A urologist colleague of mine recently described the impact of long waiting times on his patient, named Linda (name has been changed). He had just completed a multi-hour surgical removal of a large, infected stone from Linda’s kidney. An operation, he pointed out, that he shouldn’t have had to do.
Linda had been seen in an emergency department several weeks earlier and treated for symptoms of a kidney stone and had been referred non-urgently to see a urologist. But due to long wait times and relatively low severity of symptoms, she hadn’t received an appointment.
Unfortunately, while waiting her symptoms progressed to the point that she needed urgent surgery. An outpatient procedure that would have taken about an hour had now taken several hours, with a worse outcome for the patient. He described it as a “death spiral of waiting”; an issue that could have been handled quickly was delayed until it become complicated, leading to longer wait times and more complications for other patients.
Linda’s experience with long wait times in Canada are reflected in the research. We not only feel like we’re in a “death spiral of waiting”, we are. Compared to 10 other OECD countries, Canadians have the lowest access to same-day or next-day appointments.
The Wait Time Alliance has developed wait time goals which are monitored yearly. However, defining a wait time goal is a little like defining an acceptable defect rate; low is good but zero is better. These goals haven’t had much impact so far; after several years of “slight progress” wait times in many provinces actually increased last year. And perhaps more worrying, just like squeezing a water balloon, it is likely that shifting resources to a small number of high priority issues has led to increasing wait times for procedures that are not monitored.
If we want to limit the impact of disease on patients then our wait time targets for all medical care should be zero. As soon as a patient would benefit from appropriate medical intervention, they should have access to it.
We can look to the Netherlands to see that a system approach to reducing wait times can have impact. Similarly to Canada, there was significant public dissatisfaction and wait times were a high priority political issue. Through a transformation of health system organization, wait times have dropped significantly. In 2008, 40% of specialties exceeded an average outpatient wait time of 4 weeks. In 2012 only 24% of specialties exceeded 4 weeks, and 68% of specialties had decreased their wait times.
These changes have had consequences. Incentivizing production without effectively controlling for appropriateness has predictably resulted in an increased volume of procedures and an increase in overall costs (although cost per procedure has dropped). More worryingly, evidence of significant practice variation between regions means it’s likely that some patients are being over-treated, particularly when indications for treatment are uncertain.
This suggests that systems for measuring and managing appropriateness of medical care are necessary, particularly when wait times are very low. Patients should be offered treatment according to indications that are based on both cost and effectiveness. Compliance with indications should be monitored, although health providers must retain the option to deviate from indications when justified. Disincentives to discourage over-use may be needed, such as co-payment or deductibles for certain types of medical care.
Informed patient choice is an important component of appropriateness. Just because a service is immediately available does not mean that patients must make immediate use of it. In fact, confidence that a service will be available when it is needed, without waiting, may provide patients and providers with more opportunity for sober consideration than the current pressure to go on a wait list in anticipation of future need. It may be prudent to build in short wait times for potentially harmful treatment to ensure time for considered reflection (a cooling-off period).
Once an appropriate decision to treat has been made, patient morbidity is minimized when there are no wait times. However, productivity may drop if providers are idle when wait times are very low. A short wait list (buffer) to ensure financial and operational efficiency may be required, likely less than a week and far lower than current wait lists in Canada, although in-line with those in the Netherlands.
If we want to avoid the “death spiral of waiting”, then we must eliminate waiting times and ensure the appropriateness medical care. We have an obligation to prevent future patients from the harm that unnecessary waiting caused Linda.
The comments section is closed.
The information posted above needed to include what we, as the public, can do to help obtain the funding or systems improvement to reduce wait times.
Here is a similar story to one recounted above.
Just heard from my son in Toronto who went to ER at St Joseph’s Hospital in Toronto 3 weeks ago. They inserted a stint in order that he could pass urine. He waited three weeks to see a urologist today. Surgery is not scheduled until the 2nd week in May.
Where do I find a list of wait times at hospitals who are able to perform ureteroscopy?
It is a shame that our public system has to bring everyone down to suboptimal care levels, just because that’s the best way for everyone to be the same. Isn’t that a form of communism?
Anyway…
The big issue is that there are no ORs available for urologists to practice in. Don’t mention that there aren’t enough surgeons, there are too many! They just have nowhere to work because our useless government won’t fund the opening of new surgical centers nor will relax bureaucratic barriers that allow physicians to band together to build and operate their own.
The wait times are a direct result of government incompetence.
Wait a minute here. We were told that the patient was not even given a follow up appointment, That has nothing to do with wait times. That is about not doing what is appropriate after diagnosis.
Turning this into a waiting list problem is a way to divert attention from how the case was initially handles and turns it from an individual case problem into a “System’ Problem.” That is a bad call, Go back to the emergency room and find out why they don’t make proper referrals. You will notice that the patient does receive attention once her condition becomes “urgent.” Our entire system is flawed in this way – it responds to the urgent and neglects the important.
In my experience managing wait times if fa more complicated that most people realize. Assuming that other factors are being managing, such as providing appropriate care, the goal for wait time targets is not zero, rather it is minimizing wait times so that there are no measurable adverse health consequences resulting from a patient waiting to receive medically necessary care. One way to express this is to have wait times targets that don’t contribute to deterioration in a patient’s health and well being, and are as short as reasonably achievable taking into account the need to optimize the operational capacity and cost-effectiveness of the health care system.
There is a “natural” wait time associated with providing health care services that reflects the practices of individual physicians as well as each health service. Efforts to shorten the wait time normally increases the cost of care provided as it often requires creating excess capacity to handle periods of peak demand, and results in inefficient use of health care professionals.
The key is to have an efficient health care system, that has sufficient capacity to handle the population’s health care needs and optimizes how each health care service functions.
LOVE your article!
STOP patient waiting!
Shawn
http://WWW.stoppatientwaiting.com
Wait times would not even be an issue without government distortions of the healthcare market supposedly aimed at controlling costs and equalizing access to healthcare. The whole system of ObamaCare can be characterized as one big waiting line – or rationing. If you want to reduce waiting times under ObamaCare, tell me how I can get past the bureaucrat who will be standing in my way.
> Disincentives to discourage over-use may be needed, such as co-payment or deductibles
I think we need to consider more than that; e.g., eliminating the government monopoly on most health care delivery.
At root, what needs to be grappled with is that the goal of equal, universal coverage is fundamentally at odds with a goal of zero wait times. Then, a moral decision needs to be made: Is it OK, in the quest for egalitarianism, to outlaw more timely, better care from private providers and accept the long wait times (and/or exploding costs) that such prohibition brings, or is it better to remove restrictions on private care and thereby reduce wait times while accepting the resultant inequality; i.e., a diverse range of service levels priced accordingly, like any other product or service sold on a free market.
Having a zero wait list time is both unrealistic and likely not optimal for high quality care. Volume-based competency is well documented as an important ingredient to better clinical outcomes especially in surgical procedures – and in order to maximize that, waiting lists will have to exist as a consequence.
(See: http://frontdoor2healthcare.wordpress.com/2012/10/31/wait-lists-a-necessary-evil-but-how-long-is-too-long/)
If your surgeon has a zero wait time, it means he/she is not doing enough surgeries and not getting enough practice to keep up his/her skills. We need to stop dreaming and accept that wait lists is a reality – and instead focus on finding the right balance between supply/demand (which starts with concrete data, which we are still lacking).
re Ed’s comment:
I basically agree. Certainly it is true that a surgeon must be operating frequently to keep up his skill level but your statement that, “If your surgeon has a zero wait time, it means he/she is not doing enough surgeries” is not really correct. Actually it does not follow that a short or zero wait time does not mean a surgeon is not doing enough surgeries. He can still be fully booked or almost fully booked in his office and the OR.
Nevertheless, as you say, we have to accept that wait lists are a reality – and instead focus on finding the right balance between supply and demand.
Dear Ed,
Thank you for your thoughtful comments. I appreciate your suggestion that volume-based competency should be considered during efforts to reduce wait time.
There are a number of situations where a short wait list may be appropriate. I make reference to a patient wait time “buffer” that is necessary to ensure optimal utilization of expensive/limited health resources (such as surgical teams and facilities). For high volume procedures, only a very small buffer is required to ensure a statistically low chance of idle time. Such a buffer eliminates idle time, thereby maximizing procedural volumes (and maintenance of competency).
There may be alternatives to utilizing a wait time buffer solely to ensure volume-based competency. One option may be concentration of care (thereby reducing the aggregate impact of waiting due to wait time buffers for multiple providers). Of course, a comprehensive analysis of care concentration is outside the scope of this short discussion. Surgical simulation and other continuing medical education initiatives may also prove useful to maintain competency without the need for buffers (particularly for low volume procedures).
I would suggest that creating wait times solely as a means to ensure volume-based competency be done with consideration of the negative effects that wait times may have on quality of care. Evidence from other countries would suggest that, in general, wait times in Canada can be much shorter before we are confronted with potentially harmful effects. In parallel to initiatives to reduce wait times, I fully agree that additional data is required to fine-tune our efforts.