Doug Thomson
CEO, The Canadian Orthopaedic Association &
The Canadian Orthopaedic Foundation

Now that the dust is settling from the Romanow Commission, what's next in terms of the COA's advocacy efforts? In the last issue of the COA Bulletin, Dr. William R. J. Rennie mentioned a number of initiatives, including a standards committee collaborating with ICES. In somewhat the same vein, here's an experiment in treatment-delivery that may have some ideas to offer to orthopaedics. What caught my eye was the familiar issue of overly long waiting times for health services.  

In the late 1980s, Ontario's health ministry, hospitals and heart specialists launched a retrospective study in response to a growing public crisis of confidence with respect to delivery of specialized care - namely coronary by-pass surgery. Media reports of patients dying while waiting for cardiac surgery, frequent cancellations, as well as long waiting times and waiting lists, prompted the Ontario Ministry of Health to initiate a pilot triage and registry programme in the Metropolitan Toronto area. Under the programme's auspices, a consensus panel was struck to develop guidelines to identify the urgency of a patient's clinical status and an estimate of the maximum time the patient could safely wait for surgery. This Urgency Rating Score (URS) resulted from the collaboration of cardiologists, cardiovascular surgeons and community and academic representatives who identified seven clinical factors based on their extensive experience and a thorough literature review. URS proved to be a critical stepping-stone to the expanded, province-wide programme that ultimately became known as the Cardiac Care Network (CCN).

Funded by and accountable to the Ministry, the CCN set for itself two principal goals: developing an accurate, reliable database using common terminology in order to standardize triage, and also advising the Ministry on coordinating cardiac-care services. Central to the effort were nurse/practitioners who gathered data, updated and monitored hospital registries. Aside from facilitating inter-regional referrals between registered centres, thus reducing waiting times and waiting lists, the data was analyzed on a monthly basis to capture trends and improve the Network's efficacy.

Here's how it works: when a cardiac specialist determines that a patient needs an advanced cardiac procedure, a standardized data form is completed that includes demographic and clinical information about the patient. Based on the patient's symptoms, the computer database issues a URS and a recommended waiting time. Specialist and coordinator work closely to keep each other informed and make sure that patients are receiving consistent and accurate information about surgery schedules. The data from each cardiac hospital is transmitted nightly to the CCN's central computer for regional and provincial analysis. At all stages, the confidentiality of all information in the registry is strictly protected.

The impact on waiting times is impressive. In 1999/2000, median waiting times were 36 days for elective patients, eight days for semi-urgent patients, and three days for urgent patients. And despite an increase in the number of people waiting for by-pass surgery, the median wait time for urgent patients remained constant. What's more, the CCN provides a forum for interaction among clinicians, non-clinicians, front-line health workers and policy-makers, which has resulted in a broader understanding of the issues and improved public-education programmes.

The Network credits two main strategies for its success. Recommended solutions are determined by expert consensus panels; to date, there have been nine such panels on a wide variety of clinical and manpower issues. Taken together, they provide a primary source of advice to the government on everything from diagnostics to rehab, which are then often translated into policy. The other important initiative is the development of the centralized patient registry/data base, which now contains more than 100,000 records, providing accurate, objective information that scientific investigators and government policy-makers can use to respond to service demand.

The CCN is willing to share its lessons learned. The Network's full report on its efforts for the past decade is available in PDF format from its web site (www.ccn.on.ca). While the model may not be completely applicable to the issues the COA confronts, the results are enviable and desirable. The CCN influences government policy and funding decisions, has adequate financial resources, an impressive list of successes and the good will of the cardiology and patient communities. These are all goals to which the COA aspires. The clinical details may be different, but the CCN lists a number of basic components that are necessary for a successful network:

• a clear purpose
  
• clear priorities with realistic timeframes and practical goals
  
• clinical leadership and partnership with stakeholders
  
• simplified data-gathering and input
  
• dedicated funding for full-time network staff
  
• ongoing reporting to government about activities and achievements
  

While these points may appear to be obvious and generic, they belie the incredibly hard work undertaken by the cardiac community, most notably in achieving consensus on a spectrum of important issues. The CCN experiment shows that the government is willing to work with clinical professionals and even properly fund a long-term programme – provided there is hard data to work with and the specialists reach agreement among themselves. Unity of mind and purpose is essential for breaking gridlock, whatever the cause. Keep in mind that it took the CCN two to three years to move from blueprint to action even with consensus. Factionalism merely postpones any positive changes even longer.

Thus, to move forward, Canada's orthopaedic professionals must agree to agree. I'd appreciate hearing the membership's thoughts on all of this.