Standing committee members, mesdames et messieurs, thank you for this opportunity to discuss monitoring, management, and reduction of wait times for cardiac procedures.
My name is Kevin Glasgow. I am chief executive officer of the Cardiac Care Network of Ontario.
By way of background, CCN is funded by the Ontario Ministry of Health. We operate North America's largest population-based cardiac registry and integrated wait list monitoring and management system. Our pioneering wait time registry work has been adapted by several other provinces, including the Saskatchewan surgical wait list system and the Quebec cardiac surgery registry. We are also an advisory body to the Ontario ministry on cardiac matters, and are well known in our field for expert consensus panel reports on cardiac issues.These are publicly available on our website.
CCN is a national and international leader in facilitating timely and equitable access to quality cardiac care. We do this on a province-wide basis for selected cardiac procedures--specifically cardiac surgery; coronary artery bypass graft and valve surgery; coronary angioplasty, or balloon stents to open up blockages in the arteries of the heart; and cardiac catheterization, also known as coronary angiogram, dye injected to take a look at the blockages of the arteries of the heart.
In conjunction with our 18 member hospitals—every hospital in Ontario that has a cardiac catheterization, or “cath”, lab—and our regionally based cardiac care coordinators, more than 85,000 patients a year benefit from the following from CCN: clinical urgency rankings, urgent, semi-urgent, and elective, based on standardized clinical criteria; maximum wait time guidelines; monitoring while on the wait list; and patient management, to ensure that the most urgent patients receive priority access to care.
We have achieved 100% participation in the provincial cardiac registry with cardiac surgeons, interventional cardiologists, and cathing cardiologists. Essentially, we have taken wait lists out of the desk drawers of doctors, consolidated them on a hospital basis, and then consolidated them on a pan-provincial basis. One of our key success factors has been the engagement of multidisciplinary stakeholders in CCN's committee structure, where clinicians are actively engaged--with nurses, hospital officials, and ministry officials--to continually improve the cardiac system. Accountability agreements are also signed between CCN and each of our member institutions.
In your information packages, I have included background literature on how CCN works and what our procedural monitoring shows over time. Additional materials have been left with the clerk for translation.
CCN has standardized wait time definitions between hospitals and between clinicians, thereby permitting apples-to-apples comparisons. In our recent data definition review process, our expert panel included representatives from the provinces of Nova Scotia, Quebec, and Alberta, in addition to representatives from the Canadian Cardiovascular Society. Thus, a significant step was taken toward achieving common data definitions to facilitate interprovincial comparisons. CCN also has close ties with the Winnipeg Regional Health Authority and the B.C. cardiac registries.
For over a decade, CCN has publicly reported wait times by cardiac hospital. We provide, on a monthly basis, very detailed reports that go back to clinicians, hospitals, and ministry officials. Through our collective efforts, and with the support of successive governments since 1990, cardiac procedure wait times have been substantially reduced and equity in access improved. But translation of wait time data into useful information and associated monitoring of wait times can only improve patient access so far. Active system management is required to achieve the next level of wait time reductions and the next level of improvement in equity to access.
I am pleased to report that a year ago, CCN was given an enhanced mandate from the Ontario Ministry of Health to further reduce regional variations in wait times through active system management. We are achieving success in altering referral patterns and reducing waiting list bottlenecks to increase the percentage of patients receiving their procedures within recommended maximum wait times. I wish to acknowledge the conceptual and financial support of the Ontario wait time and access to care strategy in this regard.
The key action items in CCN's 10-point plan for action in reducing regional disparities are included in your package, on these two sheets, in both official languages. Our detailed 10-point plan for action is available on our website at www.ccn.on.ca.
I also wish to thank both the provincial and federal governments for their financial support for improved information technology. By the end of 2006, CCN will have a modern web-based real-time information system that will much improve the timeliness of information availability for active system management.
Now I wish to highlight some of the positive trends that have occurred in Ontario over the past year in cardiac wait times. Please refer to the handout entitled, “10 Point Plan for Action in Reducing Regional Disparities to Care”.
The first slide in this handout, which is a very important slide, shows substantial improvements in the percentage of patients receiving their procedure within the recommended maximum wait time. For example, if we look at CABG, coronary artery bypass graph elective—and this is where the federal-provincial benchmark was set at six months—we've seen an improvement from fiscal year 2004-05, with 86% of patients in Ontario receiving the procedure within the recommended maximum wait time, to the fourth quarter of the 2005-06 fiscal year—so very recently—when it's up to 98%. Similar improvements are seen across other urgency categories for cardiac surgery and cardiac catheterization.
The remaining slides in this particular handout show marked reductions in wait time disparities between high and low wait time hospitals.
On slide 2, I'll draw your attention to the schematic for elective catheterization. In the colour version, the blue top line represents a high wait time hospital, and the pink line stands for a low wait time hospital. Over the past year, they've essentially converged, which means that the percentage of patients getting the procedure within the recommended maximum wait time has improved. It's less important where you live in the province of Ontario, in terms of where you're receiving your procedure within the recommended maximum wait time.
So why has Ontario succeeded in reducing cardiac wait times and improving equity? Success has been built on several things: first, monitoring and anticipating demand; second, investing in capacity; third, coordinating and facilitating access across the system, with specific addressing of wait-time hot spots; and fourth, ensuring that physicians, surgeons, administrators, and ministry officials participate in planning for the common good.
In my invitation to meet with the standing committee, I was asked to comment on ways of dealing with wait times to the satisfaction of patients, within an environment of limited human and financial resources. I will do so by making reference to listening to patients, assisting patients, increasing throughput, utilizing capacity, planning ahead, and linking utilization to quality outcomes.
First, one must listen to patients and the public. Last year, CCN surveyed more than 2,000 patients waiting at home for elective or semi-urgent procedures, plus providers and members of the public. Some highlights of our survey—the details of which will soon be posted to our website—were as follows:
First, wait time was not then a major consideration in most physicians' decision about where to refer patients.
Second, only a minority of patients and providers were discussing wait times and options of care.
Third, we posed a theoretical question to patients and said, if you had been provided with full information on your options, would you be prepared to travel a farther distance to get your care in a shorter period of time? Twenty percent of non-urgent patients said yes, they would consider this. It is important that patients be fully informed.
As a result of this survey and other data and information, and the liaison we've done, we're in the process of further improving access to care in Ontario. We have strengthened our partnership with the Heart and Stroke Foundation of Ontario to make sure that what we do is patient focused.
A second key point is that one must assist patients and the public. So our hospital-based regional cardiac care coordinators serve as patient navigators to navigate that confusing pathway. Wait time information is also available on our website, and in our package you have examples of patient information brochures, which are given to 85,000 patients a year in the province of Ontario.
Third, one must increase throughput. CCN is currently engaged in operational efficiency benchmarking and sharing of best practices across our 18 member institutions. We're also reaching out to community hospitals that refer into the specialty hospitals. The Ontario provincial wait time strategy has also initiated improvements to surgical throughput across therapeutic areas.
Fourth, one must utilize present capacity to benefit the maximum number of patients--hence CCN's 10-point plan for action, which essentially equates to better use of current health care resources.
Fifth, one must plan for the future. CCN engages in procedural volume target-setting, looking into the future, to assist the Ontario ministry in making decisions regarding future capacity investment. We are also currently engaged in scenario planning for cardiac surgery--the volume is essentially stable--given rapid changes in that field associated with the growth of angioplasty.
Sixth--and I'll reinforce Dr. Frank's comments--one must link wait time information, utilization, to outcomes and quality. CCN and the Institute of Clinical Evaluative Sciences have collaborated on cardiac surgery report cards for a number of years. They are publicly reported on our website, and reports compare patient results by hospital. By the end of this calendar year we'll be producing an angioplasty report card, which we believe will be a Canadian first.
This brings me to my final point. A truly patient-focused wait time reduction strategy needs to address both upstream and downstream waits, in addition to wait times once the patient has been accepted to specialists' procedure lists. This means addressing the wait time to see a family physician; the wait time from the family physician referral to the specialist; and then after one's procedure, the referral time for cardiac rehabilitation. It also means reducing the need for procedures in the first place--primary prevention, and the need for repeat procedures and re-entry into the acute care system--secondary and tertiary prevention.
The recent federal and provincial initiatives directed at reducing wait times are a great start. In Ontario, we have seen substantial reductions in wait times and improvements in equity in cardiac care. This momentum needs to be sustained and applied more broadly.
I thank you for your attention and look forward to addressing your questions.