Hospital Waiting Lists Increased in 1996

Contact:

Martin Zelder, Director, Health Policy Research
The Fraser Institute, (604) 714-4548 Email: martinz@fraserinstitute.ca

Release Date: 28 July 1997

VANCOUVER, BC>>>  The Fraser Institute released today the updated edition of “Waiting Your Turn” (7th ed.), which presents the only comprehensive measures of hospital waiting lists across Canada.

The measurements of waiting times for medical care are a result of information provided by 2,694 specialists nation-wide in a survey undertaken during the latter part of 1996. The survey represents an effort to measure the extent of health care rationing in the different provinces from year to year.

The results published by the independent research organization show that more Canadians were waiting to receive medical treatment in 1996 than in 1995. According to the study, 172,766 Canadians were waiting for surgical procedures(table 1), an increase from 1995's (updated) estimate of 155,969. According to Cynthia Ramsay, co-author of the report, “There were over 16,700 more Canadians waiting for treatment in 1996 than there were in 1995. As well, those waiting were waiting longer—10.9 weeks from referral to a specialist by a general practitioner (GP) to the receipt of treatment—compared to 10 weeks in 1995.”

GP to Specialist

The waiting times for appointments to see specialists are shown in chart 1 and table 2. Manitoba had the shortest wait in the country for appointments with specialists, while Prince Edward Island had the longest. “In almost every province, the waiting time to see a specialist has increased since 1995. For Canada, the waiting time to see a specialist increased by over 9 percent from 1995 to 1996. This means that increasingly care is being rationed at the GP level. If a person cannot get an appointment with a specialist, they won't appear on the waiting list for medical treatment because only a specialist can put a patient on the waiting list for surgery,” explains Dr. Michael Walker, Executive Director of the Fraser Institute.

Specialist to Treatment

Once patients have seen a specialist, they then have to wait to receive medical treatment. Ms. Ramsay points out: “The number of people on surgical waiting lists and the amount of time they are waiting for treatment varies substantially from province to province. There is not equal access to health care across Canada.” In British Columbia, the province with the longest median waiting times, patients waited more than 9 weeks (chart 2 and table 3) for surgical procedures, a month longer than people in Quebec, the province with the shortest waiting times, where the median wait for treatment was 5.1 weeks. For Canada, the wait for treatment after having seen a specialist increased from 5.7 weeks in 1995 to 6.2 weeks in 1996.

Total Wait from GP to Treatment

In Canada, patients wait more than two months for relief of their ailments after seeing their GP—from 9.6 weeks in Quebec to 19.7 weeks in Prince Edward Island (chart 3 and table 4). As chart 4 shows, the longest waits for treatment tended to be for three specialties where the total wait a patient could expect to face exceeded 4 months: orthopaedic surgery (20.5 weeks), elective cardiovascular surgery (19.7 weeks), and ophthalmology (17.4 weeks). The shortest wait was for cancer patients being treated with chemotherapy. These patients waited on average 3.2 weeks to receive treatment.

Clinically Reasonable Waits from Specialist to Treatment

The survey also measured what specialists consider to be clinically reasonable amounts of time to wait for surgical procedures (table 5). In most cases, responding specialists thought patients were waiting too long for treatment. For example, the median actual wait for ophthalmology in Manitoba was 27.6 weeks. A clinically reasonable amount of time to wait, according to Manitoba specialists, was about 4.8 weeks. In PEI, the actual time to wait for an orthopaedic procedure was about 29.3 weeks, whereas PEI specialists felt that a wait of about 6.5 weeks was clinically reasonable. “This comparison of actual waits with clinically acceptable waits shows that many specialist physicians believe that their patients are having to wait longer for care than is healthy,” said Dr. Walker.

Chart 5 compares the weighted actual median waiting times to the weighted clinically reasonable waiting times for the different specialties in Canada. For orthopaedic surgery, the actual waiting time was 5.1 weeks longer than what was considered to be reasonable by specialists. For elective cardiovascular surgery, the median actual waiting time was 7.8 weeks shorter than the clinically reasonable waiting time.

The Wait for Diagnostic Testing

In addition to waiting to see a specialist and waiting to receive treatment, patients must wait to receive diagnostic testing (table 6). Across Canada, patients experienced an increase in the waiting times for various tests: computerized tomography (CT) scans, magnetic resonance imaging (MRI), and ultrasound. The median wait for an MRI in Canada of 8.5 weeks was more than twice that for a CT scan (3.7 weeks). The median wait for ultrasound in Canada was only 1.9 weeks in 1996, a relatively short wait compared to those for CT scans and MRIs, but a 5.6 percent increase from 1995.

Rationing through Waiting

“One explanation for the existence of waiting lists is that governments are using them in an attempt to control health care costs by limiting or rationing access to health care,” concluded Dr. Walker. If this were the case, longer waits would be associated with lower rates of provincial spending on health care. An analysis of per capita costs adjusted for the age of the population and waiting times (chart 6) is consistent with this view, although the correlation is far from perfect.

A note on Newfoundland

Anecdotal evidence indicates that Newfoundland's waiting times should be longer than those experienced in other provinces. However, Newfoundland has had below national waiting times for the last few years of our waiting list survey. This anomaly is partially the result of the small sample size. With a larger sample size, such as that of Ontario for example, there is little chance that one doctor with a very long or very short waiting list will influence the median waiting time. With smaller sample sizes though, the length of each respondent's waiting list has a greater influence on the median. For example, although the survey response rate in Newfoundland was quite high for plastic surgery at 50 percent, this represented just one of the two plastic surgeons in the province. Using a median measure will usually eliminate the problem of outliers which occurs when measuring waiting times using averages: a specialist whose patients must wait an especially long time will skew the specialty average upwards. However, when surveying one of two, or two of three specialists, the median measure will suffer from the same problem as the average. If a specialist with an especially long waiting list responds to the survey one year and not the next, the difference between years will be large but it will not necessarily be an indication of an actual change in the waiting times for a province.

Another part of the explanation for Newfoundland's apparently superior performance is that the rate of joint replacement in Newfoundland is the second lowest in the country. For many procedures, Newfoundland has lower major surgery rates than the other provinces. The effect of this is to produce lower apparent waiting times since some patients in need of an operation do not receive it, and hence do not appear on a waiting list. This theory was somewhat corroborated by the administrators of several Newfoundland hospitals who revealed in interviews with the authors in 1996 that there were not lengthy waiting lists at the hospital stage, i.e., from specialist to treatment. Waiting lists for hip replacement surgery, for example, were approximately 6 weeks long, and the waiting list for cataract surgery was about 3 to 4 weeks long. ¹

One might expect that in healthier societies less hospital services would be used, and thus there would be lower rates of major surgery. However, health indicators show that Newfoundlanders are not inherently more healthy than their fellow Canadians. In fact, the reverse seems to be true. Newfoundland has the highest provincial age- standardized death rate, at 7.6 deaths per 1,000 population versus that of 6.4 deaths per 1,000 in Saskatchewan, and a Canadian average of 6.9. Although life expectancy in Newfoundland increased in 1995 to 77.3 years from 76.7 in 1994, Newfoundland's life expectancy was the lowest of any province. Newfoundlanders can be expected to live a year less, on average, than other Canadians. Canadian life expectancy was 78.3 years in 1995, up from 78.2 years in 1994.

For the most part, “Waiting Your Turn” measures waiting lists from the time patients see a specialist to the time they receive treatment. If there are problems in acquiring the services of a specialist, or if the route to surgical care becomes the emergency room, ² then our survey will underestimate the amount of rationing taking place within a province.

A note on Quebec

A similar situation exists in Quebec. A study by the Institute for Clinical Evaluative Studies (ICES) regarding hip replacement notes that the rate of joint replacement in Quebec is only one third that in the other provinces. This, the study notes, is due to the fact that the Quebec government has a policy limiting the extent of joint replacement. The effect of such a policy is to produce lower apparent waiting times since patients in need of this operation in Quebec are simply denied it and hence, do not appear on a waiting list. If there are other such policies in Quebec or elsewhere, they would affect the comparative length of waiting times without leaving any trace in our survey.

¹ These are approximate waiting times only. They are from the Health Care Corporation of St. John's and were determined from a brief analysis of their waiting lists and an informal survey of physicians. Back

² The number of visits to emergency rooms in the 10 largest medical facilities in Newfoundland and Labrador have increased by approximately 8.6 percent since 1991/92. Department of Health, St. John's Newfoundland, 1996. <

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