Waiting Your Turn: Hospital Waiting Lists in Canada
(Seventh edition)

Introduction

“Waiting lists are not going to disappear in Canada. They're an accepted part of our system.”²

Such comments from government officials show how prevalent waiting lists have become in Canada. Generally, waiting lists are blamed on an aging population and costly new advances in technology, two trends which seem likely to continue. Preserving a universal health care system through a “reasonable” amount of rationing is openly discussed, as is the need to restrict the amount of new technology provided to hospitals in order to keep hospital costs down. What is not as openly discussed is how such an approach to health care management may adversely affect the health of Canadians, and the health of the Canadian economy.

The existence of waiting lists for medical procedures and treatments is one manifestation of the rationing of health sector resources which is taking place in Canada. To the extent that non--price rationing of hospital capacity is occurring, monetary and non--monetary costs may be borne by Canadians even though these costs are not explicitly recognized. These unrecognized costs may include, for example, lost work time, decreased productivity associated with physical impairment and anxiety, and physical and psychological pain and suffering.

A working person incapacitated by an illness bears the costs of the loss of work. These costs are not included in those associated with running the health care system. Cancer patients needing radiation therapy who must drive long distances either to regional health centres or to the United States bear costs in terms of lost time that are not included in health costs nor in any way compensated by the health care system. A woman with a lump in her breast who is told she must wait four weeks for a biopsy to determine whether the lump is cancerous finds little comfort in the advice from her physician that epidemiological research shows that it doesn't matter to the outcome if the biopsy is delayed that long. The woman's anxiety and tangible psychological pain are not included in the costs of operating the health care system.³

In each of these cases, the savings to the government's budget are real and are matched by real though uncounted costs to Canadian health care consumers. While it is difficult or impossible to measure these costs, it is possible to measure the extent of queuing or the length of waiting lists to approximate the extent to which these costs may be mounting.

A number of health sector administrators are sceptical about the meaning and usefulness of waiting lists. They are sceptical both of the relevance of waiting lists as an indicator of the performance of the health care sector and of the reliability of such data as a measure of the extent of rationing of health care services.⁴ An earlier Fraser Institute publication evaluated various theoretical issues related to hospital waiting lists, including their relevance as measures of “excess demand.”⁵ The discussion defended the proposition that waiting lists are a potentially important barometer of performance in the health care sector. It also provided estimates of waiting lists for a set of hospital procedures in British Columbia. That study was followed in 1991 by a five--province study similar to the initial BC study. Since 1992, all 10 provinces in Canada have been surveyed.

Non--price rationing is also inefficient because it obscures differences in intensities of demand across different sets of consumers. To the extent that some consumers desire a given product more than other consumers, strict non--price rationing might result in those consumers who desire the product less actually obtaining it. All other things being constant, efficiency is promoted when those consumers who most value a product obtain it. For example, while a non--working spouse and his wife may be equally rationed by a system of waiting lists, the working wife might be willing to pay a little more to be able to get back to work. This would be quite rational behaviour on her part even if she and her husband were suffering the same disability. The reason is that she is suffering the additional costs of lost wages, which are not included in the cost of health care and which are not compensated by the universal health care system. With identical illnesses, the wife and husband do not have the same intensity of cost, nor the same need for the medical service that they are both being denied by waiting.

At least two prominent qualifications can be raised about the social inefficiencies of rationing by waiting. One is the claim that many procedures and treatments are performed where the social costs outweigh the social benefits. In these cases, it would be more desirable to discourage the consumption of a given amount of medical services by price rationing rather than by non--price rationing. In other words, let the working wife pay the increased costs of earlier treatment so that she can get back to work and let her husband wait for an opening on the “elective” surgical waiting list. That is the appropriate approach unless one is prepared to argue that patients will pay any price to receive specific treatments and that government bureaucrats are better able to determine whether treatment is warranted at any cost of providing it.

A second qualification is that non--price rationing of a vital product such as medical services is fair and is perceived to be fair by society. To the extent that fairness is an objective, one might argue that non--price rationing provides collective benefits that outweigh the inefficiencies identified above. However, depending upon how the non--price rationing occurs, the resulting distribution of benefits may not be any improvement upon the price--rationing outcome. If, for example, in a rationing circumstance, personal acquaintance with the head of surgery leads to less waiting, then rationing by waiting simply becomes a cover for a system of personal privilege. Even if the probability of knowing the chief of surgery were not related to income, the replacement of rationing by price with rationing by acquaintance will only create a different form of unequal access.

The fairness argument can be further qualified if we recognize the potential for providing direct cash transfers to poorer people to enable them to compete in the marketplace for any specific good or service. The argument against direct subsidies is that it is easier to target subsidies--in--kind to appropriate recipients. In the context of health management, this would mean that one would subsidize lower income people needing specific health care services. However, given the unexpected nature of many illnesses or accidents, it will be difficult to identify these people before the fact. Furthermore, given the potential for catastrophic illness and the associated high costs of treatment, some amount of direct subsidization might have to be extended to a large portion of the population and not just to low--income groups. In this case, the deadweight efficiency losses associated with a system that provides direct cash transfers to poorer people may not be significantly different from those associated with transferring income in--kind through non--price rationing.

To take the analysis a step further, the government might consider subsidizing purchases of private health care insurance by lower--income individuals and families thereby indirectly “targeting” health care assistance. The subsidy could be geared to a family's ability to pay so that it could approximate the full cost of the insurance premium for some buyers. At the same time, prices would be relied upon to “clear” the market for medical services.

To be sure, there are many arguments that have been made both for and against private medical insurance systems.⁶ For the purposes of this report, we accept that the public provision of and payment for health care services is an institutionalized feature of Canadian society for the foreseeable future and that extensive use of market pricing mechanisms to ration scarce capacity is unlikely. Under these circumstances, the extent of any excess demand, as well as how that excess demand is rationed, are relevant public policy issues, since the social costs associated with non--price rationing should be set against whatever benefits are seen to be associated with it.

Non--price rationing and methods of adapting

There are several ways in which non--price rationing can take place under the current health care system and many ways by which individuals adapt to rationing. One form of non--price rationing is a system of triage—the three--way classification system developed by Florence Nightingale for sorting the wounded on the battlefield in wartime. Under such a system, the physician sorts the patients into three groups: those who are beyond help, those who need and will benefit from immediate care, and those who can wait for care.

In peacetime, there may also be a shortage of resources, which requires physicians to employ the triage system to make choices about the order in which people should be treated. In such a selection process, physicians effectively ration access by implicitly or explicitly rejecting candidates for medical treatment whom they would otherwise treat. In the absence of well--defined criteria, doctors might be expected to reject those candidates least likely to suffer morbid consequences from non--treatment and those whose life expectancy would be least improved by treatment. The British experience suggests that some doctors use a foregone present value of earnings criterion for selecting patients for early treatment, thereby giving lower priority to critically ill patients.⁷ The experience of Canada's largest cancer treatment centre suggests that doctors are giving priority for radiation treatment to people whose cancers may be curable, as opposed to using the radiation machines to provide palliative care or limited extensions to life expectancy.⁸

Although both males and females can expect to live, on average, about five years longer than they did 20 years ago, the number of years that Canadians can expect to live in good health has actually declined, by 2.3 years for females (chart 1) and 0.4 years for males between 1978 and 1991.⁹ The reason for this decline is not obvious. However, it is consistent with the findings of recent surveys showing that there is an increasing amount of rationing in the health care system. It has long been known that when rationing emerges in a health care system, the elderly are the most likely to feel the impact.¹⁰ The reason is that in a classic triage system, older patients tend to get placed at the end of the queue as they will benefit less from treatment (i.e. for fewer years).

The available evidence on the magnitude of supplier--induced demand for medical services is, at best, ambiguous. The view that this is a modest problem is supported by the fundamental economic argument that competition among physicians will promote a concordance between the physician's interests and those of the patient. General practitioners usually stand as agents for patients in need of specialists. Specialists carry out the bulk of hospital procedures. General practitioners who can mitigate medical problems while sparing patients the pain and discomfort of hospital treatments are more likely to be perceived as doing a good job than those who encourage short--term or long--term hospitalization as a cure. This suggests that general practitioners have an incentive to direct patients to specialists who will not “overprescribe” painful and time--consuming hospital treatments.

Placing excessive numbers of patients on hospital waiting lists may also have direct costs for opportunistic specialists. For example, the latter may come to be seen as using a disproportionate share of hospital resources. This may make it more difficult for them to provide quick access to those resources for patients who are in more obvious (to themselves and to their general practitioners) need of hospital treatment. Similarly, patients facing the prospect of a relatively long waiting list may be tempted to search out other doctors with better connections to hospital facilities.

As an additional consideration, there is no concrete reason for any single physician or group of physicians to believe that an individual physician's waiting lists will significantly affect government funding policies or that they will be net beneficiaries of any increased funding that does occur. In the face of obvious incentives to “free--ride” on the strategic behaviour of other physicians, there may be no significant bias for physicians to inflate hospital waiting lists or even to over--report the number of patients they have waiting for admission to hospital.

An often--mentioned concern about measuring waiting is that hospital waiting lists are biased upward by a failure of reporting authorities to identify individual patients listed by more than one doctor and by a failure to prune waiting lists of individuals who have either already received the requested treatment or who, for some reason, are no longer likely to require treatment. Our survey results indicate that doctors generally do not believe that their patients have been booked on waiting lists by other physicians.

In summary, while there are hypothetical reasons to expect that hospital waiting list parameters will overstate true excess demand for hospital treatments, the magnitude of any resulting bias is unclear and is probably relatively small, given countervailing factors that may reduce measured amounts of waiting.

Hospital waiting list survey

In order to develop a more detailed understanding of the magnitude and nature of hospital waiting lists in Canada, the authors of this study conducted a survey of specialist physicians. Specialists were surveyed rather than hospital administrators because a substantial number of hospitals either do not collect waiting list data in a systematic manner or do not make such data publicly available.¹¹ In those instances where institutions--based data are available they have been used to corroborate the evidence from the survey data.

The survey was conducted in all 10 Canadian provinces. Mailing lists for the specialists polled were provided by Southam Business Lists. The specialists on these lists are drawn from the Canadian Medical Association membership lists. Specialists were offered a chance to win a $2,000 prize as an inducement to respond (without regard to whether they actually chose to complete the questionnaire). Though answering physicians were undoubtedly motivated in part by the lottery, the large percentage of answering specialists indicates concern about waiting lists for surgical procedures in Canada. Quite clearly, the medical profession has a collective interest in promoting an increased flow of financial and other resources to the health care sector. Nevertheless, it should not be assumed that the survey results are, therefore, unreliable. In particular, it should not be assumed (for reasons suggested earlier) that individual physicians responding to the survey have skewed their responses in a particular direction since physicians were not pre--selected as to their views about the adequacy of current funding or their views about current health care arrangements. There is a wide dispersion of views amongst physicians about the desirability of greater ease of access and there is no reason to believe that those who want to create the impression of longer lists are either more likely to distort their responses or more likely to respond to the survey than those who do not.

The authors chose to survey specialists rather than general practitioners because the former have primary responsibility for health care management of surgical candidates. Survey questionnaires were prepared for 12 different medical specialties: plastic surgery, gynaecology, ophthalmology, otolaryngology, general surgery, neurosurgery, orthopaedic surgery, cardiovascular surgery, urology, radiation oncology, medical oncology, and internal medicine. For the 1990 survey, the questionnaires were pre--tested on a sample of individual member specialists serving on the relevant British Columbia Medical Association specialty committee. In each subsequent use, suggestions for improvement have been made by responding physicians and these modifications have been made to the questionnaires. Adhering to the questionnaire format of the 10 specialties originally surveyed, radiation oncology and medical oncology were added to the survey in 1994. The survey used for general surgery is included in Appendix 1 of this report. The questionnaires for all of the specialties follow this format, with only the procedures surveyed differing between specialties. The data were collected in December 1996.

For the most part, the survey was sent to all specialists in a category. In the case of internal medicine in Ontario, 500 names were randomly selected. The response rate of 31 percent overall is considered quite high for a mailed survey. The response rate in the five provinces initially surveyed (British Columbia, Manitoba, New Brunswick, Newfoundland, Nova Scotia) was 20 percent. This year, the response rate for these same provinces was 35 percent, an increase of 2 percent from last year. In Prince Edward Island, 52 percent of specialists responded to the survey (up from 38 percent last year). The response rate was 40 percent in Newfoundland this year (up from 35 percent), 43 percent in New Brunswick (up from 33 percent), and 35 percent in Nova Scotia (up from 33 percent).

Methodology

The treatments identified in all of the specialist tables represent a cross--section of common procedures carried out in each specialty. They were suggested by the British Columbia Medical Association specialty boards in 1990, with some procedures being added since then (at the suggestion of survey participants).

At the suggestion of the Canadian Hospital Association, median measures of waiting have been used since 1995 rather than average measures.¹² In using average waiting times, there is the problem of outliers: the presence of a specialist whose patients must wait an especially long time will skew the specialty average upwards. If such a specialist responds to the survey one year and not the next, the difference between years will be large but will not necessarily be an indication of an actual change in the province's waiting times. For the most part, the use of medians avoids this problem. A median is calculated by ranking specialists' responses in either ascending or descending order, and determining the middle value. When the middle of the ranking lies between 2 responses, the median is the average of these 2 responses. So, if the median wait reported is 5 weeks for a procedure, half of the specialists reported waits of longer than 5 weeks while half of the specialists reported waits of less than 5 weeks.

The major findings from the survey responses are summarized in tables 2 through 44. Table 2 reports the median time a patient waits for an appointment with a specialist. This period is measured from the time a general practitioner refers the patient to the specialist. The wait for an appointment with a specialist is calculated as the median of the weeks indicated by responding specialists. These appointment medians are then weighted by the ratio of the number of specialists surveyed in each specialty in a province to the total number of specialists surveyed in the province, to obtain the weighted median reported on the last line of table 2.

Tables 3 through 14 report the time a patient must wait for treatment after having seen a specialist, where the waiting time per patient is the median of the survey responses. The weighted medians reported in the last line of each table are calculated by summing the products of the median wait for each operation, and the ratio of the number of persons undergoing each operation and the total number of operations performed in each specialty by province.

Tables 15 through 26 report the estimated number of patients waiting for surgery. To allow for inter--provincial comparisons, these tables also report the number of people waiting for surgery per one hundred thousand population.

The number of people waiting for treatment is estimated using the average of the weeks waited for treatment as reported by responding specialists and the Statistics Canada's Health Report No. 82--216--XPB, “Hospital Morbidity and Surgical Procedures 1993--94.” This report provides a count of the total number of surgical procedures performed annually by each province. To estimate the number of individuals waiting for surgery at any given point, we divide the average weeks waited for a given operation by 52 and then multiply this number by the total number of persons undergoing this operation annually. Thus a waiting period of, say, one month, implies that on average, patients are waiting one twelfth of a year's total capacity to get their surgery. The next person added to the list would find one twelfth of a year's patients ahead of them in the queue. The main assumption underlying this estimate is that the number of surgeries performed will neither increase nor decrease within the year in response to waiting lists.

There are a number of minor problems matching Statistics Canada's operation categories to the ones reported in our survey. In several instances, an operation such as rhinoplasty is listed for more than one specialist. In these cases, average waiting times are identified with the classification of the responding specialist. Hence, the flow or number of patients annually undergoing this type of operation is divided between specialties according to the proportion of overall surgery performed in each specialty. In other instances, an operation polled in our study has no match in the Statistics Canada report. For example, there is no match for the urology operation, “ureteral reimplantation for reflux,” in the Statistics Canada report. In these cases, we make no estimate of the number of patients waiting for these operations.

Tables 28a and 28b offer a comparison of median waiting times and the estimated number of patients waiting across specialties and provinces. Of course, our calculation of the estimated number of patients waiting in each specialty includes only those patients waiting for the operations surveyed. The operations we surveyed represent between 60 and 70 percent of non--emergency surgery performed in each of the provinces studied.

The final row of table 28a shows the weighted medians of the 12 specialties listed above. These weighted medians are calculated by summing the products of median waiting and the proportion of polled surgery.

To estimate the number of people waiting at any time for non--emergency surgeries that were not included in our survey, we found the residual operations for each province. The estimate of residual waiting is the product of the residual number of operations in each province and the provincial weighted averages divided by 52 (weeks). The estimates of residual waiting are reported in table 28b, as are the estimates of the total number of patients waiting in each province at any given time during the year.

Tables 32 through 43 report the median number of weeks that specialists consider to be clinically reasonable to wait for treatments. The methodology of these tables is comparable to that of tables 3 through 14.

Data verification with government, hospital, or other sources

In April 1996, all of the data were sent across Canada to provincial ministries of health or the regional health authorities (where appropriate). Replies were received from British Columbia, the Calgary Regional Health Authority, Saskatchewan, Manitoba, Ontario, Newfoundland, Nova Scotia, and Prince Edward Island. Information from the Capital Health Authority (Edmonton) was taken from their internet site on which they post quarterly performance reports.

The Ministry of Health and the Ministry Responsible for Seniors in British Columbia recently committed to publishing the waitlists and waiting times for health services in the province, however, they felt that it would be premature to share any such information with the public at this time.

Our data show British Columbians waiting 12 weeks for urgent heart surgery and 36 weeks for elective. Data from the BC Cardiac Patient System show that patients generally wait less than a week for emergency surgeries and approximately 14 weeks for cardiovascular surgery in general. In 1996, about 50 percent of heart patients received their bypass or valve surgery within 12 weeks, 36.7 percent waited 12 to 24 weeks, 11.3 percent waited 24 weeks to a year for their surgery while 1.7 percent waited for more than a year. The longest wait for bypass or valve surgery was over 3 years.

Our survey found BC cancer patients waiting approximately 2.8 weeks to see a radiation oncologist and 3.7 weeks to begin radiotherapy treatment in 1996. The BC Cancer Agency's (BCCA's) standard for waiting times in the province is that patients should wait a maximum of 2 weeks from referral to specialist, and a maximum of 2 weeks to receive treatment after having seen a specialist. Data from the BCCA show that 66 percent of Lower Mainland patients received their radiotherapy within the 2 week time frame, and 57 percent of Vancouver Island patients received their treatment within this period. According to the BCCA, there were 377 people waiting for radiotherapy in the province as of April 1997 (table 25).

The Calgary Regional Health Authority (CRHA) has developed a centralized operating room management information database for its region. The CRHA provided data on the numbers of people waiting for surgery at hospitals within its jurisdiction, as well as the median number of weeks patients were waiting. Our waiting times for the province of Alberta tended to be longer than those kept by the CRHA.

The Capital Health Authority, which serves Edmonton and most of Northern Alberta, shows cardiovascular surgery patients waiting approximately 11.4 weeks for urgent surgery (inpatient and outpatient) and 28.6 weeks for elective in its most recent performance report. These numbers are comparable to our survey results which show patients in Alberta waiting 13.6 and 27 weeks for urgent and elective heart surgery, respectively.

Taking into account the numbers of people waiting in both the Edmonton and Calgary regions, our survey results most likely underestimate the numbers of people waiting for treatment in Alberta, with the exceptions of neurosurgery and cardiovascular surgery.

The department of health in Saskatchewan provided us with waiting list data for a number of

specialties.¹³ In general, our survey tended to provide longer estimated waiting times (any large divergences are noted on the relevant specialty tables). While our survey underestimates the number of people waiting for ophthalmology in Saskatchewan, it accurately measures the amount of time most of these patients are waiting. Saskatchewan Health data for November 1996 showed that 2 of 18 physicians performed one--third of that month's ophthalmology procedures. The average wait time for patients of these two surgeons was about one year, while the average wait time for patients of all the other physicians was about 3 months. Our survey data record median wait times for most ophthalmology procedures in Saskatchewan of 12 weeks, although the weighted median for the specialty is 9.2 weeks.

The Manitoba Ministry of Health has begun developing a centralized waiting list system for cardiac and orthopaedic surgery. Its preliminary reports show patients waiting fewer weeks for joint replacement surgery than our survey result of 23 weeks. Data from the Manitoba Cardiac Sciences Program (MCSP) were used to supplement the survey data collected for cardiovascular surgery. The MCSP central waiting list provides a detailed description of the amount of time being waited for surgery by level of urgency. The program has been in effect since October 1996 and its goal is to create a managed list for cardiovascular surgery based on risk criteria.

The Ontario Ministry of Health does not collect waiting list information except in the area of cardiovascular surgery. It preferred not to comment on any of our survey results. However, information from the internet site of the Cardiac Care Network of Ontario indicated that there were approximately 1,580 patients waiting for open heart surgery in the province. The wait time for emergency/urgent surgery was 0.4 weeks, 1.6 weeks for semi--urgent surgery, and 11.1 weeks for elective. Our survey results have 629 patients waiting 0.1 weeks for emergent surgery, 1.7 weeks for urgent, and 15.9 weeks for elective.

The Newfoundland and Labrador Department of Health responded to our request for data verification but, unfortunately, it does not maintain waiting list data. The Health Care Corporation of St. John's, one of the province's regional authorities, did confirm that our survey underestimates the number of patients waiting for cardiovascular surgery in the province. There are approximately 200 people waiting for this type of surgery in Newfoundland. An informal survey conducted by a local physician found patients waiting approximately 22 weeks to see a cardiovascular surgeon, 15.5 weeks to see an orthopaedic surgeon, 6.5 weeks to see an internist, and 5 weeks to see a plastic surgeon.¹⁴ Our data show these waits to be 8, 8, 4, and 10 weeks respectively.

Nova Scotia's Department of Health tabled a report on waiting times to the Legislature last year. It was a retrospective look at waiting times from specialist to treatment for the fiscal years 1992--93 to 1995--96. It does not measure the waiting times to see a specialist. In general, our survey results provide lower estimates of the waiting times for treatment in Nova Scotia, with the exception of otolaryngology procedures, for which our waiting times consistently are longer than those of the Department of Health. A detailed comparison of our survey results with the Department of Health data can be found in Appendix 2.

Prince Edward Island also responded to our request for provincial waiting list data. Overall, the province's Health and Community Services Agency felt the data accurately reflected the waiting list situation, with a few exceptions. The Agency provided us with data on plastic surgery,¹⁵ urology, and internal medicine waiting times. Our survey found the wait time for hernia/ hydrocele to be 16 weeks for urology, and 3 weeks for general surgery, whereas the Agency's operating room scheduling office put the wait at 8 weeks. As well, our survey data show a waiting time of 5 weeks for angiography and/or angioplasty (patients must go out of province for angioplasty). Agency data show a waiting time of less than one week for the peripheral angiography done in PEI.

Data comparability with other waiting list studies

In 1967, a survey of British Columbia hospitals was done by the British Columbia Hospital Insurance Service, the forerunner to MSA.¹⁶ This study estimated that in 1967 the total number of people on hospital waiting lists in British Columbia exceeded 12,000—0.6 percent of the population in BC that year. Our estimate of 26,743 people waiting for surgery in BC, an increase of 1,868 from our updated 1995 estimate, represented 0.7 percent of the population in 1996. In 1996, not only were there more British Columbians waiting for hospital treatment after having seen a specialist but they were waiting 28 percent longer than they were in 1995.

A brief survey of Ontario hospitals undertaken in October 1990 for the General Accounting Office of the United States Government¹⁷ suggests that patients waiting for elective orthopaedic surgery were waiting from 8.5 weeks to 51 weeks, that elective cardiovascular patients were waiting one to 25 weeks, and that elective ophthalmology patients were waiting 4.3 to 51 weeks. Our survey found Ontario patients waiting 10.6 weeks for orthopaedic surgery, 15.9 weeks for elective cardiovascular surgery, and 9.3 weeks for ophthalmology procedures in 1996.

A study of waiting times for radiotherapy in Ontario¹⁸ found that the median waiting times between diagnosis and initiation of radiotherapy for carcinoma of the larynx, carcinoma of the cervix, and non--small cell lung cancer were 30.3 days, 27.2 days, and 27.3 days respectively. Our survey results for 1996 fall within 2.3 to 6.3 weeks of these estimates. We record a wait of 28 days for radiotherapy of larynx cancer, 30.1 days for cervix cancer, and 33.6 days for radiotherapy treatment of lung cancer in 1996 (waiting times from referral, to meeting with a specialist, to treatment). However, our estimate that prostate cancer patients were waiting a median of 42 days for radiotherapy is much lower than Mackillop's finding that patients with carcinoma of the prostate were waiting 93.3 days.

An international study of waiting times for selected cardiovascular procedures found that, in Canada, 13.3 percent of waiting times for elective coronary bypass surgery fell in the 2 to 6 week range, 40 percent in the 6 to 12 week range, 40 percent in the 12 to 24 week range, and 6.7 percent in the over 36 weeks (9 months) range.¹⁹ For all of the heart procedures surveyed, the waiting times were longer in Canada, Sweden, and the United Kingdom than in the United States. Our survey found that the provincial waiting times for elective bypass surgery tended to be in the 24 to 36 week range in 1996, with the waiting time for elective cardiovascular surgery in Canada increasing from 9.8 weeks in 1993 to 16.2 weeks in 1996 (graph 4).

Lastly, a 1994 study on knee replacement surgery in Ontario found that the median wait for an initial appointment with an orthopaedic specialist was 2 weeks in the United States and 4 weeks in Ontario. The median waiting time to receive a knee operation was 3 weeks in the US and 8 weeks in Ontario.²⁰ Our survey found that in Ontario in 1994, the wait to see an orthopaedic specialist was 9 weeks and the wait to receive hip or knee surgery was 15 weeks. By 1996, these wait times were 8 weeks and 12 weeks respectively.

Focus on cardiovascular surgery

Cardiovascular disease is a degenerative process and the decay of the cardiac surgery candidate is gradual, therefore, under a system of rationed supply some cardiac surgery candidates tend to be bumped by patients with other conditions that require immediate care. This is not a direct process but rather a reflection of the fact that budgets for hospitals are set separately for “conventional illness” and for other, high--cost interventions such as cardiac bypass. Only a certain number of the latter are included in a hospital's overall annual budget. Complicating matters is the on--going debate about whether cardiac bypass surgery actually extends life. If it only improves the quality of life there will be no statistics that point to a decay of health care in the population and, hence, no basis for increased funding.

The result has been lengthy waiting lists, often as long as a year or more, followed by public outcry, which in turn has prompted short--term funding. In Newfoundland earlier this year, the long waiting list for heart procedures was blamed for at least one death. The result is that Newfoundland may send people to other provinces for their heart surgery. Across Canada though, many governments, including BC, Alberta, and Ontario, have had to provide additional funding for heart surgery in their provinces. In the past, US hospitals have also provided a convenient short term solution to excessive waiting lists for cardiac surgery. The British Columbia government contracted Washington state hospitals to perform some 200 operations in 1989 following a public outcry over the six--month waiting list for cardiac bypass surgery in the province.

Survey results: estimated waiting in Canada

Waiting for an appointment with a specialist

Table 2 indicates the median number of weeks that patients wait for initial appointments with specialists after referral from their general practitioners or from other specialists. Most waits for specialists' appointments are less than 2 months in duration. However, there are a number of three month waits (or longer): to see a plastic surgeon in British Columbia; an ophthalmologist in Nova Scotia or Prince Edward Island; a neurosurgeon in Alberta or Ontario; or a urologist in Prince Edward Island. The weighted medians, depicted in chart 2, suggest that Manitoba has the shortest wait in the country for appointments with specialists, while Prince Edward Island has 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, and by 27 percent since 1993 (graphs 1 and 2).

Time spent waiting for treatment

Several general observations can be made about tables 3 through 14 and tables 32 through 42. Residents of all provinces surveyed are waiting significant periods of time for hospital treatments. While some treatments have short waits, most procedures require waits of at least a month. Seventy--six percent of the actual weighted median waiting times are greater than the weighted median of what specialists considered to be reasonable waiting times. For example, the median wait for ophthalmology in Manitoba is 27.6 weeks. A clinically reasonable amount of time to wait, according to Manitoba specialists, is about 4.8 weeks. In PEI, the actual time to wait for an orthopaedic procedure is 29.3 weeks, whereas PEI specialists feel that a wait of 6.5 weeks is clinically reasonable. The differences between the median reasonable and median actual waits for the specialties are summarized in table 44.

Ranking the provinces according to the weighted medians reported in table 28a indicates that the longest median wait for surgery occurs in British Columbia and the shortest in Quebec. There is a 4 week difference between the shortest and the longest weighted median. Graphically, the median waits for treatment by province can be seen in chart 3. For Canada, the wait for treatment after having seen a specialist increased from 5.7 weeks in 1995 to 6.2 weeks in 1996. In 1993, the wait for treatment after having seen a specialist was 5.6 weeks (graphs 3 and 4).

Table 30 presents a frequency distribution of the median waits for polled surgery by province and by region. In all provinces, the majority of polled operations have waiting lists of less than three months. The Prairie provinces collectively have the lowest proportion of waits under three months, while BC has the greatest proportion of median waiting times over six months. In contrast, 97 percent of Quebec's median waits and 92.2 percent of Ontario's median waits are under three months long and none are over six months.

Number of people waiting for treatment

In 1995, a new statistic was added to tables 15 through 26. Provincial populations vary greatly, thus it is hard to gauge the differences in waiting list length based solely on pure numbers of people waiting. A couple of examples should illustrate this point. In Quebec, there are 1,645 people waiting for surgery by an otolaryngologist, while there are 268 people waiting for an otolaryngology procedure in Manitoba. The pure numbers of people waiting would imply that there are more people waiting for these types of treatments in Quebec. However, they translate into more people waiting per 100,000 in Manitoba; 23 people waiting per 100,000 population in Manitoba, and 22 people waiting per 100,000 in Quebec. In Ontario, there are 6,288 people awaiting orthopaedic surgery, or 56 per 100,000 population, while in Prince Edward Island, there are 89 people waiting, the equivalent of 65 per 100,000 population. Table 27 provides a summary of these statistics.

Further comparison with last year's results

In order to compare this year's data with last year's, it was necessary to update last year's calculations using Statistics Canada's Health Report No. 82--216--XPB, “Hospital Morbidity and Surgical Procedures 1993--94.” The comparison of median waiting times is shown in table 29a. The number of people waiting for surgery or treatment in 1996 as compared to the number of people waiting in 1995 appears in table 29b.

Our study shows an overall increase in the waiting times for all provinces except Manitoba, New Brunswick, Nova Scotia, and Prince Edward Island. PEI shows the greatest improvement in waiting from specialist to treatment, but this improvement was more than matched by an increase in the waiting time to see a specialist (mainly due to a large increase in the wait to see an ophthalmologist). Meanwhile, the median wait in British Columbia increased by 28 percent, and in Saskatchewan by 29 percent between 1995 and 1996.

Most provinces experienced an increase in the number of people waiting as well. The only provinces that had fewer people waiting for surgery were Manitoba, New Brunswick, and Prince Edward Island. The number of people waiting for surgery in Canada increased from 155,969 in 1995 to 172,766 in 1996. There are 11 percent more people waiting for surgery in Canada, and they are waiting 8.8 percent longer to receive treatment after having seen a specialist. Specialists were asked to attribute the change in their waiting lists to the availability of operating room nurses, technical staff, beds, operating room time, a change in patient load, or to other factors. The main factors influencing the change in waiting lists were the availability of operating room time (31.9 percent), a change in patient load (20.8 percent), and the availability of hospital beds (15.8 percent).

Clinically reasonable waiting times

In almost every instance, the responding specialists felt that waiting times for treatment were excessive. When asked to indicate a clinically reasonable waiting time for the various procedures, specialists generally indicated a period of time substantially shorter than the median number of weeks patients were actually waiting for treatment. Table 43 summarizes the weighted medians for the specialties surveyed. These weighted medians were calculated in the same manner as those in table 28a. The variability among the provincial weighted medians is less than it was in table 28a.

Chart 4 compares the actual median number of weeks patients are waiting for treatment in Canada after having seen a specialist with the median number of weeks specialists feel are reasonable to have patients wait. The largest positive difference between these two periods is for orthopaedic surgery where the actual waiting time is 5.1 weeks longer than what is considered to be reasonable by specialists. The largest negative divergence is for elective cardiovascular surgery, where the median actual waiting time is 7.8 weeks shorter than the clinically reasonable waiting time.

Estimated total waiting in Canada

While waiting times for surgery convey a mixed impression about the apparent extent of health care rationing, there is much less ambiguity when the overall wait for health care is considered. This overall wait, which records the time between the referral by a general practitioner to the time that the required surgery is performed, includes an additional wait for the appointment to see the specialist. Table 31 and chart 5 present the combined waiting times. They indicate that patients wait more than two months for relief of their ailments, from a weighted median of 9.6 weeks in Quebec to 19.7 weeks in Prince Edward Island.

Across Canada, the longest waits for treatment are for neurology, ophthalmology, orthopaedic surgery, and elective cardiovascular surgery. The median waits for these specialties are 4 months or longer. As is indicated in Chart 6, the median total wait for neurosurgery in Canada is 16 weeks, 17.4 weeks for ophthalmology, 19.7 weeks for elective cardiovascular surgery, and 20.5 weeks for orthopaedic surgery. The shortest wait in Canada is for cancer patients being treated with chemotherapy. These patients wait approximately 3.2 weeks to receive their treatment.

Health expenditures and waiting times

Consistently, Ontario performs better than most of the other provinces with regard to hospital waiting lists. The model of waiting lists that underlies our analysis, and which has been sketched out in this study, is that waiting is a manifestation of rationing. It would, therefore, seem to follow that one possible explanation for the result in Ontario is that the province is simply engaging in less rationing than are the other provinces. Rationing is not, of course, a necessary consequence of the way in which the health care system is organized, but merely a possible consequence of that organization if the budgetary allocations to the health care sector are insufficient to keep up with the demand. Budget constraint leads to constraints on the supply of health care services, to an excess of demand over available supply, and thus to the observed rationing by waiting.

It follows from this that one possible explanation for Ontario's superior performance is that Ontario simply spends more money on health care than the other provinces and that this enables it to respond more fully to the demands of patients than is possible in other provinces.

In order to determine whether actual experience accords to this theory, we calculated a crude measure of public expenditures on health care in the form of adjusted per capita expenditure on health care in each province by the public sector. (We calculated how much each province would spend per capita on health care if they were to spend the national average on the various age groups, then subtracted this value from how much they are actually spending on health care per capita. The reason for using this method of weighting is that if a population in a particular province has more people in age cohorts that are more in need of health care, i.e. the elderly, the same dollar amount per capita spent on health care in that province would yield a less effective supply effort than it would in a province with fewer elderly citizens.) This is displayed in chart 7, which shows the differences from the national average in weighted per capita expenditures for all provinces and the differences from the national median waiting time, by province. (Waiting time is measured from patients' appointments with their GP to the time they actually receive treatment.) Provinces spending more than the national average tend to have waiting times below the national wait. Conversely, those provinces that spend less than the national average generally have waiting times above the national median. However, Manitoba and Quebec have below average costs and waiting times while British Columbia and Alberta have above average costs and yet have waiting times greater than the national median.

Obviously, there are many factors that influence the waiting times in the provinces and that operate in conjunction with the supply of resources, for example: the age of the population and, therefore, the underlying demand for health care (for which we have tried to make adjustments); the management of resources, including the extent of effort to decrease the number of patients on specific doctors' waiting lists; the extent of same--day surgery; the average length of hospital stays; and the extent of reliance on private clinics.

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. As discussed earlier, 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 Newfound--land'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.²¹ 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.²² 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.²³

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 6.9.²⁴ 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 1994.²⁵

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,²⁶ then our survey will underestimate the amount of rationing taking place within a province.

A note on technology

The wait to see a specialist and the wait to receive treatment are not the only waits that patients face. Within hospitals, limited budgets force specialists to work with scarce resources. Chart 8 gives an indication of the difficulties that specialists in Canada have in gaining access to modern medical technologies compared to their counterparts in the United States. In 1995, there were 234 computerized tomography (CT) scanning centres in Canada, about half as many per million people as there were in the United States (in 1993), and there were almost 5 times as many magnetic resonance imagers (MRI) in the United States per million people than in Canada.

Our study looked at the wait for various diagnostic technologies across Canada. Chart 9 shows the median number of weeks patients must wait for access to a CT scanner, an MRI, or an ultrasound machine. The median wait for an MRI in Canada (8.5 weeks) is more than twice that for a CT scan (3.7 weeks) and is probably an underestimate of the actual waiting time since specialists who do not prescribe MRI tests because of the lengthy waits for access to a machine are not included in the calculation of the median. The longest wait for an MRI is in Ontario (11.1 weeks). Ultrasound tests are quite common and many specialists have their own machines, which resulted in a median wait for ultrasound in Canada of only 1.9 weeks in 1996, which is a relatively short wait compared to those for CT scans and MRIs, but which is a 5.6 percent increase from 1995.

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Last Modified: Wednesday, October 20, 1999.