Care Models to Consider
highlights from the Halifax symposium

Michael J. Dunbar M.D., FRCSC, PhD
Halifax, NS

Eric Bohm, M.D., FRCSC
Winnipeg, MB

Ted Rumble, M.D., FRCSC
Toronto, ON

At this year's symposium at the Annual Meeting in Halifax, speakers presented on a variety of models of health care delivery that have been shown effective in significantly improving patient access.

As we all know, current demand by Canadians for orthopaedic services significantly outstrips supply. Consequently, patients face the longest waiting times of any specialty for elective consultation and surgery. Resource restrictions and population demographics further exacerbate the situation.

By way of introduction to the day's topic, Dr. Ted Rumble presented data on surgeon density in Canada as calculated by the National Standards Committee (NSC). In 2006, there were 3.7 orthopaedic surgeons per 100,000 population - or 3.0 on a full-time equivalent (FTE) basis. This ratio falls far short of the 4.5 per 100,000 that the NSC determined was the minimum surgeon density required to meet the population's orthopaedic-care needs. Canada is not expected to reach that level of surgeon density until 2029. Even then, with only 3.6 per 100,000 on an FTE basis, it would still not be enough.

He noted that constraints make it impossible to substantively increase the number of orthopaedic surgeons in Canada. As a result, the NSC has examined the potential for physician assistants (PAs) to help redistribute the workload of orthopaedic surgeons. PAs have been integral to the delivery of health care in the US for decades. Known as clinical assistants in Manitoba, they have provided care since 2003. Several pilot projects employing PAs are currently underway in Ontario. 

Alberta's Ministry of Health is busy re-thinking how its health system delivers hip and knee arthroplasty care. Data presented by Dr. Cy Frank on a 2005-06 pilot project undertaken by the Alberta Bone and Joint Institute show why. The revised approach to hip and knee arthroplasty relies on case managers, accountability contracts and streamlined information flow to deliver an evidence-based, "integrated continuum of care." Primary-care physicians refer all MSK patients to a centralized assessment team comprising trained nurses, physiotherapists and occupational therapists, who then determine which patients clearly need surgery. These are referred to orthopaedic surgeons; whereas non-surgical patients are sent to receive appropriate care from other health care providers.

Dr. Cy Frank speaks at the symposium in Halifax.

The pilot received $20 million in new Alberta funding and took the form of a randomized trial involving 1700 patients, three health regions and 20 of Alberta's highest volume surgeons. Outcomes with the new approach were superior to the traditional one. Patients experienced greater improvement in physical and social function, greater reductions in pain, and expressed higher levels of satisfaction. Waiting times were reduced from 145 working days to 21. Adherence to evidence-based standards increased, and hospital stays - along with their attendant costs - decreased. Additionally, there were no differences between the groups in complication rates. Based on the success of this pilot, Alberta is planning a roll out to other health regions across the province.

Dr. Eric Bohm talked about his experience as an orthopaedic surgeon working with clinical assistants at the Concordia Hospital in Winnipeg. He noted that PAs have significantly enhanced the delivery of orthopaedic care and are well received by nurses and patients. In a study at Concordia, physician assistants freed up for their supervising orthopaedic surgeon the equivalent of four, 50-hour work-weeks per year - time that surgeons put to good use doing administrative work, research or other clinical activities.

In the operating room, using PAs as first assistants instead of general practitioners freed up the equivalent of 1.5 general practitioners working 40 hours per week for 44 weeks per year (based on a surgical volume of 1400 joint replacements per year). The "double room" model facilitated an increase in primary joint volumes of 42%. The increased throughput associated with the double room model lowered median patient wait times from 44 weeks to 30 weeks, which is close to the national benchmark. This represents a 32% reduction in median waiting times compared to the previous year. Given these results, it's not surprising that the University of Manitoba is planning to start a PA training programme soon.

Formerly a physician assistant with the Canadian Forces, consultant Tom Ashman noted that PAs are able to work in a variety of settings including the office, clinic, OR ward and ER. Also, since PAs provide services that mirror their supervisors' surgical practice, they can also be quite an effective incentive when recruiting and retaining orthopaedic surgeons. Currently, Ashman is the Executive Director of the PA Development Foundation of Canada, a non-profit organization that is seeking to promote physician assistants and integrate them into Canada's health care delivery system.

Dr. Leif Sigurdson, a plastic surgeon at Halifax's Queen Elizabeth II Health Sciences Centre, recently completed his MBA thesis, in which he conducted a financial analysis of the role that physician assistants could play in a hospital setting. At the symposium, he presented data from two Halifax hospitals that showed conclusively PAs would significantly increase surgical productivity. His business case analysis demonstrated that integrating PAs could be achieved in a cost-effective manner. Moreover, the ability for a surgeon to run two ORs simultaneously with the help of a PA would mean achieving even greater efficiencies.

Of course, the common thread to these presentations is that new kinds of health care professionals - like the case managers and triage experts in Alberta or the PAs in Manitoba - must be introduced into Canada's health care system, if specialists and surgeons are to remain in short supply. Governments of all stripes keep asking for innovative solutions to the crisis in health human resources and the resulting crisis in patient access. We believe that Canada's orthopaedic surgeons have risen to the challenge and have viable solutions that should be seriously considered and then acted upon. The COA will continue to press for these sensible and effective strategies with government and national/provincial medical societies so that Canadians can receive the best orthopaedic care in a timely manner.