A Study in Contrast
Alberta and Québec's Wait-Time Solutions

Dennis Jeanes
Manager, Communications and Advocacy
Canadian Orthoapedic Association

There can be no greater mug's game than comparing wait-time data from different provinces. Forget trying to figure out whether there has been any measurable across-the-board progress. No less an expert than Dr. Glenda Yeates, President and CEO of the Canadian Institute for Health Information, had to voice her frustration this May to the Commons Health Committee: CIHI has only been able to compare three provinces in terms of their wait-time performance for joint-replacement surgery (and four provinces for cataract surgery). At the same hearings, representatives of the Wait Times Alliance noted "a huge variation" in the quality of wait-time reporting from different provinces. And as to the bureaucratically hermetic Québec, its wait-time data remains - to borrow from Churchill - a mystery wrapped in an enigma.

Sometimes, anecdotal information must suffice. Admittedly, two interviews with two orthopaedic surgeons from two provinces - even if they have such impeccable credentials as Alberta's Dr. Bill Johnston and Québec's Dr. John Antoniou - hardly fill the void in wait-time quantitative science, nevertheless the interviews present such a vivid contrast, they deserve comparison.

Currently, thanks to boom times in the oil patch and a government clear of debt, Alberta is restructuring and investing in its health care system. As part of an aggressive action plan announced in April by new Health and Wellness Minister Ron Liepert, a new centralized agency rules the roost: Alberta Health Services (AHS), which for a number of months now has been responsible for overseeing the planning and delivery of health services for the entire province. Indeed, in a bid to streamline the health care bureaucracy and improve patient access to care, all nine CEOs of the province's regional health authorities have been re-assigned or let go, along with the heads of the cancer and mental health boards and the Alberta Alcohol and Drug Abuse Commission.

New monies and centralization of services are very much part of the Alberta model for reducing wait times for hip and knee arthroplasty. "At the start, Calgary, Edmonton and Red Deer got together to look at the problem, so it was an Alberta-wide initiative that was driven through the Alberta Orthopaedic Association," recalls Dr. Bill Johnston, a Past President of the COA and currently Site Medical Director for the University of Alberta and Stollery Children's hospitals. "Now other centres are coming on board. I think it's important to note that the suggested solutions were really initiated by the orthopaedic community, from within, so there was true buy-in, which wouldn't have happened if the initiative had come from on high."

Johnston acknowledges, though, that "we did get good support from Alberta Health," receiving new funding and a commitment to increasing such scarce resources as beds, OR time, nurses and other health care providers, which meant that health-delivery budgets elsewhere weren't cannibalized to reduce wait times in hip and knee arthroplasty. Since complaints about surgical wait times were the most common complaints to which the ministry had to respond, and with the prospect of new designated resources, hospitals saw it was in their best interests to try to deal with the problem. Buy-in from Alberta's orthopaedic surgeons, plus buy-in from the government and hospital executives, represents one of those rare social-policy trifectas that make real progress on the ground possible.

One of the first crucial steps in implementing the model was to centralize the waiting list. "We found that at least 30% of patients who were on the waiting list didn't belong there," says Johnston. "They were either already operated on, didn't want their surgery, were on multiple waiting lists and, sometimes, had died. So to say somebody is on a waiting list can mean different things." The ability to distinguish patients on a clean list who are ready to "come in at a drop of hat" from those who still need medical workup or from those who need time to get their lives in order - "farmers are a classic example" - has helped lead to a drop in wait times "down from over a year to see somebody to under three months."

Centralized patient intake was another important contributing factor in reducing wait times in Alberta, especially T1 referral times from family doctor to surgeon. "We allowed patients and GPs to either pick the first available surgeon if they did not have a preference," says Johnston, "or they could pick a particular surgeon, which might have delayed things slightly, but since everybody's wait lists are coming down, the wait for an individual surgeon isn't that long." Another feature of central intake are the multi-disciplinary pre-op clinics, which allow everybody on the treatment team to educate patients and answer questions from their perspective. Recognizing that there is too much information to absorb in one clinic, patients typically have at least three visits. "If you're trying to get patients through the system quickly, and efficiently," says Johnston, "they need as much information as possible. Certainly they know what's going to happen to them every day of their hospital stay, including what day they're going home. Follow-ups are at the clinic, and it's all standardized, so we'll see each other's patients if they have problems that need tending on an urgent basis."

Having proven itself effective in reducing hip and knee arthroplasty wait times, Johnston firmly believes the Alberta model has potential in other clinical areas and points to efforts by a spine surgery group and a sports injury group to develop a similar treatment path with centralized wait lists, patient intake and standardized follow-up. Johnson has even heard of similar initiatives in diabetes management: "I think we have proven that it does give us an advantage, so this whole concept has got a lot of other applications."

Compared to Alberta, says Dr. John Antoniou of Montreal's Jewish General Hospital (and the COA Bulletin's Scientific Editor), Québec's Ministry of Health and Social Services has embarked on a very different top-down approach, with very different results: "In the last year, rather than really increasing the number of joint surgeries, they seem to have only increased their rhetoric."

Antoniou's dismay refers to the Ministry's wait-times guarantee initiative and its centralized wait list. In Québec, once the decision for surgery is taken, patients are automatically entered onto a government wait list at the same time as the surgeon's. If at the end of six months a patient hasn't received the surgery, the Ministry reserves the right to send him or her to a roster of surgeons who don't have long wait times, which could be anywhere in the province. "If you refuse - and most patients want to stay with their surgeon - well, then you're no longer on the official wait list," says Antoniou. "In effect, the government is taking choice away from the patient. If a patient's a little sick or has cardiac issues and has to get clearance - if there's any medical reason for an extended delay - then they're also off the official list. When patients get that call after six months, I doubt very many understand the consequences of turning down the government."

So, where do these patients go? They join the phantom legions of patients on the unofficial wait list who are now solely the surgeon's responsibility. The Québec government has its web site, with its own numbers, that lists regional hospitals and their official wait times. "Our official wait time is a little over six months, so we're somewhat in arrears of the decision date. We're basically told by the hospital to get patients off the list somehow ... send them somewhere else. But the patients don't want to go anywhere else. It's an absurd situation where the onus is on the surgeon to somehow make the problem go away, without giving more resources or significantly increasing the number of hips and knees being done."

In the meantime, according to news sources, Québec's new Health Minister Yves Bolduc is anxious to put so-called "lean thinking" to work for improving the quality and efficiency of health care in the province. It's a concept adapted from Toyota that "places delivery of care within a continuous, patient-centered cycle of quality improvement." How those heady notions translate into clinical reality remains to be seen, but the bottom line, says Antoniou, is that "in my practice, and all my partners' practices - and we do mostly hips and knees - our wait times have all gone up."