A urologist colleague of mine recently described the impact of long waiting times on his patient, named Linda*. He had just completed a multi-hour surgical removal of an infected staghorn calculus 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 renal colic with an outpatient referral to urology. 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 have developed waiting 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 morbidity 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.
* Not the patient’s real name.