Finding solutions to wait times

In this episode, OMA Executive Vice President of Economics, Policy and Research Dr. Jim Wright and surgeon Dr. Najma Ahmed discuss the proposed use of ambulatory care centres to tackle the surgical backlog.

Transcript

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Georgia Balogiannis: In this podcast the Ontario Medical Association looks at current issues of interest in health care. Spotlight on Health gives you all the straight talk. We're Ontario's doctors and your health matters to us. I'm Georgia Balogiannis for the Ontario Medical Association. 

The COVID-19 pandemic caused a backlog of more than 21 million surgeries and procedures in Ontario. On this podcast, Dr. Najma Ahmed, chief of surgery at St. Michael's Hospital in Toronto, and Dr. Jim Wright, OMA chief of economics, policy and research, discuss how to tackle the consequent wait times.

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Dr. Jim Wright: We already had a waitlist problem, it's a lot worse than it was, and that has real implications for the outcomes of patients who need surgery and procedures. There is an inarguable fact that for those patients that are appropriate, either in terms of their health or the procedure, that care can be delivered more efficiently and probably at higher quality in what's called an ambulatory setting. Because obviously, there's some procedures that are, let's say, too big to be done in an ambulatory setting, and you have to be relatively healthy, you can't have other — what we call comorbidities — other diseases that might make you a much more complicated patient.

The current model is not sufficient. The estimates are that ambulatory surgery can deliver care 20 to 40 percent more efficiently, so at lower cost and faster. You've got a bunch of cases — they need to be done somewhere. Why wouldn't you want them done in the fastest, most efficient, which provides similar or better quality than having it in a hospital? 

If you can get your oil changed, do you want to go to a place that specializes in oil change, get you in and out, does a great job at a cheaper cost? Or do you want to go to a big fancy garage that has a mechanic who does everything and it costs you more, it takes longer, and you get the same job? Ambulatory centres can focus on those procedures they do really well, do them really efficiently, in shorter operative time.

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Dr. Wright: Accreditation Canada has a highly sophisticated program that evaluates acute care institutions. Why not broaden that umbrella so that they also look at these ambulatory centres? You've got an entire hospital system; they have quality and safety departments. That's an infrastructure that you would want to partner with these ambulatory centres, integrated with planning around surgical and procedural care. 

So, they would create partnerships with the hospitals; this is the segment of the population you should be looking after, we’ll look after the sicker, more acute care.

It's really creating a integration and a partnership that is currently lacking. The model includes not just the partnerships with the hospitals and setting them up operationally independent, but it's also this idea of centralized referral, which the government is starting to do. Some places can have waitlists as short as four weeks, others could be 16 weeks. Well, why don’t you smooth that out through centralized referral? 

Ontario Health Teams have a mandate of addressing population health for their catchment. They're not yet ready to take on that role. But, ultimately, they could be in partnership with the regional planning tables. They could be the broker — they could be the ones who help decide who goes where, and their job is to integrate that care.

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Dr. Wright: We are behind virtually most other jurisdictions in our use of ambulatory surgery and procedural care. The United States has — any case that can be done in an ambulatory centre is done in an ambulatory centre. This was an inevitable development, and we're behind the rest of the world, but if you can separate inpatient and outpatient, you achieve efficiencies and possibly quality that you just can't achieve consistently in the same way in an acute care institution that mixes those two streams.

We've talked to some of our stakeholders, both through informal conversations, increasingly formal conversations, looking at ideas, reviewing multiple, multiple revisions over about a year. We're going to try and engage the government — we've talked to all the political parties, we've talked to the Minister of Health, we've talked to the premier. So, we've come up with something that we think is immeasurably better. There's a lot worth thinking about here as we think about the model of care for ambulatory surgery and procedures in this province.

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Dr. Najma Ahmed: In our healthcare system, where we're very good actually I would say at providing urgent emergent care, but where we sometimes are not, we're not as thoughtful, is patients who need surgery but on a less urgent basis. We do pretty well when someone's going die today or tomorrow. But there has been a chronic problem in the healthcare system related to less urgent care needs — important and medically necessary, but maybe not, today, a crisis kind of diagnosis. And those patients have for a long time been displaced, and the pandemic has only made that worse. 

Somewhere between 300,000 and 350,000 procedures have been delayed because of COVID. A lot of screening tests have also been delayed — mammograms, colonoscopies — because of lack of access to the healthcare system. And the literature is clear that even a four-week delay for treatment for cancer surgery — radiation and chemotherapy — can increase mortality. It is a huge daunting task and the patients are suffering.

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Dr. Ahmed: The idea of moving less-complex surgeries in otherwise pretty healthy patients to a freestanding centre, where that is their focus — less complex surgery and pretty healthy patients getting their surgeries done, in and out — it would unburden our larger acute care hospitals.

I think that it would be wise that these freestanding centres be associated with an acute care hospital, because in the vast majority of times, things go very well. But it doesn't mean always. 

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Dr. Ahmed: This is going to require a significant investment of money for infrastructure. This cannot come out of existing hospital budgets because everyone's possible budgets are capped. Governments don't like to have that conversation, even though it may in the long run save money and provide more care for more patients. I think the government, and all of us, must move forward to bring this idea to fruition in a manner that's safe for patients. 

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Dr. Ahmed: Our health system simply doesn't have the capacity to respond to the needs of all of the patients in a timely and safe way. This is an absolutely essential critical need in our healthcare system, and it will require political will.

Other jurisdictions have moved forward and shown that it can be done safely. And we should take lessons from those jurisdictions, put together teams of experts including health care professionals, surgeons, anesthetists, nurses, policymakers, to bring this idea to fruition. It cannot happen absent significant inflow of money to build these centres, to outfit the centres, to buy the medical equipment, to have the health human resources to run these places. They cannot wait. And COVID has shone a light on the fact that's been a chronic problem. And now it's an acute problem that needs immediate attention.

This is a health care issue. And that's the function of the healthcare system is to solve the health care issues for Ontarians.

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Georgia Balogiannis: This podcast is brought to you by the Ontario Medical Association and is edited and produced by Jodi Crawford Productions. To learn more about the Ontario Medical Association, please visit oma.org.

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