Monday, December 19, 2011

Fraser Institute report on wait times flawed

By Don McCanne, M.D.
Senior Health Policy Fellow
Physicians for a National Health Program
15 December 2011

A critique of Waiting Your Turn: Wait Times for Health Care in Canada - 2011 Report, by Bacchus Barua, Mark Rovere and Brett J. Skinner, Fraser Institute December 2011

"This edition of Waiting Your Turn indicates that waiting times for elective medical treatment have increased since last year. Specialist physicians surveyed across 12 specialties and 10 Canadian provinces report a total waiting time of 19.0 weeks between referral from a general practitioner and receipt of elective treatment." - Fraser Report

The Fraser Institute has released its 21st annual report on wait times for health care in Canada. This report is used widely to condemn Canada's reliance on their single payer medicare program for the financing of health care. It helps to fulfill the Fraser Institute's libertarian agenda of advocating for privatization of their health care system. Today's comment takes a critical look at this report.

The findings in the report are based on the solicited opinions of Canadian physicians. Questionnaires were sent to 10,737 of the 68,000 active Canadian physicians. Of these, 1,696 physicians responded (15.8% response rate). Distributing these responses amongst the 12 specialties and ten provinces results in single digit tallies for 63 percent of the categories, and often only one physician falling into a given category. For instance, only one specialist in internal medicine represented the views of all internists in the province of Prince Edward.

Besides questioning whether these numbers are adequate to represent the views of all Canadian physicians, there are two other factors that may have skewed the results.

As an enticement to return the questionnaires the physicians were given the chance to win $2000. Physicians with an entrepreneurial mentality - those who more likely favor privatization of health care - might be more favorably inclined to try for this reward. More altruistic physicians who really care about the problem of queues might be insulted by this attempt to buy responses with a prize.

A great many Canadian physicians strongly support their medicare program and oppose the current efforts to privatize both the delivery system and the health insurance system. These physicians are acutely aware of the agenda of the Fraser Institute and would be much less likely to cooperate in their biased studies.

Thus it is unlikely that the sampling truly represents the views of mainstream Canadian physicians.

Another important consideration is that this study was heavily weighted toward elective surgeries. Emergency conditions were not included. Patients in Canada have excellent access when a true emergency exists. So this study is not looking at acute, urgent conditions.

Instead, this study was looking more at patients with chronic conditions which are usually managed over a long period of time, sometimes for a lifetime. Yet the authors imply that the disorders for which they are treated began at a single point in time in the generalist's office.

In reality, when the physician and patient decide that it is time to consider more options for managing a chronic problem, often a decision is made to obtain a specialist's consultation. These are not emergencies so a routine appointment is scheduled. Except for a few specialties, most of these appointments are within a reasonable time interval.

Once the patient sees the specialist, more time is consumed for appropriate comprehensive evaluation of the problem before a decision is made on definitive management. Again, these time intervals are mostly reasonable.

Once the decision is made to schedule the elective surgery or other procedure, then excessive waiting times can be more objectionable. But how long are these waiting times?

The specialists were asked what a reasonable waiting time was for their given procedures, and how long their patients had to wait. With the exception of plastic surgery and orthopedics, most waiting times were very close to those that the specialists considered to be reasonable. (Internal medicine was also an outlier for endoscopy and non-urgent angiography.)

The Fraser report is very deceptive because they add to the time between scheduling a procedure and completing a procedure the time for the routine request by a generalist for a consultation, and the time for the specialist to complete the full evaluation before deciding on the specific management. If you separate these out, most of the intervals are quite reasonable. The 19 week wait reported by Fraser has little meaning, since it does not represent the time between scheduling a procedure and completing it.

The much more credible study from the Canadian Institute for Health Information confirms that Canada is doing quite well in delivering care within medically recommended wait times.

 "At least 8 out of 10 Canadian patients are receiving priority area procedures, such as hip replacements, cataract surgery and cancer radiation treatment, within medically recommended wait times, according to a new study from the Canadian Institute for Health Information (CIHI). The study provides the first comprehensive national picture of how long Canadians wait for care in priority areas as compared with evidence-based benchmarks of acceptable waits"

This does not mean that there are no problems. There is a very major problem, and it is political. Conservative politicians who currently control much of the government would like to privatize the health care system. Their approach is to abandon their role as stewards of the health care system, deliberately allowing longer queues to develop. Then the public is told that the only way to fix these outrageous delays that are killing people is to turn to the private health care markets in order to bypass the queues. As this view gains traction there is greater support for what amounts to a two-tiered system - the best of care for the relatively wealthy, and an under-funded public program for the masses.

Sound familiar? Only we're far ahead of them in fragmenting our system.

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