A report released by the Canadian Institutes of Health Information (CIHI) follows the wait times for five interventions across all jurisdictions in Canada. These include cancer care (radiation), cataract removal, surgery for hip fractures and total joint replacements of the hip and knee. In each instance, the question posed by CIHI is: “What percentage of people receive treatment in a timely fashion?”
Establishing what constitutes “timely treatment” can be contentious, but in 2004 the provinces and territories agreed to standards for wait time maximums based on the best available evidence.
The positive news is that wait times have remained stable over time in spite of increased demand. For example, the numbers of patients receiving radiation therapy has grown by 34 per cent since 2010, yet 98 per cent of patients are treated within the benchmark. Surgery for hip fractures has shown an improvement of 6 per cent to 84 per cent for timeliness. Eighty-three per cent of hip replacements were performed within benchmark, while 79 per cent of knee replacements made the mark. For cataract surgery, the number within benchmark was 80 per cent.
Unfortunately, CIHI is not able to address the question of appropriateness of treatment. The critical question: “Does this patient really need this surgery, now?” remains unanswered.
Other studies show Canadian wait times in a mixed light. In a study by the Organization for Economic Cooperation and Development, Canada fares well in terms of timeliness of access compared to six OECD peer countries (United Kingdom, Australia, New Zealand, Finland, Estonia and Portugal). Canada ranked first in cataract surgery and second in knee and hip replacements. (The other two interventions are not tracked in the other nations.)
But a third study by the Commonwealth Foundation found that Canada does not fare well compared to peer nations with universal healthcare when accessing appointments for primary care and consultations for specialty care. Since accessibility is one of the five core principles of the Canada Health Act, it is an issue that needs urgent attention. Furthermore, delays experienced in accessing these services would add to the total wait times for healthcare interventions.
In other words, there’s much room for improvement in the Canadian health system.
Fortunately there are means at hand to address the problems of wait times and appropriateness of care – means that are being deployed successfully in Canada. This includes the work of the Cardiac Care Network in Ontario, the Alberta Bone and Joint Institute and the Choosing Wisely Canada initiative of the Canadian Medical Association. But we need a broader uptake of such practices across the country.
Best practices not only enhance healthcare efficiency, but they also result in substantial economic savings too – a minimum of 15 per cent according to most analyses. So how do we get there?
Effective wait time management requires support from government leaders as well as cooperative administrative and clinical leadership. IS/IT infrastructure support to manage centralized wait lists is fundamental, as is a committed full-time staff monitoring wait times performance in jurisdictions, measuring performance against benchmarks and identifying “outliers” or patients who are experiencing untoward delays.
With these elements in place, a system can be created that includes the ability to track the key information of broad trends, as well as the means to identify individual problems.
In addition to timely care, we must also establish a clear rationale for treatment in the first place: Is this knee replacement really necessary now or should the patient lose weight or possibly have non-surgical management? When, why and how interventions need to be undertaken should be re-examined across the country.
Building on the successes of practices already established in some regions of Canada should set the agenda for the future – to enhance efficiency and quality of care at lower costs. Acting now will only strengthen Canada’s most coveted social program.
Robert McMurtry is an active orthopedist and formerly Dean of Medicine at Western University and Assistant Deputy Minister of Health Canada.