ORIGINAL ARTICLE
Toward Standard Definitions for
Waiting Times
by Claudia A. Sanmartin and the Steering Committee of the Western Canada Waiting List Project
Claudia A. Sanmartin,
MSc, PhD, Senior
Analyst, Statistics
Canada, was a research
associate with the
WCWL Project.
Members of the Steering Committee:
(Chair) Dr. Tom Noseworthy, Professor, Department of
Community Health Sciences, University of Calgary,
Alberta; Dr. Morris L. Barer, Director, Centre for
Health Services and Policy Research, and Professor,
Department of Healthcare and Epidemiology,
University of British Columbia, Vancouver, British
Columbia; Dr. Charlyn Black, Co-Director, Manitoba
Centre for Health Policy and Evaluation, and
Associate Head and Associate Professor, Department
of Community Health Sciences, University of
Manitoba, Winnipeg; Ms. Lauren Donnelly, Acting
Executive Director, Acute and Emergency Services
Branch, Saskatchewan Health, Regina; Dr. David
Hadorn, Research Director, Western Canada
Waiting List Project; Dr. Isra Levy, Director, Health
Programs, Canadian Medical Association, Ottawa;
Mr. Steven Lewis, Partner, Access Consulting,
Saskatoon, Saskatchewan; Mr. John McGurran,
Director, Western Canada Waiting List Project,
and Research Associate, Department of Public
Health Sciences, University of Alberta, Edmonton;
Dr. Sam Sheps, Head, Department of Healthcare
and Epidemiology, University of British Columbia,
Vancouver, British Columbia; Dr. Mark C. Taylor,
Assistant Professor, Department of Surgery, University
of Manitoba, Winnipeg; Mr. Laurie Thompson, Chief
Executive Officer, Health Services Utilization and
Research Commission, Saskatoon, Saskatchewan;
Mr. Darrell Thomson, Director, Economics and Policy
Analysis, British Columbia Medical Association,
Vancouver, British Columbia; Ms. Barbara Young,
Regional Utilization Consultant, Clinical Evaluation
Services, Calgary Regional Health Authority,
Calgary, Alberta.
Abstract
There are no standard or universally accepted definitions of waiting times for a
broad range of health services and procedures. The Western Canada Waiting
List Project, like other similar projects, has recognized the need to establish such
standard definitions to improve the accuracy and comparability of waiting time
information across procedures and jurisdictions and of information provided to
patients. This article proposes standard definitions of waiting times for surgery
and magnetic resonance imaging.
imely access to healthcare services has become a primary concern
for most Canadians. One of the key issues is lengthy waits for
specialized services such as elective surgeries and diagnostic tests.1
A recent survey conducted by Statistics Canada on access to
healthcare services revealed that approximately 20 percent of those
who required specialized services over a 12-month period reported
that they had difficulties accessing care. Most indicated that waiting
for care was the problem. Approximately one in four of those who
did wait for care indicated that their waiting time was unacceptable,
and one in five reported that they experienced adverse effects such
as stress, anxiety and pain.2 It is evident that waiting for care is an
issue for some patients. There is little accurate, reliable information
to determine precisely how many patients wait for care and for how long.3
T
Governments at all levels have been called upon during the past several years
to reduce lengthy waits and improve overall access to healthcare services.
There have been numerous debates, however, regarding the actual extent of
the problem and the best way to address it. In 1989, Health Canada released
the first national report on the state of waiting times in Canada. One of the
report’s most important recommendations pertained to the development of
reliable and comparable waiting time data for a broad range of medical
procedures so that patients, healthcare providers and governments could
have a better and more accurate understanding of the extent and nature of
waiting times. Furthermore, the development of these data systems must
begin with standard definitions for waiting times (i.e., when the waiting for
care begins and ends).4,5
The need for reliable information has never been greater. In September 2000,
on a set of 14 indicators, the First Ministers agreed to provide comparable
information across all provincial and territorial jurisdictions and improve
overall accountability within the system. One of the three areas of reporting
is quality of healthcare services. Waiting times for selected diagnostic and
surgical procedures was selected as one of the indicators to provide
Healthcare Management Forum Gestion des soins de santé
49
information on accessibility of services.
Reporting began in September 2002 and
the next report is due in November 2004.6
Over the past several years, provincial
ministries of health across the country
have been working toward the
development of waiting list strategies
and management systems. Waiting list
information and management for cardiac
services has existed for more than a
decade in Ontario through the Cardiac
Care Network. Patients awaiting selected
cardiac services are placed on the
provincial-wide registry and followed
throughout the course of their wait and
eventual surgery (see www.ccn.on.ca
for more info). British Columbia has
made waiting time information by
hospital and physician available to the
public for several years through the
Ministry
of
Health
Web
site
(www.healthservices.gov.bc.ca/waitlist).
In Manitoba, the Cataract Waiting List
Program was developed to track and
prioritize patients waiting for cataract
surgery.7 In Saskatchewan, plans have been
proposed for a province-wide surgical
wait list management strategy.8 This is
just to name a few.
Despite these efforts, no standard or
universally accepted definitions of waiting
times exist for a broad range of services
and procedures. Such standards are
needed to improve the accuracy and
comparability of waiting time information
provided to patients, healthcare providers
and policy makers. Standard definitions
will also serve to improve the comparability
of data across procedures and jurisdictions.
The establishment of standard definitions
represents the first step in determining
whether patients are gaining access to
care within a reasonable and acceptable
period of time.
The Western Canada Waiting List Project
(WCWL) is a federally funded partnership
of 19 organizations that was created to
develop priority tools to assist in the
management of waiting lists.9 In addition
to the development of the tools, the
WCWL Project also focused its efforts on
the development of standard definitions
of waiting times for general surgery, hip
and knee replacement surgery, cataract
50
surgery and magnetic resonance imaging
(MRI). A comprehensive list of waiting
periods potentially facing patients seeking
these services is identified and defined
based on an examination of the standard
paths to care for these procedures. The
major issues and challenges facing the
implementation and operationalization
of standard definitions for waiting times
are discussed and recommendations are
proposed regarding future efforts in
this area.
Definitions Currently Used
Waiting times have been studied, both
within Canada and internationally, using
various definitions. Most studies
conducted to date have focused on three
distinct waiting periods: waits to see the
specialist, waits to receive hospitalbased services and total waiting time.
The differences lie primarily in how these
waiting periods are defined (i.e.,
precisely when the waiting period begins
and ends).
The waiting time for a specialist consultation has been defined as the time
between the referral from the primary
care practitioner to the consultation.10-13
In the early 1990s, this definition was
introduced in the National Health
Service in the United Kingdom to ensure
the comparability of national waiting time
statistics for specialist consultations.11
Specialist waiting times have also been
defined as the time between the visit to
the primary care physician and the
specialist consultation.12
The majority of studies conducted to
date have focused on waiting times for
hospital-based services such as surgery.
In most cases, waiting times were
defined as beginning when the patient
was booked for surgery and placed on the
hospital waiting list.5, 6, 13-16 Alternatively,
surgical waiting times were also defined
as the time between when the patient
and physician decided that treatment
was necessary and desirable (often
referred to as the “decision to treat”), and
the date of treatment.14 The decision to
treat is often assumed to take place
during the last presurgical consultation
with the specialist or surgeon. This
Healthcare Management Forum Gestion des soins de santé
definition is commonly used in studies
where, in the absence of waiting list data,
waiting times were estimated retrospectively using health administrative data
(i.e., hospital and physician payment
data), and the date of the last presurgical
consultation was used as a proxy date for
the day of the treatment decision.1, 15-16
Finally, some argue that the only true
meaningful measure of waiting is the
“total waiting” time to care. One of the
earliest definitions emerged from the
United Kingdom where researchers
defined total waiting time as beginning
when the patient seeks care, often
marked by the first visit to the primary
care practitioner, and ends when the
treatment has been provided.16 A similar
definition has been proposed in Canada
by the British Columbia Medical
Association.6
There are clearly various definitions used
to report waiting times for medical
services in Canada and abroad. While
many of these definitions may be
appropriate for specific procedures, their
variability represents a problem when
there is a need to aggregate or compare
waiting time information across
jurisdictions, procedures and specialty
groups. Standard definitions for waits
represent the first step to improving the
management and reporting of waiting
time information.
Defining Waiting Times:
A Path-to-Care Approach
A comprehensive understanding of the
“standard” paths to care can provide
information regarding the potential
waiting periods faced by patients during
the course of care and highlight the key
processes that may serve to define the
start and end of each waiting period.
Paths to care were developed in
consultation with WCWL panel members
for surgery (i.e., general surgery, hip
replacement and knee replacement) and
MRIs using a Delphi approach in which
members were presented with an initial
path and asked to revise or change as
necessary. Several iterations were
conducted until a model was agreed on.
The work of the WCWL Project was
conducted by clinical panels established
for each procedure area. The panels
comprised 12 members including
specialists (in the relevant field),
referring physicians, academics and
representatives of the regional health
authorities. They were chaired by an
experienced and respected leader in the
relevant clinical area selected by the host
region. Selected members from the knee
and hip replacement panel, general
surgery panel, cataract panel and MRI
panel participated in the development of
the standard definitions.
Figure 1: Waiting Times for Surgery
Surgery
Wait #4b
Placement on Hospital
Waiting List
(Booking)
Wait #4a
Waits for Surgery
Given the similarities in the paths to care
for general surgery, knee and hip
replacement and cataract surgery, a
single path to care was developed to
represent waiting times for surgery
(figure 1).
Waiting time for primary care (wait #1): The
first waiting period likely experienced by
patients is the waiting time for a primary
care consultation with either a general or
family practitioner. This waiting period is
defined as the time between the date of request
for a consultation to the date of the primary
care consultation.
Waiting time for initial specialist/surgical
consultation (wait #2): Once the initial
primary care consultation has been
conducted, the physician may recommend
a visit to a specialist or surgeon. In the
case of cataract surgery, however, patients
may be referred directly to an ophthalmologist by an optometrist. The second
waiting period, therefore, is defined as
the time between the date of referral and the
date of the specialist/surgical consultation.
Waiting time for the decision to treat (wait #3):
Following the initial specialist/surgical
consultation, patients may take different
paths leading to the treatment decision.
The waiting times experienced by
patients will vary depending on the
course of treatment. The decision to treat
may be made at the initial specialist/
surgical consultation or a subsequent
presurgical consultation if the patient
requires more than one consultation to
reach a treatment decision. In the first
case, patients will not experience any
Decision to Treat
Diagnostic Test
Wait #3
Wait #3a
Specialist/Surgical
Consultation
Referral to Other
Specialist(s)
Wait #3b
Wait #2
Primary Care
Consultation
Optometrist
Consultation
Wait #1
First Contact with
Primary Care
Practitioner
waiting. In the latter case, the time
lapsed between the first consultation
and the decision to treat cannot be
considered a waiting period (in the
traditional sense), since prior to a
decision to treat, there is no treatment
for which the patient is waiting. In some
cases, patients may be placed on a
waiting list in anticipation of the
potential need for treatment, assuming
they will need care once they reach the
top of the queue. The waiting times for
these patients, however, will appear
exceedingly long compared with the
waits of those placed on the list following
the treatment decision. This may occur in
situations where waiting lists are “gamed”
to improve access for selected patients.
Waiting time for major diagnostic tests (wait
#3a): Alternatively, diagnostic tests may
be required to make or confirm
diagnoses and treatment decisions. In
some cases, only specialists may make
requests for diagnostic tests, while in
other jurisdictions, the request may be
made directly by a primary care
practitioner. The waiting time for
diagnostic tests (wait #3a), therefore, is
generally defined as the time between the
date of the request for a test and the date of
examination.
Waiting time for subsequent specialist/surgical
consultation (wait #3b): Patients with more
complex diagnoses may be referred to a
second specialist or surgeon for further
consultation before a decision to treat
Healthcare Management Forum Gestion des soins de santé
51
can be made. For example, patients
requiring surgical treatment may be
referred to the surgeon following an
initial specialist consultation. In such
cases, patients may be facing a subsequent specialist consultation waiting
time (wait #3b) defined as the time between
the referral date from the first specialist to the
date of the subsequent specialist/surgical
consultation.
Waiting time for surgery (wait #4): Once
the decision to treat has been made,
patients will likely face a final waiting
time for surgery. As noted in the
literature and in the path to care, this
waiting time may begin at one of two
points in time: at the time of the
treatment decision, or at the time of
hospital “booking.” In the case of the first
starting point, the last presurgical
consultation with the specialist or
surgeon is commonly assumed to be
when the decision to treat is made. The
surgical waiting time, therefore, may be
defined as the time between the date of the
decision to treat and the date of surgery (wait
#4a).
book patients or place patients on
hospital waiting lists.
Waits for MRI
The route to MRI examinations, like other
diagnostic tests, will depend in part on
the jurisdictional policies that determine
access to these services. In many cases,
patients referred for MRI examinations
may experience waits similar to those
discussed above for surgery, namely
waits for a primary care consultation
(wait #1) and for an initial specialist
consultation (wait #2) (figure 2). The
same definitions are applied to these
waits and therefore do not require further
discussion. There are several options for
defining waits for MRIs.
Waiting time for receipt of request for MRI
(wait #3a1): In some areas, MRIs can only
52
Waiting time for MRI (wait #3a2): The
more significant waiting period for MRIs
begins after the request has been
received and reviewed by the radiologist.
This waiting period is defined as the time
between when the request for an MRI has been
accepted by the radiology department or MRI
clinic and the date of the MRI examination.
Figure 2: Waiting Times for MRI Examinations
MRI Examination
Wait #3a(2)
Alternatively, the surgical waiting time
may begin when the patient is booked for
surgery or placed on the hospital waiting
list. The surgical waiting time, therefore,
may alternatively be defined as the time
between the date of booking or placement on
the hospital waiting list and the date of
surgery (wait #4b).
This definition, however, does not
capture the elapsed time between the
decision to treat and the date of booking
or placement on the hospital waiting list.
In most cases, this waiting time is likely
to be negligible when physicians request
bookings immediately following the
treatment decision. However, they may
choose to delay this request for various
reasons (e.g., confirmation of operating
room time). Although the patient has
been waiting for surgery since the initial
decision to treat was made, their
“official” waiting time, as calculated
using the booking date or date of
placement on the waiting list, will be
significantly shorter. The validity of this
definition, therefore, is dependent in part
on the processes and strategies used to
be requested by a specialist; in other
areas, they can be requested by a primary
care practitioner. The first waiting period,
therefore, is defined as the time between the
request for an MRI and when the request is
accepted by the radiologist. This waiting
period is likely negligible if requests are
made in a timely manner. However, given
the lack of standard processes within and
across jurisdictions, it is difficult to
estimate whether, or to what extent, this
is the case in all areas.
Request received and
reviewed by the
radiologist
Wait #3a(1)
Request for MRI
Note: In some
jurisdictions
GPs are
permitted to
request MRIs
Healthcare Management Forum Gestion des soins de santé
Specialist Consultation
(incl. Hospital inpatients)
Wait #2
Primary Care
Consultation
Wait #1
First Contact with
Primary Care
Practitioner
Referral to Surgeon
Alternatively, the two waiting periods can
be combined in the following definition
for MRI waits: the time between the date of
request for an MRI examination and the date
of the examination (wait 3a). This definition
may be appropriate in jurisdictions
where standard request forms or letters
are used that provide a referral date.
Since the waiting period for patients
begins when they and their physician
decide that an MRI is necessary, this
definition more accurately reflects the
waiting time experienced by patients.
Discussion
Building on the existing information
regarding definitions for waiting times
and the expertise of the WCWL clinical
panels, waiting times for surgery and
MRIs were identified and defined.
Standard definitions can be applied
across a range of services and procedures
with similar waiting periods.
The implementation and operationalization of such standards will likely meet
various challenges. The degree to which
processes and procedures used to deliver
care are standardized across procedures
and jurisdictions will affect the ability to
operationalize standard measures of waits.
Measuring waits for specialist/surgical
consultations or MRIs, for example, is
dependent on the availability of accurate
information regarding the referral
processes for these services. Currently,
various methods are used to refer
patients including phone, mail, fax or, in
some cases, e-mail. Valid information
regarding referral dates is critical to
measure waits that begin with this date.
The availability of existing waiting time
data and the use of standard procedures
in the delivery of care will also affect the
ability to implement national standards
for waiting times. In some provinces such
as Ontario and British Columbia,
information systems are in place to
capture waiting time data for a range of
procedures. This, however, is not the case
in all jurisdictions nor for all specialty
groups. The implementation process
may involve the establishment of information systems to collect data based on
standard definitions of waiting times.
Perhaps the immediate challenge lies in
the next steps toward the establishment
of standard definitions for waiting times
in Canada. To achieve this goal, a
national initiative must be mobilized to
seek consensus regarding standard
definitions among key stakeholder
groups including physicians, healthcare
managers, policy makers, patients and
academics as well as relevant national
groups charged with reporting the state
of the healthcare system. Wherever
possible, standard definitions should be
identified and adopted for similar
waiting experiences within and across
specialty and procedure groups. This
process should be supported by a
structure, newly established or currently
existing, with the ability and capacity to
work at the national level and across a
broad range of healthcare services.
7. Bellan L, Mathen M. The Manitoba cataract waiting list
program. Canadian Medical Association Journal
2001;164(8):1177.
8. Glynn P, Taylor M, Hudson A. Surgical wait list
management: a strategy for Saskatchewan. A report to
Saskatchewan Health; January 2002.
9. Hadorn DC. The Steering Committee of the WCWL. Setting
priorities for waiting lists: defining our terms. Canadian
Medical Association Journal 2000;163(7):857–860.
10. Hochuli VK. Orthopaedic waiting list reduction through a
review of service provision: the problems encountered.
Royal Society of Medicine 1988;81:445–447.
11. Department of Health. NHS data manual: aggregate level
data. Version 5.0. United Kingdom: the Department;
September 1997.
12. British Columbia Medical Association. Waiting list report.
Vancouver: the Association; April 1998.
13. Williams DRR, West RJ, Hagard S, Dias AFS. Waiting list
monitoring using information from hospital activity
analysis and SBH 203 returns. Community Medicine
1983;5:311–316.
14. Hanning M. Maximum waiting-time guarantee—an
attempt to reduce waiting list size in Sweden. Health Policy
1996:17–35.
15. Coyte PC, Wright JG, Hawker GA, Bombardier C, Dittus RS,
Paul JE, et al. Waiting times for knee-replacement surgery in
the U.S. and Ontario. New England Journal of Medicine
1994;331(4):1068–1071.
16. Bloom BS, Fendrick AM. Waiting for care: queuing and
resource allocation. Medical Care 1987;25(2):131–139.
Efforts to establish standard definitions
for waiting times represent one of several
strategies being developed to address
the issue of waiting lists and waiting
times in Canada. Together, these
approaches clearly mark a shift toward
the development of strategies to provide
valid and accurate information on
waiting times better to inform patients,
healthcare providers and policy makers.
Acknowledgment
The Western Canada Waiting List Project was supported by a
financial contribution from the Health Transition Fund (Health
Canada) as Project NA489. The views expressed herein do not
necessarily represent the official policy of federal, provincial or
territorial governments.
References and Notes
1. Romanow RJ. Commission on the future of health care in
Canada. Ottawa: the Commission; 2002.
2. Sanmartin C, Houle C, Berthelot JM, White K. Access to
healthcare services in Canada, 2001. Statistics Canada
catalogue no. 82-32259–2. Ottawa: Minister of Industry;
2002.
3. DeCoster C. Measuring and managing waiting times: what’s
to be done? Healthcare Management Forum 2002;15(2):6–10.
4. McDonald P, Shortt S, Sanmartin C, Barer M, Lewis S, Sheps
S. Waiting lists and waiting times for healthcare in Canada:
More management!! More money?? Ottawa: Health
Canada; 1998.
5. Sanmartin C, Shortt SED, Barer ML, Sheps S, Lewis S,
McDonald P. Waiting for medical services in Canada: lots of
heat, but little light. Canadian Medical Association Journal
2000;162(9):1302–1310.
6. Government of Canada. Healthy Canadians: a federal report
on comparable health indicators 2002. Ottawa: Her Majesty
the Queen in Right of Canada; 2002.
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