Evidence of meeting #76 for Health in the 41st Parliament, 1st Session. (The original version is on Parliament’s site, as are the minutes.) The winning word was patients.
A recording is available from Parliament.
Conservative
The Chair Conservative Joy Smith
Pursuant to Standing Order 108(2), the study of technological innovation, which is one study that we have been doing.... It's been extremely interesting, one of the best studies that we've done.
As individuals we have Dr. Jason Sutherland, assistant professor, and Emad Guirguis, general and cosmetic surgeon.
Dr. Guirguis, do you mind beginning? You have your PowerPoint in front to of you. You have a 10-minute presentation, sir.
Thank you.
Dr. Emad Guirguis General and Cosmetic Surgeon, Lakeview Surgery Centre, As an Individual
Thank you very much.
It's indeed an honour to be invited to speak to this committee.
I've been in practice now for approximately 20 years. I graduated from McMaster University, where I attended medical school. I went on to the University of Ottawa, where I trained in general and cosmetic surgery. I practise in Barrie, Ontario, my hometown. The University of Ottawa and Ottawa bring back a lot of memories.
After 16 years of practice in a hospital setting, we came up with a concept that was literally out of the box. It was innovation in delivering health care in out-of-hospital surgery facilities—advanced health care, including general anesthetic procedures. As a model, while we do many procedures at Lakeview Surgery Centre, we are going to present the obesity management with the lap band program.
In summary, we're going to talk about creating an accredited surgery facility: how it's done, how accreditation licensing takes place, and why we focus on obesity. We will talk about our lap band program—what is a lap band? I brought a model, which we'll see during the presentation—and our own Lakeview Surgery Centre experience.
In building the centre approximately four years ago, we consulted with the City of Barrie building and zoning department. We worked very closely with them, in compliance with all their regulations. We bought a property, literally on the water, on Kempenfelt Drive. We created a separate front entrance, graded the driveway for full wheelchair access, and developed a new electrical transformer for some of our advanced equipment. We installed a generator for backup electricity, and then built a side entrance and exit for evacuation, in the event of an emergency.
We installed a commercial elevator that has high capacity, redesigned the flooring and ventilation using advanced technology with engineers and architects who specialize in health care facilities. We installed oxygen, suction, and medical air in the infrastructure of the building. So everything is actually built into the infrastructure of the building.
Literally, we have a fully accredited and licensed operating room with a view of Kempenfelt Bay and a four-bed recovery room, which also looks onto Kempenfelt Bay.
Keep in mind this is a fully accredited licensed facility. There's a private accreditation group called the CAAASF, the Canadian Association for Accreditation of Ambulatory Surgical Facilities. Plus, in the last two years the College of Physicians and Surgeons has recognized that this is an evolving field, doing out-of-hospital surgery, including advanced surgery. The College of Physicians and Surgeons inspects the facility, as well, to make sure it is in compliance. Essentially, we have created a hospital in an out-of-hospital facility.
As you can see, obesity is defined by the BMI, or body mass index. Normal weight is under 25 BMI. We focus on managing the severely obese and morbidly obese patients with a BMI of over 35. There are very interesting trends in obesity in Canada. In 1985, across the country, less than 10% of the population at that time was obese. Fast-forward to 2006, and now we have the majority of provinces with an over 20% obesity rate. The average Canadian overall obesity incidence is 23%. Not only is this astounding, the growth in our obesity population, but the associated chronic medical conditions that have a major impact on health care funding and expense are directly associated with the level of obesity.
For example, in regard to high blood pressure, there is about four times the likelihood patients will have high blood pressure, if they're in the obese category, and six times the likelihood they will have type 2 diabetes, sleep apnea—where they literally fall asleep during their sleep with heavy snoring, gallstone disease, or strokes. These are all associated with increasing obesity.
Furthermore, the mortality rate is on the rise. It is directly linked to obesity rates. In 1980 there was only about a 5% mortality rate associated with obesity; as we get into the 2000s, in 2005 it approached 10%.
The surgical options are twofold. There's the lap band and the gastric bypass.
Do diets work? This is a very typical study looking at diets.
When a person starts a diet, and it doesn't matter which diet it is.... When a person who is in the severely obese category starts a diet, they will lose some weight initially. But when you track those patients a year and five years after they have started a diet, no matter what diet it is, whether or not it's associated with counselling, the obesity rate is actually higher. So in fact, conventional diets exacerbate obesity, something we're not told by the diet industry.
I brought the lap band. The concept is.... We create two things. One, we create a small pouch for the stomach. The patient eats food, and after eating a small portion they feel satisfied, and they feel satisfied for a longer period of time. The patient doesn't get hungry between meals. Two, we're also compressing the vagus nerve, which is the nerve that gives us the feedback mechanism to fullness and satisfaction.
Essentially, there are two things. There's an anatomically small stomach, plus we're also compressing the vagus nerve for the feedback loop to feel satisfied with meals.
This is adjustable and reversible. This is what we call a port. This is all underneath the skin attached to the muscle. We can adjust the degree of compression around the stomach and the pouch. So much like our waist, as we lose weight the circumference of the waist goes down; it's the same with the stomach. We lose weight, and the circumference of the stomach goes down. So the patient comes in for what we call adjustments. We put in some salt water, which snugs up the lap band.
We are looking at what we call the green zone. This is what we're achieving with the lap band. We put in enough saline so that patients feel satisfied with small portions. They have good weight-loss control, and there are no abnormal or punitive symptoms, such as discomfort or acid reflux. There are patients in what we call the yellow zone. That's when there's not enough fluid in the band. Then there's the red zone, if the band is too tight.
We can adjust it, and we have control over the degree of satisfaction with meals.
All of what we call the co-morbid or associated conditions with obesity decrease substantially after the lap band surgery, including high blood pressure, diabetes, sleep apnea, and acid reflux. Furthermore, the death rate associated with obesity drops significantly after a patient has had a lap band. There is quite a major difference in the death rate between the two.
This has become very accepted in the medical field. There are several societies now. The Canadian clinical practice guidelines recommend bariatric surgery, lap band surgery, or gastric bypass surgery for patients who are obese with associated medical conditions. It's highly effective in achieving sustained weight loss in resolving co-morbidities.
At Lakeview Surgery Centre we have developed a team. I am the medical director. We have a nurse who is the director of weight management. We also have a certified dietician, a psychologist, and a personal trainer who work with our patients to ensure long-term success of this really chronic condition. It's now accepted that obesity is a chronic condition, untreatable by conventional means.
In terms of the first 59 patients we operated on with the lap band, you can see the starting weight at the top with the dark bar, and the end weight below. As you can see, some of our patients weighed over 400 pounds. All of the patients are losing weight successfully, and more importantly, are keeping the weight off. The average weight loss was 45 pounds, or approximately 20% of the patient's total body weight. The range in patients just starting the program is from three pounds to patients who have lost over 100 pounds, with a small number of complications.
This is just a case in point, in conclusion. A patient came to us in 2010. She was 57 years old. Her BMI was 46. She weighed 304 pounds. She had high blood pressure. She had acid reflux. She was on two medications for those conditions. We tracked all the patient's progress with a graph. After 21 months, she lost 101 pounds, or approximately 33% of her body weight. Her BMI dropped from 46 to 30, and she came off all her medications. This is what a typical patient looks like. It is a very rewarding field, to work with patients who are obese who finally achieve success after years of agonizing diets and yo-yo dieting.
In conclusion, out-of-hospital surgery facilities are innovative and safe in delivering health care to our communities. The lap band program, specifically as a model that we used here for this presentation, is safe and effective in combatting the obesity epidemic.
Thank you very much for your attention.
Conservative
The Chair Conservative Joy Smith
Thank you very much. That was very interesting.
Now we'll go to our second guest.
Dr. Jason Sutherland, please.
Dr. Jason Sutherland Assistant Professor, Centre of Health Services and Policy Research, University of British Columbia, As an Individual
Thank you.
I'd like to take the first couple of minutes to introduce myself. I'm a faculty member at the Centre for Health Services and Policy Research at the University of British Columbia in Vancouver, where my specialty lies in evaluating the organization, delivery, and funding of health care systems. I'm a Scholar of the Michael Smith Foundation for Health Research and I'm also Canada's Harkness Fellow in health policy.
I'm currently studying the health reforms that President Obama has enacted in the United States in Medicare. I'm working in Washington, D.C., as a foreign scholar for the next 10 months.
I welcome your questions in both English and French.
The international results are in. Canada again ranks last in the ranking of the top 11 industrialized countries in terms of access to many kinds of hospital-based care and specialized care, with substantial waits for hospital care and to see a specialist. I think the persistence of these trends is demonstrating that we are clearly performing very poorly on some aspects of the health care delivery system.
Recent data also shows that Canadian governments are spending over $60 billion a year on health care in the provinces, with another $30 billion each on drugs and physician care, based on 2012 statistics provided by the Canadian Institute for Health Information. Where does this put us internationally? We're definitely in the top percentile for spending per capita among nations. This draws a really harsh light on the paradox between our very poor access to specialized care and our very high expenditures.
Given these findings and the persistence of these findings, we should be paying much more attention to how we spend these massive amounts on health care. The way we pay for our health care provides incentives for providers of health care to act in certain ways and engage in certain behaviours. For example, global budgets, which are the way that we fund most health care providers, reward cost minimization and rationing of health care.
What are the results of the behaviours that we're currently paying for? There are many examples of inefficiencies, ineffective care, and unsafe practices in health care. Two significant ones certainly spring first to mind.
First, from time of referral, the time to see a specialist often exceeds more than 12 months. In other words, from the referral from your general practitioner to a surgical consultation, the median time exceeds a year. That's a long time if you're in agony, or your quality of life is suffering, or you're debilitated.
Second, this is very shocking but is not news to many of you who work in the health care industry: every single day there are thousands of patients who are in hospital beds and are ready to be discharged safely, but there's no place for them to go. They even have a name for them: “alternative level of care”. It's a very prevalent problem in our Canadian hospitals. This use of hospital beds is inefficient and unsafe for patients and has detrimental effects on the hospital staff who care for them. It's also associated with the clogging of our emergency departments, something I've written about extensively.
We should, I believe, expect more from our health care system and strive for a high-performing health care system on cost efficiency, access, higher quality, and safe care. In my forthcoming report on the use of funding methods to change the delivery of care, I advocate using policies that have been proven effective in other countries in improving access, especially to surgical care. I also advocate that we curtail policies that ration resources and restrict access to care and lengthen wait-lists.
To do so, we should create incentives for the health care system as to what we think we want from it. For example, if our policy imperative is to improve access, then we should use a funding mechanism that rewards access to hospital-based care. This is known as activity-based funding and is the predominant form for funding hospitals across the industrialized world. There are also many strategies that other countries have developed for mitigating the risks of rising expenditures from these kinds of methods.
Similarly, we can develop, design, and implement incentives for community care providers to pull waiting patients from the hospitals when it is safe to do so; I refer back to my comment that every day in hospitals there are thousands of patients who are waiting to go home. By doing so, we'll improve our access to hospital-based care for those thousands of patients waiting for their elective surgeries and hopefully improve the clogging of our emergency departments.
Now I want to highlight the two provinces that are trying to figure out how to use these innovations to try to achieve their policy aims of improving access.
First off, British Columbia is starting implementation and experimentation with activity-based funding for elective procedures, as a small proportion of overall hospital funding, to increase the volume of elective surgery and improve access and decrease wait-lists. An evaluation is ongoing of the effectiveness of these policies, but they're widely implemented in many other countries.
On the other hand, Ontario is using a new policy initiative for certain chronic conditions, tying funding to best practices of care. That is, they are funding, they are creating incentives, to reward providers to provide the evidence-based care that patients with those conditions have. This is known as QBP, for quality-based procedures.
A third example originates in the United States. I'm currently studying it. It employs innovative strategies for addressing the seams between the silos in the delivery systems. That might be between post-acute-care providers or between the hospital and home. Known as bundled payments, the incentives are based on reducing avoidable or unnecessary care. Research has demonstrated its feasibility in some Canadian provinces already.
So what's missing from these policies in order to execute innovations to address the limitations in our current health care system? Well, much work needs to be done. Our national health information agency has to adapt and provide the plumbing for these innovations to be successful. I think this is an achievable goal in the short term.
In the medium term, I believe one agency should also specialize in identifying innovative and successful health delivery strategies that work in regions or in provinces and in disseminating that information elsewhere. Currently there's not a clearing house for good ideas, and I think that would be a useful role to be played in the medium term.
In the long term, I believe there's a very prominent role to be played by collecting patient-reported outcomes and patient-reported experience measures so that we can tie patients' experiences and their outcomes with how to direct care and resources to those who need it the most, and waiting patients.
With that, I conclude. I'd like to thank the committee for the opportunity to present my views on the state of innovation in the health care system in Canada.
Conservative
The Chair Conservative Joy Smith
Thank you very much, Dr. Sutherland. Some of your ideas are very insightful, and we look forward to hearing more.
We'll now go into our seven-minute Qs and As, when we will give the committee members a chance to ask you those questions.
We'll begin with Ms. Davies.
NDP
Libby Davies NDP Vancouver East, BC
Thank you very much, Chairperson.
Thank you to both of our witnesses for being here today.
At the beginning of your remarks, Dr. Guirguis, I think you said that your facility is “a hospital in an out-of-hospital facility”. That sounds like a bit of an oxymoron, but I think we understood what you meant.
I wonder if you could tell us about the Lakeview Surgery Centre. Is it a private facility?
General and Cosmetic Surgeon, Lakeview Surgery Centre, As an Individual
Yes, it is.
NDP
Libby Davies NDP Vancouver East, BC
For your patients who go there, how are they covered? You're in Ontario, right? Are they covered through OHIP, the insurance plan in Ontario? How does that work?
General and Cosmetic Surgeon, Lakeview Surgery Centre, As an Individual
That's actually an excellent question.
Lakeview is funded completely outside the taxpayer's purse. We funded the centre ourselves. We did not ask the provincial or federal government for any funding for the centre.
In terms of the procedures that are performed there, we are total advocates for the Canada Health Act. We believe the population has access to insurable services and everyone should have equal access. So right off the bat we're proponents of the Canada Health Act.
That said, we have performed both OHIP-covered procedures, or public-covered procedures, and private procedures. If a service is insured by the provincial government, then we do not charge any extra for that procedure—for example, inguinal hernia repair, thyroid surgery, breast cancer surgery—whereas if it's not covered by the government purses, if you will, then the patients or third-party insurers would fund that procedure.
NDP
Libby Davies NDP Vancouver East, BC
But there's no sort of extra-billing for any procedure that is covered under OHIP, like—
General and Cosmetic Surgeon, Lakeview Surgery Centre, As an Individual
No, we're totally respectful of—
General and Cosmetic Surgeon, Lakeview Surgery Centre, As an Individual
NDP
Libby Davies NDP Vancouver East, BC
It would be as if you went to any other publicly funded facility?
General and Cosmetic Surgeon, Lakeview Surgery Centre, As an Individual
Exactly. Of course, the challenge from an operational point of view is that if a procedure is covered by the provincial government, such as a hernia, for example, we can only bill the province for the procedural fee alone, so that the owners ourselves would have to absorb all the other costs: the nursing costs, the anesthesia costs, and the facility costs. It becomes very difficult to perform publicly funded procedures in an out-of-hospital facility.
However, the provinces.... For example, Ontario has said that it would like to see more procedures that are publicly funded procedures funded in out-of-hospital facilities. We really believe strongly that this is the way of the future. You extract out procedures that can be done safely as outpatient procedures and have them funded properly in an out-of-hospital facility.
NDP
Libby Davies NDP Vancouver East, BC
Okay. I wish we could have more time to go into this, because I do feel that it's a bit of a murky area in terms of what we consider to be a private facility and what kinds of fees are charged, but anyway, I did want to ask you that basic question.
I'd like to turn to Dr. Sutherland.
I think what you're putting forward is quite fascinating. There's a question that just jumps out at me. We know that health care is provincially delivered, but of course there is major federal funding. In your opinion, are there any mechanisms at the federal level or any incentives? Is there anything that exists that actually would be taking us in the direction of activity-based care or some of the other models? It seems like such a hodgepodge, right? It's happening in B.C. and it's happening in Ontario, and I think our research notes say it's also in Alberta.
Why isn't it happening across the country and what is the gap federally? If you could really identify that, that's what we need to focus on to figure out what we should be saying to the federal government to ensure that these good models for funding, which in the long run will be better for the system, are actually being activated.
Assistant Professor, Centre of Health Services and Policy Research, University of British Columbia, As an Individual
Those are very complex issues you're raising there in a very long question. I'll try to knock them off as I can. First off—
Conservative
Assistant Professor, Centre of Health Services and Policy Research, University of British Columbia, As an Individual
First off, specifically with regard to activity-based funding, I think the promise of that mechanism is certainly aimed at improving access to surgically based care. There are limitations to it that are associated with the often increasing physician- and hospital-based costs with regard to an increasing volume of care. If you're willing to go with a policy imperative of improving access, this proves to be an effective mechanism for doing that. Given that many countries have tried this, it's well known what the side effects are and how to guard against those side effects.
However, I would point back to the federal wait-times strategy as one effective mechanism that actually opened the door for activity-based funding at different levels in Canada. Many provinces use that as a contracting mechanism to bulk-purchase additional surgical care from their hospitals or from their health authority's or health region's hospitals. I think that was very effective in improving access for elective care, and I think it's certainly one mechanism that could be logically extended into many other conditions beyond the Cinderella services.
NDP
Libby Davies NDP Vancouver East, BC
Are you talking to the five areas that were identified? They were knee surgery or hip surgery.... Is that what you're referring to?
Assistant Professor, Centre of Health Services and Policy Research, University of British Columbia, As an Individual
Yes, and cataracts and cancer. There's a number of the five that I would deem to be almost Cinderella services that have benefited from the additional contracting on that. It is a mechanism that can be expanded essentially to all elective surgeries quite readily.
NDP
Libby Davies NDP Vancouver East, BC
Is there anything else that we should be considering for the federal government to do in terms of advocating for more of a national perspective on these different types of funding models? Is it targeting funds to particular outcomes and saying that if you want this extra money you have to show that your outcome is whatever you base it on?
Assistant Professor, Centre of Health Services and Policy Research, University of British Columbia, As an Individual
Well, I think the federal wait-times strategy was a very innovative method for trying to get this contracting with activity-based funding down, because now the provinces are very familiar with the mechanism. At the same time, it opens the door for perceived inequities between different kinds of surgeries if you're not in the Cinderella services of the five conditions. For example, hernia repairs may get pushed out for additional hips and knees, because the marginal revenue goes to those patients.
Conservative