The Fixing Health Care series presents 10 common problems faced by patients in Canada, along with 10 solutions that the authors argue can be achieved within our existing publicly funded health system. While the ‘problem’ scenarios in the series are fictional, the authors offer these examples to echo the patient experiences they have encountered through their work in health care and social services.
The Problem: Wait times for surgery are too long and often result in worsening conditions that could have been otherwise avoided
Yan is a pretty healthy guy, but he has had pain in both arthritic knees for several years and has been waiting for knee replacements. He quit skiing with his family about five years ago, but he was still able to play ball and tag with his grandchildren until about 2½ years ago. Last year, his family doctor referred him to an orthopedic surgeon and Yan waited nine months for an appointment.
The surgeon told Yan that he would need replacements for both of his knees, and that the wait for surgery would be as long as a year. Due to the pandemic, he has now been waiting for 18 months and still does not have a date for surgery.
Yan can no longer walk and is using a wheelchair. He has become very depressed by his loss of independence and mobility, and this seems to be aging him even more quickly. His family is worried and can’t understand how service can be this slow.
The Fix: Canada can reduce its surgery backlog more quickly by opening dedicated community surgery centres
Too-long surgery wait times in Canada have been lengthened considerably by massive interruptions to surgical services during the COVID-19 pandemic.
In an October analysis of OHIP data, the Ontario Medical Association estimated it would take 14 months to clear the province’s heart-bypass surgery backlog, 19 months to clear a hip-replacement bottleneck, 25 months to attend to those waiting for cataract surgeries and 30 months to address Ontario’s knee-replacement waitlist. Of course, these numbers were released prior to the Omicron and BA.2 subvariant waves of COVID-19. Similar delays have also been reported in provinces across the country.
Canada has a clear need to increase its surgical capacity and reduce wait times for patients, especially in the short term. This will undoubtedly require more surgeons, nurses and anesthetists, which will in turn cost substantially more money if we address the backlog using our prepandemic approach of conducting surgeries exclusively at hospitals. Instead, the throughput of some operations could be increased by at least 30 per cent, for virtually the same cost, if we transferred appropriate surgeries from hospitals to dedicated community surgery centres.
Health insurance companies in the United States have encouraged the relocation of many surgeries away from hospitals and into specialized clinics (often referred to as ambulatory service centres), an approach that has been shown to reduce the cost of care by increasing throughput. American studies have found that operating times have been reduced by about 25 per cent in some ASCs, while costs to the public health system can be up to 50 per cent lower.
Some provinces have suggested that surgery centres should be developed by private organizations that would bill the government for services. In Ontario last year, the government put out a call for independent contractors to develop cataract surgery centres, for example, while the Alberta Surgical Initiative will rely heavily on private clinics to help clear the province’s COVID-19 surgery backlog.
We think this is the wrong approach. These organizations might select patients representing the easiest cases that are fastest (and cheapest) to manage, leaving more complex and expensive patients (who might benefit from a surgery centre’s services) to the public hospital system. Private centres may also encourage surgeons to undertake inappropriate surgeries (for example, arthroscopy for knee arthritis) that do not help the patient in the long run but are profitable for the operator.
We firmly believe that hospitals should manage and operate surgery centres to ensure that the right patients get the right operations in the appropriate location. High-quality care can be ensured in these centres by using the same comprehensive, quality-review processes our public hospitals have already established.
What’s more, we already have a highly successful example of a publicly operated Canadian surgery centre in British Columbia, a model that could be replicated across the country. Over the past few years, B.C.’s Jim Pattison Outpatient Care and Surgery Centre (JPOCSC) has demonstrated that shifting surgeries to community centres is safe and effective. An independent clinical study of the JPOCSC published in October last year found the facility to be proof that a “publicly funded outpatient surgery program can be successfully operated in Canada under full control of a provincial health authority.”
If you haven’t worked in a hospital, you might wonder why surgery times would be shorter in community surgery centres, and why the cost might be cheaper. The main reason is that hospitals are designed to accomplish a large variety of treatments and tasks, from emergency departments and maternity wards, to intensive care, medical imaging, lab testing and much more. Community surgery centres, however, are solely focused on the efficient and safe provision of procedures at a high volume.
These centres do not provide every type of surgical procedure. Instead, they concentrate on common operations – for example, joint replacements in otherwise healthy people, cataract lens operations, or certain laparoscopic procedures. This focus allows them to become more efficient and time effective (as well as safer) in the limited types of operations they are providing (but without selecting surgeries based on profit margin).
A community surgery centre is also physically designed for efficiency as well as patient satisfaction. Instead of moving between multiple departments in a hospital, upon entry a patient will move through the centre’s purpose-built, sequential stations for completing surgery, from donning a hospital gown to having a final, predischarge assessment. Anesthesia is often accomplished with “regional freezing” techniques (instead of general anesthesia, whereby the patient is rendered unconscious), which can shorten recovery time and hasten discharge. The surgery itself is often performed in a chair that can fold into an operating table, allowing for every stage of the process, including pre- and post-op care, to occur without moving the patient from one surface to another. These simple design features allow substantially more surgeries to be completed in a day.
COVID-19 has had an impact on commercial real estate as well. Many of the vacant spaces in office towers or malls across the country could be converted into publicly managed community surgery centres, without any capital expenditure by our hospitals on new buildings. These community centres would make care faster and less expensive, allowing us to clear the COVID surgery backlog and improve future patient experiences.
About the authors:
Dr. Robert Bell is professor emeritus in the Department of Surgery at the University of Toronto, former deputy minister of health for Ontario and former CEO of the University Health Network. Anne Golden is past president of the United Way of Greater Toronto and the Conference Board of Canada. Paul Alofs is former CEO of the Princess Margaret Cancer Foundation. Lionel Robins is past chair of the Princess Margaret Cancer Foundation, and a board member for the United Jewish Appeal Federation and the Betel Senior Centre.
More from the Fixing Health Care series:
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