admissions for public and private patients. Most
emergency admissions are for maintenance and noninvasive procedures. For elective admissions, we observed
large volumes of procedures on urinary and digestive systems, which tend to involve regular admission. Some
procedures have very long waiting times like ear, nose and throat and musculoskeletal, and although most
hospitals provided all types of procedure, there are some procedures like oncology and endocrine that tend
to be performed by specialised hospitals.
The results show that emergency admissions affect the waiting time for some procedures more than others.
Emergency admissions lengthen the waiting time of ear and mastoid process elective patients regardless of
payment status. A one standard deviation increase in emergency admissions is associated with approximately
34 days longer waiting time for these patients.
We found six procedures where emergency admissions have a positive and significant effect on public patients’
waiting times with no significant impact on private patients: procedures on nose, mouth and pharynx; procedures on
the musculoskeletal system; procedures on the ear and mastoid; procedures on male genital organs; and maintenance
procedures and procedures on the nervous system. For these procedures, representing 20% of public admissions, a

6
As an alternative to the hospital-procedure level analysis, we conducted the analysis by specialty (cardiothoracic, ENT, general, gynaecol-
ogy, neurosurgery, ophthalmology, orthopaedic, plastic, urology, vascular, dental, renal dialysis, obstetrics and other) and find that emer-
gency admissions have large positive effects on the waiting times of public patients and for specialties which tend to have long waiting
times. Results of this analysis are available on request.

Copyright © 2012 John Wiley & Sons, Ltd. Health Econ. (2012)
DOI: 10.1002/hec
 EMERGENCY ADMISSIONS AND ELECTIVE SURGERY WAITING TIMES

Table II. Regression results for the impact of emergency admissions on waiting times

Waiting time Waiting time Waiting time

All admissions (i) Public admissions (ii) Private admissions (iii)

Emergency admissions 0.0023 (2.26)** 0.0025 (2.43)** 0.0001 ( 0.08)
Specialist women and children 16.844 (0.18) 11.389 (0.12) 10.156 ( 0.13)
Large 12.145 (0.84) 13.397 (0.92) 4.738 (0.57)
Medium 4.516 ( 0.34) 4.255 ( 0.31) 21.665 (1.90)*
Small 38.640 ( 2.15)** 40.567 ( 2.23)** 10.932 (0.81)
Other 90.956 ( 1.97)* 101.993 ( 2.18)** 37.223 (1.28)
Available bed 0.138 ( 2.35)** 0.141 ( 2.38)** 0.012 ( 0.34)
Inner region 5.977 ( 0.48) 6.538 ( 0.52) 12.338 ( 1.08)
Outer region 0.332 ( 0.02) 0.990 ( 0.06) 12.630 ( 0.93)
Remote/very remote 34.190 (1.46) 30.806 (1.41) 14.033 (1.00)
% Male admissions 45.813 ( 0.71) 32.361 ( 0.49) 9.989 ( 0.21)
% Patients age <20 years 3.809 (0.04) 23.337 (0.24) 40.913 ( 0.49)
% Patients age 20–39 years 63.789 (0.77) 79.455 (0.89) 109.026 ( 2.05)**
% Patients age 60–69 years 30.236 ( 0.39) 12.573 ( 0.15) 109.091 ( 2.33)**
% Patients age 70–79 years 127.125 (1.26) 148.277 (1.38) 33.723 ( 0.69)
% Patients age 80+ years 45.271 ( 0.43) 17.494 ( 0.17) 174.378 ( 4.54)***
No. diagnoses 3.652 (0.51) 2.590 (0.34) 6.379 (1.78)*
% Same day planned admissions 67.170 (2.95)*** 70.612 (3.04)*** 18.435 (1.33)
% Patients with 7-day urgency 1.740 (0.04) 7.570 (0.17) 3.621 ( 0.14)
% Patients with 30-day urgency 45.855 (0.86) 55.565 (0.93) 7.963 ( 0.36)
% Patients with 365-day urgency 84.872 (2.36)** 91.743 (2.39)** 30.452 (1.30)
Constant 36.099 (0.62) 18.094 (0.27) 84.409 (2.38)**
R2 0.1858 0.2024 0.2227
df 22 22 21
n 108 107 100
t-statistics are presented in parentheses. Let i indexes a hospital; {w, wpub, wpri} denotes overall mean waiting time, mean waiting time of
public patients and mean waiting time of private patients, respectively; ed is the number of emergency admissions; x1 denotes a vector of
patient profile measures; and x2 denotes a vector of hospital profile, namely, hospital group, average available bed and location. The
results are derived from estimating the following equation by ordinary least square: yi = a + gedi + bx1i + dx2i + ei, where yi = {wi, wpubi, wprii}.
*Statistical significance at 10%; **statistical significance at 5%; ***statistical significance at 1%.

one standard deviation increase in emergency admissions is associated with 23–49 days longer waiting time for
public elective patients. Although the waiting times of patients in queues for relatively common procedures are
not significantly affected, those who experience increased delay from emergency admissions are those who already
tend to have long waiting times. For example, using average emergency admissions, the wait for musculoskeletal
procedures for public patients would be higher by 26 days, and the mean wait for such procedures is 128 days.
For private patients, emergency admissions have a positive association with waiting times for ear and mastoid
procedures, but this affects only a small number of private patients. There is also a positive significant effect on wait-
ing times for oncology and breast procedures, affecting 1.4% of private admissions. Although private admissions are
a small proportion of all elective admissions to public hospitals, the generally insignificant coefficients in column
(iii) are unlikely to reflect merely sampling errors. For instance, private admissions for musculoskeletal procedures
are well represented in the sample (33% of private admissions), and we found a very small and insignificant impact.
A potential limitation of our analysis is that there remain unobserved hospital characteristics such as
‘quality’. If good quality hospitals have more ED admissions or attract more private patients, and good quality
means lower waiting time, then we would underestimate the emergency admission impact. Were quality
observable, it is possible that the impact of emergency admission on waiting time would be larger.7

7
We experimented including common measures of hospital quality, namely, acute myocardial infarction case and mortality, hospital stan-
dardised mortality rate and readmission rate, and found that the impact of emergency admission on waiting time is robust to their inclusion.
The results are available on request.

Copyright © 2012 John Wiley & Sons, Ltd. Health Econ. (2012)
DOI: 10.1002/hec
 Table III. Regression results for ED admission by procedure
No. elective No. elective
Waiting time all Waiting time public Waiting time private Mean No. emergency public private
admissions (i) admissions (ii) admissions (iii) waiting time admissions admissions admissions
Procedures on eye and adnexa 0.0031 (1.07) 0.0031 (1.18) 0.0024 ( 1.32) 212 2 037 16 769 1 833
Procedures on nose, mouth and 0.0063 (2.50)** 0.0062 (2.37)** 0.0023 (1.03) 196 1 540 7 508 1 064
pharynx
Procedures on musculoskeletal 0.0038 (2.39)** 0.0041 (2.66)*** 0.0005 (0.24) 138 31 839 22 648 2 143
system
Procedures on ear and mastoid 0.0043 (2.03)** 0.0042 (2.05)** 0.0048 (2.29)** 125 336 3 455 375
process
Procedures on male genital 0.0050 (3.23)*** 0.0049 (3.32)*** 0.0020 (1.46) 105 1 082 6 241 905
organs

Copyright © 2012 John Wiley & Sons, Ltd.

Obstetric procedures 0.0013 (0.11) 0.0012 (0.14) 0.0007 (0.38) 101 43 838 5 484 479
Dental services 0.0039 (1.21) 0.0042 (1.45) 0.0001 ( 0.22) 90 590 2 803 952
Procedures on digestive system 0.0017 (0.60) 0.0018 (0.88) 0.0000 ( 0.50) 77 29 600 63 200 8 416
Maintenance only 0.0030 (2.29)** 0.0032 (2.50)** 0.0005 (0.28) 71 319 512 12 489 860
Procedures on nervous system 0.0033 (2.10)** 0.0036 (2.50)** 0.0002 ( 0.65) 70 7 470 6 396 1 151
Dermatological and plastic 0.0019 (0.86) 0.0020 (1.20) 0.0007 (0.48) 64 14 402 14 049 1 923
procedures
Gynaecological procedures 0.0029 (1.79) 0.0029 (1.97) 0.0014 (1.33) 60 6 234 20 078 2 828
Procedures on endocrine system 0.0014 (0.25) 0.0015 (0.44) 0.0007 (0.59) 58 210 1 633 315
Procedures on cardiovascular 0.0003 ( 0.77) 0.0004 ( 0.48) 0.0002 ( 0.14) 44 16 960 12 254 3 091
system
Procedures on breast 0.0015 (0.41) 0.0013 (0.35) 0.0017 (1.67)* 34 333 3 635 529
Imaging services 0.0006 ( 0.39) 0.0005 ( 0.31) 0.0006 (0.41) 29 80 614 3 702 1 061
M. JOHAR ET AL.

Noninvasive, cognitive and 0.0016 (0.54) 0.0016 (0.65) 0.0008 (0.83) 23 115 403 21 638 5 598
other interventions
Procedures on respiratory system 0.0017 (0.55) 0.0017 (0.73) 0.0006 (0.38) 22 10 647 3 579 922
Radiation oncology procedures 0.0009 ( 0.30) 0.0016 ( 0.35) 0.0016 (1.98)* 18 667 680 215
Procedures on urinary system 0.0012 (1.34) 0.0010 (1.08) 0.0003 (0.32) 16 6 656 66 430 16 852
Procedures on blood and 0.0005 ( 0.86) 0.0003 ( 0.74) 0.0003 (0.08) 11 1 081 1 679 480
blood-forming organs
R2 0.387 0.378 0.248
df 62 62 61
n 1372 1360 992

Let j indexes a procedure. The results are derived from estimating yij = a1 + g1edi + b1x1ij + d1x2i + fprocj + (procj * edi) + uij, where yij = {wij, wpubij, wpriij} by ordinary least square. For a given
procedure, the reported number is the marginal effect of emergency admissions on waiting time for a specific procedure, that is, the estimate of ( + g1), and not coefficients of interaction
terms between procedure category and ED admissions, . The t-statistics in parentheses are based on the interaction terms. *Statistical significance at 10%; **Statistical significance at 5%;
***Statistical significance at 1%.

Health Econ. (2012)

DOI: 10.1002/hec
 EMERGENCY ADMISSIONS AND ELECTIVE SURGERY WAITING TIMES

4. CONCLUSION

The interaction between the management of emergency and the elective surgery admissions is often
discussed or assumed, but there is a lack of empirical evidence to quantify the strength of the rela-
tionship and how delayed treatment varies across patients. We found that, controlling for capacity,
increased pressure from emergency admissions can considerably lengthen waiting times of elective
patients.
To accommodate emergency admissions, it appears that public hospitals delay the treatment of public
patients, but not private patients. This result is consistent with the finding that private patients receive prefer-
ential treatment in admission (Dimokou et al., 2009; Johar and Savage, 2010). This suggests that hospitals
place a greater weight on the financial incentives to increase throughput of private patients compared with
the possible damage to reputation associated with long public patient waiting times.
In 2009, the federal government introduced explicit financial incentives for public hospitals to meet waiting
time targets, and only recently have hospital report cards in the form of a hospital comparison Web site,
MyHospital, become easily accessible to consumers. The impact of these heightened incentives for increased
performance in terms of public waiting times will be able to be assessed with the availability of more recent data.
It will be interesting to test if these policies have reduced the adverse effect of emergency admissions on the waiting
times of public patients.
Our results challenge the goal of equity of access in the public hospital system. The potential health costs
associated with delayed treatment is not uniform across patients. Better waiting list management may reduce
the adverse impact of bed competition from emergency admissions. While increasing capacity might seem
the obvious response to bed competition, simply increasing the number of beds may not reduce elective surgery
waiting times as they stimulate new demand for elective procedures in public hospitals (Stavrunova and
Yerokhin, 2011). A more direct and effective approach to achieve more equitable treatment of patients in public
hospitals may be to focus on hospital scheduling systems.

ACKNOWLEDGEMENTS

This work was supported by the Australian Research Council (grant no. DP0986785). The NSW Inpatient and
Waiting Time data was provided by the NSW Department of Health. The use of the data has program ethics
approval from the University of Technology, Sydney.

REFERENCES

Australian Institute of Health and Welfare. 2008. Elective surgery in Australia: New measures of access. Australian Institute
of Health and Welfare: Canberra, 88p. Cat No.: HSE 57.
Australian Institute of Health and Welfare. 2009. Australian hospital statistics 2007–08. Australian Institute of Health and
Welfare: Canberra, 416p. Cat No: HSE 71.
Bagust A, Place M, Posnett, JW. Dynamics of bed use in accommodating emergency admissions: stochastic simulation
model. British Medical Journal 1999; 319(7203): 155–158.
Dimokou S, Parkin D, Devlin N, Appleby J. Identifying the impact of government targets on waiting times in the NHS.
Health Care Management Science 2009; 12(1): 1–10.
Harper PR. A framework for operational modelling of hospital resources. Health Care Management Science 2002; 5(3):
165–173.
Hodge W, Horsley T, Albiani D, Baryla J, Belliveau M, Buhrmann R et al. The consequences of waiting for cataract surgery:
a systematic review. Canadian Medical Association Journal 2007; 176(9): 1285–90.
Johar M, Savage EJ. Do private patients have shorter waiting times for elective surgery? Evidence from New South Wales
public hospitals. Economic Papers 2010; 29(2): 1–15.
Johar M, Keane MP, Jones G, Savage E, Stavrunova, O. Expected waiting time and the decision to buy private health
insurance. Health Economics 2011; 20(S1): 68–86.

Copyright © 2012 John Wiley & Sons, Ltd. Health Econ. (2012)
DOI: 10.1002/hec
 M. JOHAR ET AL.

Oudhoff JP, Timmermans DRM, Knol DL, Bijnen AB, van der Wal G. Waiting for elective general surgery: impact on
health related quality of life and psychosocial consequences. BMC Public Health 2007; 7: 164.
Richardson DB, Mountain D. Myths versus facts in emergency department overcrowding and hospital access block. Medical
Journal of Australia 2009; 190(7): 369–374.
Sobolev BG, Sanchez V, Kuramoto L, Levy AL, Schechter M, FitzGerald JM. Evaluation of booking systems for elective
surgery using simulation experiments. Healthcare Policy 2008; 3(4): 113–124.
Stavrunova O, Yerokhin O. Equilibrium model if waiting times for non-emergency procedures in the NSW public hospitals.
The Economic Record 2011; 87(278): 384–398.
VanBerkel PT, Blake JT. A comprehensive simulation for wait time reduction and capacity planning applied in general surgery.
Health Care Management Science 2007; 10(4): 373–385.
Vassilacopoulos G. A simulation model for bed allocation to hospital inpatient departments. Simulation 1985; 45(5): 233–241.

Copyright © 2012 John Wiley & Sons, Ltd. Health Econ. (2012)
DOI: 10.1002/hec