Policy strategies to reduce public wait times, part VIII
This is the eighth part of a series examining the policy barriers and solutions to reducing surgical wait times in Canada. The series has been adapted from a research paper by Andrew Longhurst. The complete paper with reference list for the footnotes is available here.
Wait times are caused by a mismatch between patients who are on waitlists (demand) and capacity based on the current organization of the workforce and services (supply). Waits for scheduled surgeries (i.e., non-emergency) exist in all countries; they are influenced by population demographics, health system financing and governance, and how services are organized. Health systems that rely heavily on private finance, such as the US, do not provide equitable access.[1] In the US, there are still wait times. They are just determined by ability to pay and access to insurance, leaving some without care entirely.
Strategies to increase public sector capacity must be implemented with a long-term view. Short-term funding for temporary additional capacity is unlikely to reduce wait times over the long term.[2] Canadian provinces have largely focused on short-term injections of funding – with an increased focus on outsourcing surgeries and medical imaging to for-profit clinics – rather than a sustained focus on system-level redesign and improvement.
Single-entry models and improved waitlist management
Wait times can be reduced if instead of being referred to a specific surgeon, patients are referred to a single-entry model. Single-entry models (SEMs) generally include central intake of referrals from primary care providers (or self-referrals, if appropriate), pooled referrals/waitlist among a team of surgeons, and triage for urgency and appropriateness. A patient’s primary care provider makes a referral to the SEM (comprised of surgeons and other providers, as appropriate); if the patient is a surgical candidate, the referral is then triaged based on the condition and urgency to the surgeon with the shortest wait who has the most appropriate expertise. If the patient is not a surgical candidate, they may be referred to specialized supports and non-operative therapies. In orthopedics, for example, a specially trained physiotherapist may initially assess and triage for surgical candidacy or non-operative therapy.
In many parts of the country, primary care providers refer patients to specific surgeons who each keep their own waitlists for consultations and surgeries. There is often no centralized management or oversight of these waitlists by hospitals or health authorities.[3] This creates inequities in wait times as some patients may wait much longer than others. In contrast, SEMs minimize the number of waitlists and balance the workload, ensuring that every surgeon has consistent work. This can significantly reduce long patient waits often common among senior surgeons and ensure that equally qualified younger surgeons are able to provide surgeries more quickly. Patient and provider satisfaction is high with SEMs, and can also reduce administrative burden within primary care which is also strained.[4]
After implementation of a SEM among urologists in Saskatchewan, for example, there was a 50 per cent reduction in waits within groups that adopted a single-entry model.[5] These practices don’t prevent patients from seeing a preferred specialist or prevent patients with more urgent needs from being prioritized.[6] Similar wait time improvements have been seen as a result of Vancouver’s Osteoarthritis System Integration Service (OASIS), the Winnipeg Central Intake System, across Canada and internationally.[7] Evidence shows that wait time reductions through the use SEMs are greatest across specialties for surgical referrals.[8]
A key part of any SEM is improved waitlist management, which entails minimizing the number of waitlists, equalizing the size of waitlists between surgeons within each surgical specialty, and regularly auditing waitlists to ensure patients on waitlists actually need surgery. This means that health authority staff regularly audit the lists to ensure that the patients listed are actually waiting for surgery. There is considerable variation in how waitlists are managed by different surgeons, and many surgeons’ offices do not audit their lists. In some places, surgeons are allocated OR time based on the length of their waitlist, creating a perverse incentive to add patients’ names to the waitlist even if surgery is not required. SEMs are most effective when waitlists are managed by health authorities, rather than individual surgeons’ offices.
Under fee-for-service physician compensation, a barrier to implementing single-entry models is the perception among some surgeons that health authority administration of waitlists will negatively impact their income. This concern is not borne out in practice, but speaks to the barriers of more efficient delivery under a fee-for-service payment model.[9]
Team-based care: critical to the success of single-entry models
Timely access to treatment and satisfaction improve when health care professionals work together in multi-professional teams using a single-entry model.[10] In a Canadian Medical Association Journal commentary, Dr. David Urbach and Dr. Danielle Martin state that single-entry models are an “efficient, fair, and ethical approach to addressing pent-up demand for surgery in the presence of constrained resources.”[11] Team-based care delivered through a single-entry model is more timely, consistent, and appropriate. There is evidence of improvement in quality indicators for joint replacement as well.[12] It also eliminates unnecessary steps and delays, particularly when health care professionals are supported to work to their full scope of practice. This frees surgeons’ time to perform additional surgeries and consult with patients who are indeed possible surgical candidates.
Multi-disciplinary teams can also provide education to help patients manage their conditions, and explain the benefits and potential risks of surgery. Team-based models facilitate referrals to other health services as needed. Patients may be better informed about their treatment plan and know what to expect along their journey. The team-based model also helps better prepare patients for surgery with a focus on maintaining their health status. This may result in reduced hospital surgery cancellations since patients are healthier and better prepared for surgery. It can also result in shorter wait times, more efficient use of existing capacity and lower costs per surgical case. Team-based models help ensure the consistency of care and reduce inappropriate surgical interventions. These models are used to varying degrees for certain conditions across the country.[13]
[1] Tolbert et al., 2020.
[2] Kreindler, 2020, p. 11.
[3] Oncology (cancer) and cardiology (heart) care are often exceptions.
[4] Milakovic et al., 2021.
[5] Ron Epp, director, Strategic Priorities, Saskatchewan Ministry of Health, 2015, cited in Longhurst et al. (2016, p. 32). However, wait time reductions depend on the amount of capacity within that specialty group and the wait time variations among surgeons in that group prior to adoption of central intake and pooling.
[6] Dr. Kishore Visvanathan, urologist, 2015, cited in Longhurst et al. (2016, p. 32).
[7] Camapagna-Wilson et al., 2021; Demani et al., 2019; Longhurst et al., 2016; Milakovic et al., 2021; Vo et al., 2022.
[8] Milakovic et al., 2021.
[9] Urbach & Martin, 2020.
[10] Milakovic et al., 2021.
[11] Urbach and Martin, 2020, p. 1. Central intake, pooled referrals, and team-based care pathways are often referred to collectively as single-entry models.
[12] Demani et al., 2019.
[13] Sunnybrook Health Sciences Centre, 2013; Toronto Central LHIN, 2014; Longhurst et al., 2016, 34-36; Lopatina et al., 2017, 964; Nova Scotia Health Authority, 2020.
