Don Dick is an Edmonton orthopaedic surgeon and Senior Medical Director of the Alberta Bone and Joint Health Strategic Clinical Network (BJHSCN); Dr. Linda Woodhouse holds the David Magee Endowed Chair in Musculoskeletal Clinical Research and is Scientific Director of the BJHSCN. They are both advisors with EvidenceNetwork.ca.
Canadians might have been inclined to take a sedative for an anxiety attack after reading about the Wait Time Alliance's (WTA) 2014 report card on waits for medical care in Canada. The WTA gives Canada a failing grade on the structural changes it says are needed to have the timely access to care seen in other countries.
But the report card is as notable for its omissions as it is for its findings.
Had the WTA looked more closely at developments in Alberta, for example, it would have found a province where efforts to improve access and other areas of quality are being led by the people with the most influence – the doctors, nurses, administrators and others on the front lines. It would have found a province where comprehensive data is being collected and analyzed to measure performance and target lagging areas. It would have seen that evidence-based benchmarks are being applied in crucial areas of service. It would have seen the integrated models of care that are being designed and implemented.
These are, in fact, some of the very measures the WTA calls for in its report card – already well established in Alberta.
Much of this progress has been concentrated in the area of orthopaedics, a fast growing area of concern as the population ages and lives longer. Hip and knee replacement, one of the five national areas of priority for reducing wait times, is a big part of this work.
In the orthopaedic wards of hospitals, teams have, since 2010, been using report cards to measure how they are doing in relation to benchmarks. They set targets for wait time, length of stay in hospital, pain reduction, getting patients on their feet after surgery, and many other indicators. When targets are reached, more ambitious ones are set. These teams are driving change in the most effective direction – from the bottom up.
Also across the province, data are being collected from hip and knee replacement surgeons and analyzed by the Alberta Bone and Joint Health Institute. Each surgeon gets a personalized, confidential report twice yearly on results in 17 key indicators. For example, they see their patients' wait times for consultation and surgery, their improvement in joint function, and how many had to be readmitted to hospital because of complications. These data, de-identified to protect patient privacy, are aggregated to produce a report for each of five health zones in Alberta.
Reducing length of stay in hospital for hip and knee patients has been a key part of Alberta's program to cut wait times. Patients who occupy beds longer than necessary block others who are waiting for surgery. Analysis of data showed that many patients were staying in hospital because they hadn't arranged for help with recovery at home. Renewed effort to ensure patients make the necessary support arrangements has seen hospital stay drop below the four day benchmark.
Centralized intake for hip and knee patients has, for several years, been standard practice across Alberta with the result that patients are being referred and managed much more efficiently.
These clinics routinely offer patients the option to move from the surgeons with the longest wait lists to those with the shortest.
Data on wait times – for consultation and for surgery – have become much more reliable in Alberta thanks to standardization and rules that have eliminated guesswork and confusion. Wait time data has become sophisticated enough that Alberta now can distinguish the additional wait caused by patient postponement of surgery from other factors. Early results indicate that patient postponements for personal reasons such as travel or work account for as much as 15 per cent of the "system" wait time the public sees.
Results of these measures are impressive. Since 2004, when the First Ministers set wait time reduction targets in hip and knee replacement and four other priority areas, Alberta has increased the number of hip and knee surgeries by 73 per cent with only a 5 per cent incease in the use of hospital beds. The program to reduce hospital stay saved 33,000 bed-days from 2010 to 2013 – a value of $33-million. The typical (median) wait has dropped to 15 weeks for consultation with a surgeon and 18 weeks for surgery in Alberta.
Similar work is starting in rheumatoid arthritis, knee injury and osteoporosis.
Alberta is building a culture of continuous improvement in health care. This culture is founded on more and better data, innovative thinking, an extraordinary effort to share information, and unprecedented action on the front lines. Wait time reports cards need to examine performance at this level, and Canadians should have this kind of information to grade their health system.