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Waiting and waiting for surgery

Wait-time strategies had some success, but led to distortions in priorities

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The following commentary examines wait times primarily in Ontario and examines many of their causes and solutions to reduce them. It was written for Healthy Debate Weekly by Dr. Jeremy Petch, a research co-ordinator, and Dr. Andreas Laupacius, executive director, both at the Li Ka Shing Knowledge Institute of St. Michael's Hospital in Toronto. Dr. Robert Bear practised nephrology for 30 years and was a professor at the University of Toronto and University of Alberta.

 

Three years ago, Katie (name and some details changed to protect her identity) was in a car accident on a rural road two hours outside of an urban centre. Her ankle was crushed in the accident, and after a delay of several hours due to weather, she was airlifted to the nearest trauma hospital to undergo emergency surgery.

While the emergency surgery saved Katie's foot, she was left in agonizing pain from the bones in her ankle grinding on each other. The pain was so extreme she could not walk. She was unable to work, and barely able to care for her three young children.

For the next two years, Katie sat on various waiting lists, first to see a pain doctor and then to see a specialist in foot and ankle surgery. She was prescribed powerful opioids to treat her pain, but they were not effective -- she remained unable to walk.

After an entire year of waiting just to see the foot and ankle surgeon, Katie was placed on another wait list to have her ankle fused. She had her surgery six months later.

Katie's pain is now almost completely gone, and she is able to walk for the first time in nearly three years. But while this surgery gave Katie her life back, she spent nearly two years on wait lists before finally getting the operation. What frustrates Katie and her surgeon is if she had needed surgery for her hip or knee instead of her foot, she might have had to wait only half the time.

In 2004, Canadian provinces agreed to a 10-year plan to strengthen health care, with a major focus on wait times. The plan identified five priority areas for wait-time reductions: cancer care, cardiac care, diagnostic imaging, hip and knee-joint replacement and cataract surgery.

The plan set benchmarks for wait times in these areas, and involved a substantial amount of new funding -- $1.7 billion in Ontario alone -- to increase the volume of these procedures. It also mandated monitoring and annual public reporting of wait times in these five areas.

These efforts resulted in short-term improvements in wait times in the five priority areas in most provinces. However, while the national wait-times initiative was successful in increasing short-term volume of surgeries in priority areas, the volume of surgeries in non-priority areas stayed largely stable, with a small but steady decline in recent years.

The trouble for patients is while the five priority areas are clearly very important, many non-priority surgeries are just as crucial to quality of life. In orthopedics (bone and joint surgery), for example, evidence shows the mental and physical disability caused by end-stage degenerative disease in the ankle is at least as severe as that caused by end-stage disease in the hip. Yet hip-replacement surgery is a priority, while ankle-replacement surgery is not.

In many cases, wait times for surgeries falling outside of priority areas lag well behind those identified as priorities.

In Ontario, 90 per cent of patients receive foot surgery within 323 days, compared to 218 days for knee replacement and 183 days for hip replacement.

In Alberta, waits for foot surgery are more modest, but waits for another non-priority area -- spinal surgery -- are much longer: 90 per cent of Albertan patients receive spinal surgery within 329 days, compared to 273 days for both knee and hip replacement.

But these measures are only half the story -- they show only the wait from when surgery is scheduled to when it is performed. The earlier wait -- from when patients are referred by their family doctor to when they actually see a surgeon -- is not currently monitored in either Alberta or Ontario.

Tim Daniels, a foot and ankle surgeon at St. Michael's Hospital, says the wait time to see foot and ankle specialists is much longer than to see most other orthopedic surgeons. He says many new patients must wait more than a year before he can see them, and the only reason his wait times aren't longer is he turns down roughly half of all new patients who are referred to him.

"Foot and ankle fell off the table when wait times focused on hips and knees," Alan Hudson, who spearheaded Ontario's wait times strategy until 2009, writes in an email. "Classic example of downside of target and financial incentive to do other things," he says of targeted funding for hospitals to increase the number of knee and hip replacements, but not other kinds of orthopedic surgery.

Chris Simpson, chairman of the Wait Time Alliance, agrees. "The focus on the big five priority areas made for some very nice report cards for governments, but while we were making progress in those areas, everything else got left behind," he argues.

Hudson notes, however, some innovations born of the wait-times strategy should be leveraged to improve wait times across the system. In particular, he points to the centralized system for hip and knee replacements used in the Toronto Central LHIN, where patients are assessed at a centralized facility by advance practice physiotherapists and nurses. These assessors determine whether a patient is a good candidate for surgery.

This system cuts down on wait times, because it frees up surgeons' time by not having to see patients who are not good candidates for surgery. The centralized system also gives patients the option to either pick a specific surgeon or the first available surgeon, which further reduces overall wait times. (Patients report a high level of satisfaction with this system.)

Daniels believes a system such as this could be of enormous benefit for many surgical procedures that were not included under the five priority areas.

While efficiency gains can improve wait times somewhat, a more fundamental issue in non-priority areas is their funding is not determined by population need. In other words, there is limited connection between supply and demand.

Historically, most Canadian hospitals have been funded through global budgets; stable funding arrangements determined by historical spending patterns, inflation and one-off negotiations between hospital executives and government. Under the global budget system, hospital managers have been largely free to allocate those funds according to their own priorities. This can lead to service gaps, both from lack of co-ordination between hospitals, as well as a tendency in some institutions to prioritize surgeries that cost less, says Jim Waddell, an orthopedic surgeon at St. Michaels Hospital.

This began to change when the wait-times strategy introduced targeted payments for hip and knee replacements. Where non-priority surgeries still had to be paid for out of a hospital's global budget, some hip and knee replacements were paid for individually with separate funds. This encouraged hospitals to devote more operating-room time to hip and knees.

Daniels believes the strength of targeted funding was it tied supply (surgical time) to demand (the large unmet need for hip- and knee-replacement surgery). He thinks a similar mechanism could be put in place for more surgical services, so hospitals have a financial incentive -- or at least no disincentive -- to provide the services their communities need (services with very long wait lists).

Daniels is aware that in the current fiscal climate, there is unlikely to be new money available for targeted funding, but he is hopeful Ontario's ongoing restructuring of hospital financing -- especially the move toward quality-based procedures -- will provide a cost-neutral mechanism for better connecting supply with demand.

Over the next three years, the Ontario Ministry of Health and Long-Term Care is shifting to a model where 40 per cent of hospitals' funding will come from quality-based procedures (QBPs). QBPs are a type of activity-based funding -- where hospitals are paid for the specific services they provide, rather than having to pay for everything under a single global budget.

While the chief purpose of QBPs is to improve quality through increased standardization, Waddell believes they could be the key to reducing the large discrepancies in wait times. If all orthopedic surgeries were funded through QBPs, hospitals would no longer be incentivized to prioritize surgeries with relatively short waits, simply because they cost less or had special funding. Waddell thinks this would free hospitals to prioritize surgery services based on patient needs, rather than cost.

So far, knee and hip replacements are the only orthopedic surgeries to have been designated as QBPs. Until other areas of orthopedics are brought under this funding model, the large disparities between wait times will likely continue, with some patients waiting much longer than others for no reason other than having the bad luck of needing surgery in the wrong part of the body.

 

-- Healthy Debate Weekly

Republished from the Winnipeg Free Press print edition July 8, 2013 A9

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