Still waiting after all these years

Abstract

Canadians understand that when they require nonemergent health care, they will usually have to wait. They wait in emergency rooms, they wait for diagnostic tests, they wait to see specialists, and they wait for surgery and procedures. Often, they even wait to get out of hospitals. When waits are appropriately brief, patients feel confident and satisfied. When waits are too long, however, patients and their families experience anxiety, economic hardship, needless pain and suffering, and perhaps even more serious adverse events, including death. A tremendous amount of effort and resources have been poured into the wait time dilemma over the past five years. Medical professional groups have developed evidence-based wait time benchmarks (1). The Canadian Medical Association’s Wait Time Alliance, of which the Canadian Cardiovascular Society (CCS) is a founding member, has been particularly active in advancing this issue on the national stage. Their annual report cards on wait times in Canada have served as a central lightning rod in the national debate (2). Provincial and territorial governments have worked diligently to better understand and reduce wait times for surgical procedures through improved data collection and targeted spending. Undoubtedly, there have been improvements. In Ontario, for example, meaningful reductions in wait times for cataract surgery, joint replacement, cancer surgery and diagnostic imaging have been demonstrated (3). Other provinces have also seen improvements in a limited number of targeted priorities (4). Why then, are patients, providers and payers still underwhelmed? Why are so many Canadians still dissatisfied with their experience in the health care system? In the present issue of The Canadian Journal of Cardiology, Legare et al (5) have hit the nail on the head. The authors have found that when they step into patients’ shoes and look at the whole health care experience from the patients’ eyes, a very different picture emerges from the one painted by conventionally determined and reported surgical wait times. They have shown that the wait time for cardiac surgery in Nova Scotia underestimates the true wait, as seen and experienced by the patient, because the wait time is defined as beginning on the date when a decision is made to perform the surgical procedure. While this definition is broadly accepted and widely applied, not only in the cardiac literature, but in the surgical literature in general, largely because it is intuitive and easy to measure, the surgical wait is, in fact, only one of many pieces of the continuum of care that comprise the patient’s total health care experience. The surgical wait time is, of course, only one component of the patient’s journey through a series of clinical, consultative, diagnostic and therapeutic events spanning symptom onset to recovery. The authors hint at the complexity and interdependencies of the processes that characterize and define the patient’s journey by pointing out that these cardiac surgical patients first had to access the system with a symptom or syndrome, either through the emergency room or via a primary health care provider, and then have a coronary angiogram, followed by additional testing and consultations. They have also shown us how attention to these other components of the journey can inform us about pressure points in the continuum. For example, in this series, initial presentation through the emergency room led to a more prompt angiographic evaluation and faster surgery than did presentation to a family doctor. Findings like these allow us to better understand the system’s bottlenecks in patient flow. After all, it is at these bottlenecks where negative perceptions, inequities and, potentially, suboptimal outcomes are born. It is also where inefficiency and waste are generated. The Canadian Medical Association estimates that waits exceeding medically acceptable benchmarks in just four key procedures cost our economy $14.8 billion in 2007 (6).