The 7 Access to Care Subgroups

Leadership. Knowledge. Community.

The Patient Journey - Progress 2008 Symposium: CCS Benchmarks for Access to Cardiovascular Services and Procedures:

Leadership. Knowledge. Community.2

The 7 Access to Care Subgroups

Subgroup Chair

Specialist consultation and non-invasive tests

Dr. Merril Knudtson

Nuclear cardiology Dr. Rob Beanlands

Emergent and urgent situations Dr. Blair O’Neill

Revascularization and other cardiac surgeries

Dr. David RossDr. Michelle Graham

Heart failure clinics Dr. Heather Ross

Electrophysiology services Dr. Chris Simpson

Rehabilitation Dr. Bill Dafoe


Subgroup Methodology• Used the best evidence and expert opinion and

consensus where necessary:– Searched the literature, where available

– Reviewed existing clinical practice guidelines and standards

– Surveyed Canadian centres

– Considered measures of appropriateness

– Developed a consensus opinion

– Submitted recommendations to secondary review

– Prepared findings for publication in the Canadian Journal of Cardiology


The Cardiovascular Continuum of CareOnset of

symptoms

Non-invasive testing

General practitioner

Specialist consult

Emergency departmentor hospital admission

Therapeutic procedure (e.g., surgery, angioplasty, pacemaker, ICD, ablation)

Invasive and/or non-invasive

testing

Rehabilitation

PERIOD 1

PERIOD 3

PERIOD 4

PERIOD 5Total Patient Wait Time = PERIOD 1 + 2 + 3 + 4 + 5

PERIOD 2

Secondary preventionand rehabilitation

Non-invasive testing Subspecialist

consult

Chronic Disease Management Programs

Chronic Disease Management Programs


The Patient’s PerspectiveWait-time Interval Max (wks)

Symptom onset to Family Physician Unknown

Family Physician to Cardiologist 6

Cardiologist to Angiogram 6

Angiogram to Cardiac Surgeon6*

Cardiac Surgeon to Bypass Surgery

Bypass Surgery to Rehabilitation 4

Total Wait Time for the Patient 22

In some jurisdictions, both wait periods are included in the measured interval.


CCS ACCESS TO CARDIOVASCULAR CARE RECOMMENDED WAIT TIME TARGETS

Subgroup EmergencyEmergency Semi-urgentSemi-urgent ScheduledScheduled

Specialist consultation/ non-invasive tests

< 24 hours< 24 hours Urgent SUUrgent SU

< 1 week < 4 < 1 week < 4 weeksweeks

< 6 weeks< 6 weeks

Nuclear cardiology < 24 hours< 24 hours < 3 days< 3 days < 14 days< 14 days

Echocardiography < 24 hours< 24 hours < 7 days< 7 days < 30 days< 30 days

Emergent and urgent revascularizations

NSTEACS < 48NSTEACS < 48

STEMI < 24STEMI < 24

Urgent SUUrgent SU

< 7 days < 14 days< 7 days < 14 days

< 6 weeks< 6 weeks

Revascularization and other cardiac surgeries


< 7 days < 2-4wks< 7 days < 2-4wks

< 6 weeks< 6 weeks

Heart failure disease management clinics


< 1-2 wks < 4 wks< 1-2 wks < 4 wks

< 6 – 12 weeks< 6 – 12 weeks

Electrophysiology services

<1-3 days<1-3 days Urgent SUUrgent SU

< 2 weeks <4-6 wks< 2 weeks <4-6 wks

< 3 months< 3 months

Rehabilitation < 3 days< 3 days < 7 days< 7 days < 30 days< 30 days


Preconsultation Testing and InfoThe details of the most recent cardiac investigations or

procedures:

• Copies of the most recent cardiovascular or other relevant consultations

• The indication for reassessment, if a patient has been previously evaluated

• A current list of medications, noncardiac diseases and allergies.

Can J Cardiol 2006;22(10):819-824.


Improving Access to SpecialistsImproving Access to Specialists

Cardiology


The CCS National Survey onAccess to Care

at Tertiary Cardiac Care Centres

• Summer 2007 – Summary Results


Survey Objectives

– Enable better understanding of access issues, including wait times and the use of wait time targets, for cardiovascular services and procedures across the country

– Assess awareness of and support for the CCS benchmarks

– Solicit the cardiovascular community’s views on government actions to date


Survey Methods

• Mailed hard copy of the survey to 54 tertiary cardiac centers' across Canada

• Followed up intensively over two-month period with faxes, phone calls and emails

• Received 17 responses (31%)


Response Rate by Province

0%

20%

40%

60%

80%

100%

Re

sp

on

se

ra

te

BC AL SK MN ON * PQ NB NS NL Canada

2

3 1

45

1

17

1

0 0

11 academic, 2 community, and 4 regional centres responded 13 respondents were Chiefs of Cardiology

•1 tertiary and 3 community and centres responded in Ontario


Key Themes• Despite monitoring wait times for more than 5

years, fewer than half the centres rated access as “excellent” or “very good”

• Top barriers are the availability of human resources, funding, physical resources and infrastructure

• Respondents supported the need for standardized benchmarks along the entire continuum

• Respondents strongly support the CCS Wait Time Benchmarks

• Government action in past two years has been “Fair”


How would you rate access to cardiac care at your centre?

0 2 4 6 8

Poor

Fair

GoodVery

Excellent

Number of respondents

8 of 17 rated access as “excellent” or “very good”15 of 17 have been monitoring wait times for > 5 years


Does your cardiac care centre have wait time targets for:

Yes No Not offered

Monitor only

N/A Total

Cath 12 0 1 1 14

Angioplasty 11 1 1 1 14

Cardiac surgery 9 2 1 1 1 14

Hospital transfers 8 4 1 13

Permanent pacemaker 6 6 2 14

Catheter ablation 6 4 2 2 14

ICDs 6 4 2 2 14

5 centres had wait time targets for Initial specialist consultation, echocardiography, cardiac nuclear imaging, CHF clinic, electrophysiologist consultation, CRT and cardiac rehabilitation


What was the basis for establishing the targets that you have?

0 2 4 6 8

Not spec ified

Centre-spec ific

Combination

Provinc ial benchmarks

CCS benchmarks

Number of responses

CCS benchmarks adopted in centres in BC, Alberta, Quebec and Nova Scotia.All 5 centres using provincial benchmarks are in Ontario and Quebec.


How would you rate your cardiac care centre’s commitment to setting access targets?

0 2 4 6 8 10

Little or no

Low

Good

Strong

Very strong

Number of responses

“Low” or “Little or no” reported in Manitoba and Ontario.


Prior to this survey, how would you describe your awareness of the CCS benchmarks?

0 1 2 3 4 5 6

N/A

Poor

Fair

Good

Very good

Excellent

Number of responses

The CCS benchmarks have been well communicated among the survey respondents.


How would you describe the level of awareness among professional (medical, clinical and administrative) staff?

0 1 2 3 4 5 6

N/A

Poor

Fair

Good

Very good

Excellent

Number of responses

The CCS benchmarks are not as well known among other medical, clinical and administrative staff. 38% rated “fair” or “poor”


Barriers to the adoption of access targets for a broad range of CV services and procedures, in order of importance/ significance

1. Lack of human resources

2. Lack of funding

3. Lack of physical resources

4. Lack of infrastructure

5. Liability concerns for physicians and administrators

6. No or low awareness of the CCS benchmarks

7. Not perceived as a priority at this time


Key individuals and groups whose support is necessary for the adoption of benchmarks for the full continuum of care, in order of significance:

1. Medical leadership within hospitals

2. Minister or Deputy Minister of Health

3. Hospital administrators

4. Medical leadership within academic institutions

5. Ministry or Minister of Health staff

6. Staff at regional or local health authorities

7. Medical leadership within the community


How important is it to have targets for a broad range of services and procedures across the continuum of care?• 17/17 said “Very important” or “Important”

How important is it that targets be standardized across all cardiac care centres in Canada?

• 15/17 said “Very important” or “Important”


How credible are the CCS benchmarks?

• 13/17 said “Highly credible” or “Very credible”• The other 4 said “Credible”

How important is it that the CCS benchmarks be adopted by all centres?• 15/17 said “Very important” or “Important”• The other 2 said “Somewhat important”

How feasible is it that the CCS benchmarks be adopted within 2 years?

• 14/17 said “Feasible” or “Somewhat feasible


How appropriate is it to measure access by choosing one benchmarks such as access to cardiac surgery?

Respondents

Inappropriate to not measure access to the whole continuum

8

A “cherry picked” benchmark as access to cardiac surgery is not a problem in most of the country

5

A good start if part of a strategy to address access to the rest of the continuum

3

Other (Maybe not the right one) 1

A good start 0


What grade would you give to governments for how well they have meaningfully addressed wait times for CV over last 2 years?

0

2

4

6

8

10

12

Nu

mb

er

of

rep

on

de

nts

Fail Poor Fair Good Excellent

Most respondents (71%) gave a grade of “Fair”.


Conclusions:• Improving access is about accounting for all major services

and procedures that lead to optimal care during the patient’s journey

• Improving access is about building systems and continuously monitoring results and improving upon them

• Improving access will require innovative solutions to overcome human resource issues

• Improving access is about all levels (Ministry, Administration, providers) working together to optimize the patient journey

The 7 Access to Care Subgroups

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