Jane’s story
Jane is a 60 year old woman living in Waterloo, Ontario (a number of details of Jane’s case have been changed to protect her confidentiality). For several years she has been experiencing worsening back pain, which was recently diagnosed as spinal osteoarthritis (a degenerative condition that can cause severe back pain). The pain has grown so bad that she can no longer work, and has difficulty moving around her home. Her family doctor wants her to see a number of specialists, including a rheumatologist and spine surgeon. However, the wait to see a rheumatologist in her area is six months, and the wait to see a spinal surgeon is nearly a year. Jane’s family doctor is doing his best to manage her pain while she waits to see these specialists, but it has gotten so bad that only opioid painkillers seem to be effective, and he worries about the risks of using these medications for so long. Both Jane and her doctor wonder why she has to wait so long to see a specialist.
An incomplete picture
Despite almost a decade-long focus on wait times, Ontarians still don’t know how long they are waiting to see specialists.
Canada’s premiers committed to reducing wait times as part of the 2004 health accords, which spawned programs like Ontario’s Wait Times Strategy and the National Wait Times Initiative. Since 2003, Ontario has spent approximately $1.7 billion to reduce wait times for priority areas, including cancer surgery, cataract surgery, hip and knee replacement, and diagnostic imaging. Wait times have decreased in these areas and Ontario now has good wait times by Canadian standards, although not by by international standards. All provinces now monitor and publicly report wait times. Ontario publishes wait times for surgery and diagnostic imaging on the Ministry of Health and Long Term Care’s website.
However, the wait time data published in Ontario represents only the wait between a specialist’s treatment recommendation and a medical procedure such as an operation.
But before a specialist makes a recommendation, there is another wait time – the wait to see a specialist. According to Jon Irish, the Interim Provincial Clinical Lead for Access to Services and Wait Times for the Province of Ontario, the wait to see a specialist can be much longer than the wait between a treatment recommendation and a medical procedure.
While Ontario has made significant progress in measuring and reporting wait times for treatments, there are currently no mechanisms in place to measure or report on the length of wait times to see specialists at the provincial level.
How long are Ontarians waiting to see specialists?
There have been past attempts to measure waits to see specialists, but these have relied on patient or physician estimates, and are widely viewed as unreliable due to low response rates and sample bias. Despite the methodological problems with these studies, there is general agreement that the wait times to see certain specialists can be very long.
Recent research from the University of Western Ontario supports this view. According to this study, median wait times to see doctors in several specialties in the London area are longer than 80 days. The longest waits were to see a neurosurgeon, a gastroenterologist, a rheumatologist or a dermatologist. Only cardiologists, ophthalmologists, pediatricians and physiatrists had median waits of less than 40 days.
Long waits to see specialists raise the question of why, after such large investments in reducing wait times for treatment, there are no established provincial mechanisms in place to measure, report, and ultimately shorten wait times to see specialists.
This is in contrast to the United Kingdom’s National Health Service (NHS), which tracks wait times from the moment a patient is referred by their family doctor to the time when the patient receives medical treatment from a specialist. The NHS stipulates that 90-95% of patients should wait no longer than 18 weeks (126 days) from the time at which they are referred to the time when they are treated.
Measuring the wait to see a specialist
While the Ontario Ministry of Health and Long-Term Care does not currently monitor wait times to see specialists, an electronic referral tracking system for hip and knee replacements used throughout the Toronto Central LHIN may provide a model for how such a system could work. In 2005, patients being assessed for hip and knee replacement at Sunnybrook Health Sciences Centre were experiencing long waits to see specialists, and staff members had no way to check on the status of referrals.
In response, Sunnybrook introduced a centralized electronic referral system, which allowed staff to monitor wait times to see orthopedic surgeons.
When the Toronto Central LHIN introduced a new model of care for hip and knee surgery in 2007, it adopted Sunnybrook’s referral tracking system and extended it to all six of its hospitals.
The data collected by the referral tracking system is analyzed by Access to Care (a division of Cancer Care Ontario that is responsible for monitoring wait times for all surgery and diagnostic imaging in Ontario), which provides monthly and quarterly reports to the Holland Orthopaedic and Arthiric Centre, which acts as the central intake hub for hip and knee surgery for the Toronto Central LHIN.
According to Lucy Pereira, a program manager at the Holland Centre, data on wait times to see specialists has allowed the Holland Centre to improve their processes, leading to shorter waits for patients. For example, when reviewing the data they observed that their practice of sending a patient’s appointment dates to his or her family doctor was leading to confused patients and missed appointments. “Once we looked at the data, we saw that we should be contacting patients directly with their appointment date, which also gave us the chance to explain to them directly what to expect from their appointment,” says Pereira. Shortening the lines of communication has resulted in better informed patients and fewer missed appointments, which Pereira says has reduced wait times.
The challenge of measuring wait times to see specialists
“Measuring waits for specialists is more complicated than measuring waits for treatment,” says Irish. This is partly due to the sheer volume of patients waiting to see specialists. Irish explains that “only a certain percentage of patients who see a specialist are going on to have treatment, so the number of patients that are logged onto a ‘wait for treatment’ registry will be much smaller than those logged onto a ‘wait to see specialist’ registry.”
In addition, measuring the wait to see a specialist does not always tell the whole wait times story, because referals need to be processed and a specialist may require additional testing before making a treatment decision. Effective measurement of wait times needs to be able to capture both the wait to see a specialist and the wait between seeing a specialist and a treatment recommendation.
Monitoring and reporting of wait times for specialists must also be sensitive to the urgency of patients’ conditions. Patients with very urgent conditions must be seen more quickly, so their wait times must be tracked seperately, as is currently done with wait times for cancer treatment and cardiac surgery.
It can also be a challenge to standardize reporting. Record keeping often varies between specialists’ offices, so data from one office may not be comparable to data from another.
Monitoring waits to see specialists also comes with financial costs. Maintaining databases and performing large scale analysis costs money, and responsibility for reporting these wait times will add to the workload of specialists’ office staff.
Moving towards public reporting
After nearly a decade of investment in shortening wait times for treatment, plans finally appear to be in the works to begin publicly reporting wait times to see specialists in Ontario. Using the systems piloted by the Toronto Central LHIN’s hip and knee service, Access to Care is preparing to monitor wait times to see surgeons across the province, and will publicly report these wait times on the provincial wait time website.
“Access to Care is using a very similar process to what we used for wait times for treatment: first, we establish the process, second we collect the data, third we share the data internally to work through the data quality issues, and then we’ll be ready to report the data publicly,” says Irish.
However, neither Access to Care nor the Ministry of Health and Long Term Care have announced when public reporting of the wait times to see specialists will begin, nor whether the monitoring process will eventually be extended to include all specialists.
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Thanks for asking the good question. It’s obvious that the numbers are not something to brag about, or they would have been published.
The University of Western Ontario estimate of mean wait times for specialists, being over 80 days, is one more bellwether indicator that Ontario’s Health Care System is in a moribund state –and gravely in need of systemic change.
Too much of the money being thrown at the system is going into the pockets of bureaucrats and administrators (i.e. the eHealth scandal), rather than to core health needs.
Sadly, with our aging population bulge, wait times will increase and health services will continue to decline until more resources and attention are focused on disease prevention.
For more on health care sustainability, go to:
http://ophealthchoices.wordpress.com/2012/10/15/vision-of-a-sustainable-health-care-system/
Thank you. An excellent and important article.
I have a family member who is in the position of waiting for a call from the surgeon after a radiologist reported a risk of cancer and the family doctor made a referral. Anxiety is growing as the wait continues. I finally called and was told that they way it works is that the referral to the surgeon is then sent to a central location that evaluates and prioritizes patients. Once that is done, the surgeon’s office will call the patient. I asked, “and how many months will it take after that?” I was told that the surgeon would see the patient within a month of the call.
From your article, I now understand that the reported wait times would be less than one month. I would like to add that I believe that the process of prioritization should be made public– both in the manner in which it was developed and the guidelines that exist.
I was told by a friend in the health profession that it could take up to 6 months to see a specialist. My family doctor kept insisting that I wait another 6 months,and then another 6 months, to see what was happening..the condition had been there for over a two years. With the information from my friend, I insisted on being referred to a specialist. I still had additional monitoring tests done with the family doctor during the 6 month waiting period which was used as extra documentation for the specialist. If not for the heads up from my friend, I would have been oblivious to the 6 month waiting period to see the specialist and would not have so strongly insisted upon the referral. It is a fact of which everyone needs to be aware.
Reality is that the total wait time should encompass
1. the wait to see the family doctor (sometimes weeks)or other referring professional
PLUS
2. the wait for various diagnostics that the primary care provider might order (weeks or months for ultrasounds, MRI, CT, stress testing etc) before referring to the specialist
PLUS
3. the wait to see the specialist (weeks or months or YEARS)
PLUS
4. the wait to have other diagnostics done via the specialist
PLUS
5. the wait for OR time or other publicly funded infrastructure requirement.
In total, patients can easily wait for 6 months to a year (or longer) for many standard types of care.
With the aging of the population with increased levels of acute and chronic disease we can expect wait times to increase despite more and more public spending.
Measuring and monitoring are not the fix needed but would help to quantify the extent of the problem. However, tax dollars spent to quantify the problem do not provide the front line care needed.
i was informed that i have a second intraneural tumor in my calf. i had one removed in 2010. the specialists office has told me not to expect to hear from them for an office appt for at least 20 months. i find that ridiculous. we may want to find out if its benign or not before we wait 20 months for this appt.
Excellent article. At the inception of the Ontario wait time project we had to decide on the project scope within the fiscal and time constraints imposed by the Government. The intention was that additional wait time measurements would be added to the package, once a province wide program of data capture, analysis and reporting was a reality. Its time to add to the great success of the initial program which was accomplished by hundreds of dedicated individuals across Ontario, lead by Sarah Kramer.
A significant reduction in the wait to see a specialist can be accomplished by ensuring that only appropriate cases are on that waiting list. Not every headache patient needs to see a Neurosurgeon. Jim Waddell has lead an excellent process of setting up a simple triage algorithm so that only appropriate hip pain patients are seen by Orthopaedic surgeons. The care provider is frequently not a surgeon. All specialities should follow the lead of the Orthopods in communicating simple threshold rules which will prevent wasting the patients and specialists time by inappropriate referral.
The Canadian Association of Gastroenterology has been capturing wait times for several years now; both the time from primary care physician to specialist and the time to specialist consultation or procedure. This work has been reported and can be found at
http://www.cag-acg.org/special-projects/wait-times
and at
http://www.cag-acg.org/component/content/article/1-latest-news/1716-cag-releases-2012-sage-wait-time-data
Brilliant article – Thanks so much for writing it!
While reporting isn’t perfect, I’m so thankful it’s being tried. Pay4Results has transformed senior administrators’ interest in emergency department operations. Things that get measured get fixed.
Again, great topic; well done!
Shawn
http://www.stoppatientwaiting.com