The orthopaedic waiting game
By Alan Cassels, September 2015
Vancouver Island’s aging baby boomers, coupled with stretched budgets and operating rooms, have created a perfect storm for timely access to needed joint surgery.
Sixty-eight year old Nancy Tienhaara, who works in marketing for a Victoria software company, felt she needed a new knee but couldn’t get it. The pain, she recalls, was unbearable and X-rays showed there was very little cartilage in her knees. Walking was difficult and painful. After seven weeks of waiting, she finally got in to see an orthopaedic surgeon. But she didn’t hear what she wanted to hear: She wasn’t a good candidate for surgery—her pain and immobility were not yet severe enough.
Disgusted with the system and driven by pain and desperation, she did what some Canadians do when they’re forced to play the waiting game—she left the country. Tienhaara travelled to Phoenix, Arizona and shelled out $22,000 US for knee replacement surgery. While that isn’t an option for most of us, Tienhaara felt compelled to find the money: “If I had not done so, I would be in a wheelchair today.”
Vancouver Island residents waiting for a new hip or knee, in pain and misery, tell stories that are compelling, even heart-wrenching. When I called him at his home at the end of July, Rob Brown, a retired actuary in Colwood, had just returned home from the hospital the day before with a new hip. His year of immobility waiting for a hip replacement was like “being placed under house arrest,” he told me.
Ask anyone who has had to wait for a joint replacement and you will hear the same urgent advice: “Get on that list as fast as possible.” The message couldn’t be clearer: Since you could be waiting in agony for a very, very long time, you’d be a fool not to act quickly. But how reliable is that advice? And does acting fast guarantee earlier treatment? Outside of emergency procedures, if you think you need a new knee or a new hip, how is your level of pain and immobility prioritised among other patients who are waiting?
These questions are not trivial. In fact, they lie at the heart of the sustainability of our health care system because how we manage waitlists for joint surgery is an issue—due to demand and the costs involved—that has the power to make or break Canada’s public healthcare system as we know it.
Canada spends almost a billion dollars a year for hip and knee surgery, and waitlists for those surgeries are among the hottest and most political aspects of Canada’s healthcare system.
In BC, over half a million publicly-funded surgical procedures are performed every year, of which almost 80 percent are day procedures. Hip and knee replacements currently require a stay in a hospital for about three days. Another statistic to note is that more than half of all surgeries done every year in BC are emergency or unscheduled procedures and therefore do not appear on any surgery wait time list which juggles the line-up for new hips and knees.
In Canada, a federal benchmark for “the maximum amount of time that clinical evidence shows is appropriate to wait for a particular procedure” is set at 26 weeks for both hip and knee replacement. Problem is, you’d be hard pressed to find anywhere in the country that comes close to the benchmarks. Some jurisdictions, including Victoria, miss the benchmarks by miles.
Norm Peters is executive director of surgical services and heart health at Island Health. He oversees surgery for the two main hospitals in Victoria and the Nanaimo Regional General Hospital. He is responsible for quality and strategic planning for the other five community hospitals across the island.
Peters openly admits that people in Victoria face one of the longest waiting games in the province. Even though Island Health has introduced a number of measures to address waitlists for hips and knees—aiming to perform 500 to 550 more of those surgeries this year—he doesn’t mince words about our waiting list: “We have the unfortunate distinction of being the worst performing in BC.”
If you live in Victoria and your orthopaedic surgeon suggests you are a candidate for a new joint, you might get your surgery in a year, as Rob Brown did. Or it might take longer.
The waiting game
Wait times have been studied extensively. Despite the endless analyses, along with programs created to reduce those waitlists, and money poured in to relieve the problem, the lists keep growing. Demographics play a big role (more later). But there are also more mundane communication issues at the bottom of the quagmire. Often physicians and specialists operate in silos, impervious to what their next-door neighbour is doing. Patients are motivated and moved by anecdotes, and believe surgery is vital, and always the solution. None of us have any idea whether the excruciating stories we hear about patients waiting reflect a general reality or are just egregious outliers.
The criteria for being on a list are determined by an assessment from an orthopaedic surgeon who will scrutinize X-rays, and will assess your state of pain and mobility. Is the pain keeping you awake at night? Do you need heavy-duty meds to keep pain under control? How well can you get around? What is your overall health like? Some patients, like Nancy Tienhaara, will be told they’re not yet candidates. Others might be deemed at such risk of becoming disabled they would be placed in a higher priority. As to how long each person will wait, as they say, “it all depends.”
Everyone likes to talk about “the list” and, in fact, whole conversations can happen without people realizing there are several types of lists.
Going from pain in your hip to being fully recovered from a replacement hip after a two-hour operation and a three-day hospital stay involves at least four waits. Wait One is the time from when your doctor refers you to the specialist until you are sitting in front of the orthopaedic surgeon. Wait Two is the time from when the specialist agrees you need surgery and books it—known as the decision date—to the date you actually get it. The other types of waits are the access to diagnostics, maybe an X-ray or other diagnostic test, and then the wait for recovery. The waits of most concern to patients are the first two and they happen to be the ones where there is the best reporting.
According to Neeta Das McMurty, a member of Canada’s Evidence Network who compiled a consumer backgrounder on surgical wait times, the numbers often don’t reflect reality. For example, sometimes there are patients who are put on multiple waiting lists. She writes, “One study found that up to one-third of patients should have been removed from the list because the patient has already had the procedure done elsewhere, was already admitted into hospital as an emergency case, no longer wants the procedure, or it is not medically necessary.” Sometimes the patient dies while on the list (from other causes) or has asked to reschedule their surgery for a more convenient time. Others might argue, saying there should be more patients on the list and that people are being cruelly turned away from getting on the first rung.
Clearly, managing a waitlist demands heavy-duty coordination. Norm Peters points me in the direction of the BC Surgical Wait Times website (https://swt.hlth.gov.bc.ca) where you can go online, choose a surgical procedure, and look at the types of waits you might expect. For example, as of July 31, 2015, there were 956 people on Vancouver Island (out of 3302 in all of BC) waiting for a new hip. Of these, 468 people were waiting to be treated at Greater Victoria hospitals. Of the 11 doctors listed for Victoria, two had less than 5 patients waiting and one had 149 patients waiting. Each doctor has a different number of patients waiting for a number of reasons. In this system patients can choose which doctor they’d like to see, some only work part-time, and so on.
The two key metrics represented are “50 percent received services within X weeks” and “90 percent received services within X weeks.” You will find that according to these data, half the people on the BC waitlist (in the previous three months) got their hip replaced within 19 weeks after their “decision date” and 90 percent of them got it within 52 weeks. This compares to 34 weeks and 59 weeks respectively for Vancouver Island, about the same as it is for Greater Victoria Hospitals.
There still might be a lot of grumbling about how long one has to wait, but the advantage here, at least for BC, is that these statistics are fully transparent for anyone to see. Compared to other jurisdictions, this is huge progress.
A local attempt at triage
If you live in Victoria, you’ll be, like Nancy Tienhaara and Rob Brown, sent to Rebalance, (www.rebalancemd.com) which is basically a one-stop shop. Physiotherapist Stefan Fletcher and orthopaedic surgeon Patrick McAllister started Rebalance four years ago, eager to do something about the chaotic nature of Victoria’s current wait system: impenetrable lists, overworked physicians, and underserved patients.
Fletcher is the CEO of Rebalance, and he has an air of calm about him, dressed in a polo shirt and shorts when he greets me in his spanking new 11,000-square-foot facility in the Uptown Centre. Though Rebalance is a private company, there’s something unique about it beyond the chic glass and steel décor and video monitors adorning the walls. This doesn’t look like any public health facility you’ve ever seen in Canada, but it is public in one important way: The services offered here are covered by our Medical Services Plan. Generally you don’t need anything but your Care Card and a doctor’s referral to get service here. It feels ultra-modern and efficient, an ambience very different from the one-doctor, one-office silos we’re used to. This place reflects the group’s team approach where doctors, nurses, physiotherapists, and patient navigators are all in the same place, working towards the same goal: streamlining the journey.
Fletcher comes out to greet me at reception, then steers me into his office to discuss the issue of wait times. We get down to business. The tour, he promises, comes later.
He says that prior to Rebalance there was a “huge amount of ignorance around waitlists…[with] no knowledge, no markers, no transparency, and no tracking.” The creation of his company, he says, was “driven by physicians,” essentially Victoria’s orthopaedic surgeons who wanted a more rational, patient-centred model to help people waiting interminably (and sometimes needlessly) just for a firm answer to the first question: “Do I need surgery or not?”
“It used to be nine months to two years to even see an orthopaedic surgeon,” he tells me, “and now it’s four to six weeks. Our goal,” he says, “is to get the right person to the right place at the right time.”
Is this triage, I ask?
“Absolutely. It’s 100 percent triage,” he says. The acronym they use is FAAST which stands for “first available appropriate specialist treatment.” The emphasis there is on “appropriate.” “Basically, this is the whole conservative journey,” he continues. “Get them in early. If you can, try A, B, C, D, and E. And if those fail, come back and see us.”
Those other things are mainly exercise, weight loss, and pain-relieving drugs. Maintaining flexibility and strengthening the muscles that support the joints are both considered important. The percentage of people who consult an orthopaedic surgeon who go on to have surgery—Fletcher calls this the “hit rate”—is only about 30 percent. The other 70 percent might need help—perhaps from physiotherapy or other forms of preparation including proper diagnostics such as X-rays—but they aren’t yet candidates for surgery. Fletcher says that at least half the patients who come and see his clinic “have other things they need to happen” before they have surgery and this includes weight loss and consultations with other specialists to correct other health problems.
Patients who have manageable joint pain should obviously try to avoid or delay surgery as long as possible. Recovery from surgery can take a long time and the procedure itself can involve complications. Plus there is no real guarantee how long a new joint will last. Some say you might get 10-15 years out of a new hip but then that may mean “revision surgery” down the road, which is much more complex.
Rebalance has a contract with Island Health for physiotherapy, Fletcher says, “to optimize patients pre op and to deliver post op physio after joint replacement surgery.” Rebalance’s nurses and navigators coordinate information, manage the intake, and arrange education—stuff that allows the surgeon to focus on what they do best. According to Fletcher, the satisfaction of both the patients and the physicians is “through the roof.”
He explains that patient satisfaction levels are a lot higher because people don’t have to wait as long (Wait Time One) to actually get their health complaint seen. And those who do need surgery more urgently can get in there quicker, too.
Fletcher uses his hands to explain “unravelling the nut of wait times.” He says: “What we have is this great big funnel coming in, and so the accessibility to the system is greater. We have squeezed the Wait One,” he tells me, moving his hands closer together, “yet Wait Time Two,” he says, spreading his hands far apart, “well, it’s a lot bigger.” When Rebalance got going four years ago there were about 1200 people on the Wait Two list for knee and hip surgeries; now it’s about 3000. Fletcher believes it’s because more people are being seen by surgeons. This means, he points out, that "those patients not needing surgery are also being addressed where before they were not being seen as easily.”
With the Wait Two list so long, however, it means a lot of people like Rob Brown waiting for up to a year for a new hip. How does this compare to other places, I wonder? Fletcher calls the triage systems in other places “a pile of faxes,” explaining, “The surgeon comes in and says, give me the 10 on the bottom.” At Rebalance, the triage is continuous, and if your situation changes, so too can your place in line. Despite the Province maintaining the waitlist website, access to a surgeon is still a considerable barrier in other communities, Fletcher tells me: “In Kelowna it’s nine months just to get an appointment. It’s a mess. Vancouver it’s two years—unless you want to pay privately. We are 100 percent in the public system.”
Bottlenecks and other realities
So Canadians are still waiting, and on Vancouver Island, they may wait more than a year after a surgeon has made a decision that surgery is the best option for them.
According to a study on wait times by the Organization for Economic Co-operation and Development (OECD), there are typically three key strategies to reduce waiting times: More money, enforced wait times, and better triaging.
In 2003 a federal agreement in Canada committed $5.5 billion over 10 years to the Wait Time Reduction Fund to reduce wait times for cataract removal, hip and knee replacements, diagnostic imaging, cardiac bypass surgery and cancer radiation therapy. In 2011, the Canadian Institute for Health Information (CIHI) showed that there were reported improvements for three years, as the money helped clear the backlogs, but there is insufficient data to determine if the improvements were sustained.
Wait time guarantees set a maximum wait time for certain procedures, putting pressure on system managers and physicians to provide care within a target time frame. These are helpful, but not a long-term solution.
The most hopeful strategy is what the OECD called “clinical prioritisation tools”—which is about managing and triaging patients based on need. These tools have been shown to be the best and most sustainable of the approaches.
A study published eight years ago by the Canadian Centre for Policy Alternatives analyzed waitlist reduction projects across Canada and found that better management of waitlists requires two major things: Firstly, physicians needed to go from working on their own to working in teams and, secondly, the accountability for waitlist management had to be transferred from individual surgeons to health authorities working with groups of surgeons and other health professionals. These principles essentially underpin what Rebalance has done in Victoria.
A strategy document prepared by the BC Ministry of Health, “Setting Priorities for the BC Health System,” admits how difficult it is to make progress. “Despite the attention paid to surgical waitlists and increases in volumes of elective surgeries, BC’s wait times for many procedures have not declined and performance is either stagnant or slipping. For example, the average wait time for the top 20 surgical procedures declined slightly from 2009 to 2010, but has remained mostly the same since then.”
For everywhere in Canada, how long you wait depends on many factors: your medical status (your pain levels, your mobility, whether you’ve got other health conditions, etc), which specialist you get referred to, how busy he or she is, and whether that specialist has good access to operating rooms. The overall drivers of demand, however, are largely determined by demographics.
On that front, Norm Peters calls it the perfect storm. “We [on Vancouver Island] have two of the three oldest communities in BC. We have a healthy and active population so people wear out their knees.” But it’s not just older, active people wearing out their joints. Peters blames growing levels of obesity as well for an increase in the demand for hips and knees. The Canadian Community Health Survey shows the numbers of obese people in Canada rose more than 25 percent between 2000 and 2011.
So demand is definitely on the rise.
Looking at the “supply side,” we can’t blame lengthy waitlists on a lack of orthopaedic specialists. I think my jaw might have dropped when Rebalance’s Fletcher told me there were more than 130 unemployed orthopaedic surgeons in Canada.
According to Peters, the major bottleneck is access to operating rooms. Fletcher described the practical dimensions of that bottleneck, noting the demand for anaesthetists, staff, nurses, and hospital time. He produced a graph that showed big drops in the number of procedures done in July and August when many people are on vacation, and November and December because of Christmas. Getting surgery depends on many people, not just surgeons, and it’s hard to get them to operate on you when they’re lying on a beach or eating turkey.
But beyond people, it’s money. Obviously buying more dedicated hospital time at these off-peak periods could help reduce Wait Time Two; everyone agrees that to get that down, the Province needs to put more money into the back end.
Still, Fletcher was optimistic about the future. In April, Island Health issued a Request for Proposal (RFP) for a “surgical services partner to carry out between 3000 and 4000 day procedures per year over a five-year contract term.” These will certainly reduce the pressure on waitlists by taking some other surgeries out of public operating rooms, and perhaps help reduce the backlog for joint surgery, but more innovations are needed. Fletcher saw other possibilities, too: a dedicated joint unit, where hips and knees could be done either in a hospital or a day care clinic in less than the required three-day stay. That seems sensible to me. The right patients, with the right home supports in place, may not need a full three-day stay after their surgery.
“We could profoundly influence the wait times in the public system for surgery,” Fletcher suggested. “If we can crack that nut, and continue to keep our eye on the ball at the front—entry level system—then we have cracked the nut of orthopaedics in Canada.”
I wondered about patients like Nancy Tienhaara who don’t think they can wait. She feels there are serious downsides to waiting, and a report from the Alberta Bone and Joint Institute backs her up. The report says that patients waiting longer than three months have more pain and less mobility, and there is often pain in the opposite joint for patients who wait longer than six months. It established 14 weeks as the Wait Two target.
Tienhaara notes, “Intolerable pain is the criterion provided by many doctors for agreeing to surgery for a patient. Because I did not have constant high levels of pain, I was rejected at Rebalance.”
Because pain is subjective, and experienced by everyone differently, perhaps this is why triaging patients is particularly difficult. Fletcher admitted he often has to deal with people complaining of not getting treatment soon enough, or at all. I told him the story of Nancy Tienhaara and he was sympathetic. “We deal with that all the time,” he said.
One patient pleaded with him, in tears, saying she would lose her job if she didn’t get to see an orthopaedic surgeon. He is as responsive as he can be. After all, any system has to make allowances for urgent special cases. He found a slot and put her in in two days.
It’s not as subjective as it seems though. Obviously there is a human element in managing waitlists. Clearly these are very difficult issues, but I get the feeling that at least here in Victoria, there is a sense of progress and hope. We don’t want a society that leaves people suffering and in pain when surgery could fix it. We want a system that is responsive enough so that they don’t have to travel to Arizona for a new joint. At the same time, we want a sustainable healthcare system where the most urgent care is going to those with the most urgent need. Better management of the lists is the first step. More money to deal with the mounting lists is clearly the second step. But beyond this we citizens have to remember that there are many other kinds of high-value, life-saving treatments such as those for cancer and heart disease that we still need to fund.
There’s a limit on the supply of money in the healthcare system, but there shouldn’t be a limit on how we innovate while keeping that system public and accessible for those in need.
Alan Cassels is a health policy researcher affiliated with the Faculty of Human and Social Development at the University of Victoria, and the author of Seeking Sickness: Medical Screening and the Misguided Hunt for Disease (Greystone, 2012), and the 2005 book Selling Sickness.