中国话题 关于加拿大医疗服务等候时间长短政府和民众看法不一,请看研究文章

  • 主题发起人 NewEngland
  • 发布时间 2007-11-12
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Waiting for medical services in Canada: lots of heat, but little light

[FONT=verdana,arial,helvetica]Claudia Sanmartin*, Samuel E.D. Shortt
, Morris L. Barer*
, Sam Sheps*, Steven Lewis
¶ and Paul W. McDonald** [/FONT]


[FONT=verdana,arial,helvetica][SIZE=-1]From the *Department of Health Care and Epidemiology, University of British Columbia, Vancouver, BC;
Queen's Health Policy Research Unit, Department of Community Health and Epidemiology, Queen's University, Kingston, Ont.; the
Centre for Health Services and Policy Research, University of British Columbia, Vancouver, BC;
Access Consulting Limited, Saskatoon, Sask.; the ¶Department of Community Health Sciences, University of Calgary, Calgary, Alta.; and the **Department of Health Studies and Gerontology, University of Waterloo, Waterloo, Ont. [/SIZE][/FONT]
Canadians' long-standing approval of their health care system declined significantly during the 1990s. While 61% of respondents to a 1991 Angus Reid poll rated the system "excellent" or "very good," that figure had fallen to 52% by 1995, and was just 24% in 1999.1 This erosion of confidence may have been fuelled, in part, by extensive media coverage of claims about increased waiting times for many surgical procedures and investigations. Almost two-thirds of those surveyed in a 1997 CMA poll felt that waiting times for surgery had grown over the previous 12 months, and half felt that access to specialists had become more difficult.2 These figures were up from 53% and 40% respectively in a similar 1996 poll.2
Recent surveys of family physicians,3,4 specialists5,6 and health-related nongovernmental organizations7 suggest that they share the public's perceptions. In contrast, provincial government officials generally appear much less convinced that waiting is a pressing issue.8 Moreover, empirical studies published by 3 provincial governments between 1996 and 1998 reported no significant increase in waiting times for most surgical procedures.9-11
This disagreement is but one example of the disjunction between common understandings and evidence about waiting lists in Canada. In this paper we suggest that confusion over terminology, differences in measurement approaches and a general lack of awareness of the relative effectiveness of different approaches to managing waiting lists and waiting times all hamper real progress in this area. In particular, we focus on the underpinnings of disagreements about (1) the nature and extent of waiting-list issues and (2) effective policy intervention.
[FONT=verdana,arial,helvetica][SIZE=+2]What causes variability in perceptions about waiting lists and waiting times in Canada?[/SIZE][/FONT]
The first major source of variability in perceptions about waiting times is the lack of standards governing whether and when a patient is placed on a waiting list. Episodes of illness involve highly variable diagnosis and treatment trajectories, and a single care episode may involve waits at several different points. Furthermore, although waiting time should theoretically start when the physician and the patient agree that the treatment in question is appropriate, in practice other considerations feature in the decision calculus. For example, in the absence of systematic clinical thresholds and audits, some physicians may feel impelled, in their patients' interests, to add patients' names to long lists in anticipation of future need for a service. The result is considerable variability in when patients are, or are assumed to be, placed on lists. This point may be variously defined as the date of facility notification or booking,12 the date of the last surgical consultation before surgery,9,11 the time of angiography (for coronary artery bypass grafting lists)13 or the date of the first visit to a general practitioner (GP).14 For example, 58% of organizations responding to a recent survey considered the point when a clinic is notified as the start of waiting time for MRI.15 Waiting times for knee and hip replacement and cataract surgery were also most likely to be viewed as starting at the point of facility notification.15 In contrast, waiting times for radiation oncology were more likely to be perceived as starting at the point of treatment decision.15
A second source of variability is measurement method.16-19 The cross-sectional method would be used to answer the question, "How long have patients currently on a list been waiting?" If, instead, one wished to know how long the patients who received treatment during December 1999 had waited, the retrospective method would be used. Alternatively, one could use the prospective method to track waiting times from the point at which patients were placed on a list for a treatment (e.g., total waiting time to treatment of all patients put on a list during January 1997). Finally, combinations of these 3 methods might be used to estimate the expected waiting time for patients placed on a list today. Each of these methods is legitimate for answering a certain question, and each provides a different picture of waiting times.20 There is no single "correct" question; it is thus not surprising to find variability, as different sources choose different measurement methods to meet their particular information needs or objectives.
For example, the BC Surgical Waiting List Registry and the Ontario Cardiac Care Network provide both cross-sectional and retrospective waiting-time data.10,21 The Fraser Institute's annual reports6,22-24 are based on questionnaires sent to random samples of physicians who offer opinions about the amount of time a new patient can expect to wait for a range of surgical and diagnostic procedures. This is, according to the taxonomy outlined above, expected waiting time. The British Columbia Medical Association has recently begun to collect information on waiting times for selected procedures. The data are based on responses from specialists asked to report waiting times from GP referral to first surgical consultation and from consultation to surgery.25 These appear to be retrospective, based on recent personal experiences and practices. Recent studies by the Nova Scotia Department of Health9 and the University of Manitoba11 defined waiting times as the time between last surgical consultation and date of surgery, which is also a retrospective approach.
A third source of variability lies in the statistics used for reporting waiting times. Mean and median waiting times, as well as interval measures such as proportions of patients who have waited for more than 60 days, are all common. Because waiting time distributions are almost always highly skewed by small numbers of long waits, mean waiting times can be highly misleading, particularly if they are used as representations of expected waits.
A fourth reason for disagreement about the length of waiting lists in Canada is the way in which such lists are developed and managed. Most lists are created and maintained in the offices of individual physicians or hospital surgical or diagnostic departments rather than by a regional authority or other coordinating agency.26,27 Examples of coordination among physicians are rare, and among institutions or regions, rarer still. This gives rise to 2 sources of uncertainty in reported waiting times or list lengths. First, there is considerable variability in both list lengths and waiting times among individual physicians, among institutions and among regions. Waiting-time estimates usually assume that the patient will stay on the list on which he or she was originally placed, even if waiting time would be shorter on a different practitioner's list. Second, Canadian lists are not audited. As a result, the validity and reliability of statistics based on those lists are simply not known. Elsewhere (particularly in the United Kingdom), systematic clinical audits, employing a range of methods, have consistently found significant proportions of patients on lists who should not be there. Independent chart reviews and clinical assessments, as well as patient surveys, have revealed proportions of patients inappropriately placed on lists ranging from 15% to 70%, clustering in the 20% to 40% range.28-37 The reasons for inappropriate inclusion on waiting lists encompassed a variety of situations: the procedure had already been done or was no longer required; the patient was not aware of being on a list and requested removal when so informed; the patient had died; the procedure was not appropriate for the patient; an alternative treatment was preferable; and there had been a change in the clinical condition.
[FONT=verdana,arial,helvetica][SIZE=+2]Does evidence inform Canadian policy approaches to reducing waiting times?[/SIZE][/FONT]
Respondents to a series of recent surveys, drawn from provincial ministries of health, hospitals, regional health authorities and nongovernmental health organizations, reported that the 2 most common causes of excessive waiting times were inadequate resources and poor management of existing resources.7,8 The most frequently offered solution was to increase funding (on a global basis or targeted to relieve perceived bottlenecks such as lack of operating suites) in 1 of 2 ways: "let the private sector in" or allocate additional public funding. Yet here, too, the evidence (in this case based on experiences in Canada and other jurisdictions with policies directed at shortening and rationalizing public-sector waiting lists) is at odds with widely held "understandings."
[FONT=verdana,arial,helvetica][SIZE=+1]Is there promise in a two-tier solution?[/SIZE][/FONT]
The argument that waiting times for publicly funded services can be shortened by introducing or increasing access to private care for those who wish to pay is simple and intuitive, giving it wide popular appeal. Additional private-sector capacity would reduce pressure on the public system - a win-win situation in which those who wish, and can afford, to pay receive care faster, and the rest see the line-up in front of them shrink, which reduces the critical time to procedure.
There are 2 problems with this line of reasoning. First, in a system of roughly fixed per capita human resources (in the short term), where it is increasingly argued that those key resources (e.g., physicians and nurses) are already in short supply, it is difficult to understand how channeling some of that human capacity into private activity would reduce public-sector waits. One might argue that the presence of public-sector waiting lists provides a rationale for increasing training. But whether Canadians at large would embrace the training of additional personnel, largely at public expense, so that a parallel private sector could flourish, is an empirical question, to date unasked.
Second, there is no evidence to support the contention. The presence of a flourishing private option in the United Kingdom does not appear to have provided relief for public-sector waiting lists, despite the fact that this private option is exercised by approximately 13% of the population.38 The bulk of private surgical work focuses on hips, hernias, hemorrhoids, cataracts and gynecologic problems, which are some of the conditions with the longest waiting times in the public sector. Regions with the longest waiting lists also have the highest rates of private surgery. There is concern that this link reflects the ability of surgeons who maintain long waiting lists to encourage better-off patients to jump the queue and pay for elective surgery privately.14 Despite regulations that limit the amount of private practice to be done by consultants, this policy is neither adhered to nor enforced.38-40 Similar evidence emerged recently from Manitoba and Alberta; ophthalmologists who performed cataract surgery in both public and private facilities had considerably longer median public-sector waiting times than did their colleagues who operated only within the public system.41,42
In the United Kingdom it has been suggested that the public system could subsidize patients seeking private care up to the current cost of public care.43,44 It is doubtful that such options would find acceptance from a Canadian public that continues to express strong support for a universal, publicly funded system (although there is no avoiding the fact that they do perceive problems of erosion in that public system, as outlined above). For example, when Manitoba cataract patients were surveyed before surgery, only 15% responded that they would be willing to pay for private care or accept increased taxes to guarantee more rapid access to the public system.45 Similarly, in more than 85% of cases, Canadians in line for knee replacement found waiting times acceptable, even though they were waiting longer than US patients who needed the same procedure.46,47 There has been limited Canadian experience with selective public purchase of private services in the United States,48,49 and this practice continues infrequently on an ad hoc basis. In addition, there are periodic claims about Canadians flocking south to purchase care privately, but here as well the evidence is thin.50,51
[FONT=verdana,arial,helvetica][SIZE=+1]Sticking with one tier: Just add more funds[/SIZE][/FONT]
Possibly because the relationship is considered self-evident, research examining the correlation between waiting times and changes in available resources is relatively scant. In some cases additional resources have reduced waiting times (at least temporarily). Ontario's successful attack on coronary artery bypass queues initiated in 1989, for example, combined organizational changes with enhanced resources.52 But here, as elsewhere,36,53-57 reductions in waiting times appear transient in the absence of regular, periodic infusions of additional resources.
In general, attempts to reduce waiting-list length or waiting times simply by adding resources do not appear to have succeeded over the longer term58 and may even have had adverse consequences. UK initiatives targeting patients who had endured particularly lengthy waits did, indeed, reduce long waits. Unfortunately, a key effect of these initiatives was to increase waiting times for higher-priority patients who had been on the lists for less than the list-clearing threshold time.59-61 Nor is this lack of improvement confined to surgery.62-64
Additional resources have also been found to increase list lengths or waiting times. In Manitoba the volume of cataract procedures increased considerably between 1992/93 and 1996/97; over the same period, median waiting time also increased.11 A study of several surgical services in the United Kingdom found that as the number of hospital admissions from the list increased, so too did the length of the waiting list.65 This "feedback" phenomenon reflects a tendency of family physicians to preferentially increase referrals to consultant services that appear to have shrinking waiting lists, thereby offsetting any initial reductions in list length.66 Adding surgeons to a hospital in the United Kingdom reduced pre-existing lists, but within 2 years new lists had been generated.67 Hospital-based physicians in the United Kingdom have no real incentives to cut waiting lists;43 adding resources without explicitly examining the previous threshold at which intervention was deemed appropriate simply encourages individual practitioners' reassessment of what "needs" to be treated, thus lengthening lists rather than reducing them.68 A recent Australian commentary noted that hospital managers who received extra resources to deal with long waiting lists had little incentive to reduce lists too much, as long as the prospect of attracting additional resources to deal with long lists remained.69
We do not mean to imply that additional resources are never an appropriate response to situations in which waiting times exceed acceptable clinical thresholds. Rather, the evidence speaks to a lack of the instrumentation necessary to determine the validity of waiting lists in Canada, and also suggests rather unequivocally that adding resources in the absence of other initiatives is unlikely to have any long-term positive effect on waiting times.
[FONT=verdana,arial,helvetica][SIZE=+2]If additional resources are not the magic bullet, then what?[/SIZE][/FONT]
It would be misleading to suggest that all Canadian observers hold the view that additional funding, public or private, is necessary to reduce waiting times. Indeed, increasing numbers of observers are becoming aware of the fourth reason noted above for ambiguity about waiting-list lengths and waiting times - lack of coordination and audit - and see considerable potential in addressing those issues head-on, through improved management techniques.
There is considerable experience, in Canada and elsewhere, from which to develop an evidence base for new management approaches. These approaches are of 3 general types, distinguished by whether the focus is on reducing the need for the service in question, prioritizing the patients awaiting the service or reorganizing patterns of care.
[FONT=verdana,arial,helvetica][SIZE=+1]Reducing "demand"[/SIZE][/FONT]
As we noted above, there would seem to be considerable potential in independent list audits. Furthermore, even systematic self-review can reduce the number of patients on lists.28 Periodic reassessment of patients can reduce last-minute cancellations and shorten lists by removing patients well in advance.70
[FONT=verdana,arial,helvetica][SIZE=+1]Prioritization[/SIZE][/FONT]
Prioritization approaches modify the order in which patients on a list receive the service in question. We have already noted the UK list-clearing initiatives, which were directed at patients who had been on waiting lists for inordinately long periods of time. These approaches usually involved minimal extra resources, reconfigured existing resources only temporarily, focused exclusively on patients who had been on surgical lists over a specified length of time, succeeded in reducing the number of patients waiting longer than the specified time and had limited long-term efficacy.53,59,71
In both the United Kingdom and Sweden, guaranteed maximum wait programs have been implemented for selected conditions such as coronary bypass grafting and cataract surgery. These programs give particular priority to patients who are approaching the maximum time threshold. They have tended to be accompanied by increased funding, the rationale being that without such additional resources the guarantees would not be met. The Swedish initiative appears to have partially met its goal by increasing productivity and improving waiting-list management.57
These 2 approaches target patients who have waited, or are likely to wait, longer than managerially determined thresholds (presumably guided by clinical considerations). Other prioritization strategies address all patients on a list in an effort to match a patient's place in the queue with clinically determined "urgency" and to ensure that patients receive services in order of clinical urgency and within times defined as appropriate on the basis of clinical evidence.72,73 The generally positive Ontario experience since 1991 in operating a province-wide, priority-based registry of patients awaiting coronary artery bypass grafting illustrates the local potential of such efforts.13
Waiting can also be managed by altering the way in which lists are constructed and maintained. In the absence of coordinated lists, there may be significant variation in the severity of need of the patients who receive a service and in the length of the lists maintained for the same service or procedure by different physicians. In contrast, centralized waiting lists covering the patients of all physicians in a particular region and for a particular specialty (usually surgical) are more efficient and responsive to relative priority.74-76 In Canada such centralized, coordinated management is rare outside the specialties of oncology and cardiac surgery in a few provinces.
[FONT=verdana,arial,helvetica][SIZE=+1]Other management techniques[/SIZE][/FONT]
In the United Kingdom patients who do not keep appointments are a significant problem for those attempting to manage waiting lists.77 One study reported that prior notification by patients of their intent to miss an outpatient appointment would have reduced waiting time from 6 months to 1 week.78 Some surgeons have replaced waiting lists with prearranged admission dates, which has had the effect of reducing the number of patients who did not attend for admission or who were admitted through emergency departments.79
Finally, a number of approaches to managing how and how quickly patients get onto waiting lists have shown promise in the United Kingdom. When given information on waiting times for outpatient consultation and inpatient treatment, general practitioners demonstrated a willingness to redirect referrals to the clinicians with the shorter waits.80 Moreover, to make time for seeing more new outpatients, consultants have adopted various strategies to reduce follow-up visits for previously assessed patients. For example, a UK study suggested using telephone contact to a greater extent, devolving management back to general practitioners and using nurse clinicians for selected aspects of follow-up.81
[FONT=verdana,arial,helvetica][SIZE=+2]Conclusions[/SIZE][/FONT]
The Canadian debate about access to care, and waiting lists in particular, is characterized by disturbing chasms between widely held views and research evidence. This disjunction appears to be the product of a number of factors, including lack of standard approaches to measurement and reporting of waiting-list lengths and waiting times and a general ignorance (or disregard) of the effects of competing approaches to managing waiting lists in Canada and abroad. It points strongly to the need for a better infrastructure for information about waiting lists in Canada. Without this, discussions about access to care will almost certainly continue to generate more heat than light.
[FONT=verdana,arial,helvetica][SIZE=+2]Sources of variability in reported waiting times[/SIZE][/FONT]
  • Lack of standard definition of when waiting starts
  • First visit to GP about particular problem
  • Time of treatment decision
  • Time when facility is booked
  • Last consultation before surgery
  • Different measures of waiting time
  • Cross-sectional
  • Retrospective
  • Prospective
  • Different statistics reported
  • Mean waiting time
  • Median waiting time
  • Proportion of patients waiting a given period
  • Variation in list management
  • Differences among individual physicians, institutions and regions
  • Lack of audit
[FONT=verdana,arial,helvetica][SIZE=+2]New approaches to managing waiting lists[/SIZE][/FONT]
  • Reduce demand for the service
  • List audits
  • Reassessment of patients on lists
  • Prioritize patients awaiting the service
  • Match place in queue with clinical urgency
  • List coordination
  • Reorganize patterns of care
  • Methods to reduce missed appointments
  • Redirection of referrals to clinicians with shorter lists
  • Reduction of specialist physician follow-up visits
This research was made possible through a contract with Health Canada. The full report, Waiting lists and waiting times for health care in Canada: More management!! More money??, which was completed in 1998, is available from Health Canada or from the authors.
Competing interests: This article is based on research undertaken under contract with Health Canada in 1997-98.
[FONT=verdana,arial,helvetica][SIZE=+2]Acknowledgments[/SIZE][/FONT]
 
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回复: 关于加拿大医疗服务等候时间长短政府和民众看法不一,请看研究文章

disagreements about (1) the nature and extent of waiting-list issues and (2) effective policy intervention.
 
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lack of standard approaches to measurement and reporting of waiting-list lengths and waiting times and a general ignorance (or disregard) of the effects of competing approaches to managing waiting lists in Canada and abroad
 
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Waiting times for specialized services (January to December 2005)
Introduction
Methods
Results
Limitations
Conclusion/Discussion
Glossary

Introduction
Waiting for care has been and continues to be a major issue in the health care sector. Recently provincial and federal ministries of health have adopted a range of policies and strategies to address lengthy waits for care. In 2004, First Ministers agreed to develop a 10-year plan to improve access and reduce waiting times in several key areas including hip and knee replacements and cataract surgery. The plan called for the establishment of benchmarks for medically acceptable waiting times with regular reporting to track progress towards these targets(Health Canada. 2004). In an effort to improve the state of information and to meet reporting requirements, several provincial jurisdictions have developed wait time registries to provide up to date information on waiting for procedures (Ministry of Health, B.C. n.d.), (Alberta Health and Wellness. n.d.), (Ministry of Health and Long-Term Care, Ontario. n.d.), (Nova Scotia Department of Health. n.d.).

Statistics Canada has been reporting on patients’ experiences waiting for care, including how long they wait, since the introduction of the Health Services Access Survey (HSAS) in 2001(C. Sanmartin et al. 2001), (C. Sanmartin et al. 2003). This survey was designed to provide national and provincial level estimates of patients’ experiences accessing health care services including waiting times for specialized services. The survey has now been incorporated into the Canadian Community Health Survey and currently represents the only national level information on waiting times. Preliminary results from the first 6 months of data collection were reported in January 2006. In this report, we provide updated results on patients’ experiences waiting for care based on the full 12 months of data for 2005.

Methods
Data
The report is based on a sub-sample of the 2005 Canadian Community Health Survey (CCHS). It represents approximately 98% of the population of Canadians aged 15 and older living in private dwellings in the 10 provinces. Excluded from this report are residents of the three territories, those living on Indian reserves or Crown lands, residents in institutions, full-time members of the Canadian Forces, and residents of certain remote regions. The data were collected by personal and telephone interviews between January and December 2005.

Since the respondents are a subsample of the CCHS, the same multiple sample frames of this parent survey apply. The CCHS uses the area frame designed for the Canadian Labour Force Survey (LFS). The sampling plan of the LFS is a multistage stratified cluster design in which the dwelling is the final sampling unit. The CCHS also uses two types of telephone frames: list frames and a random digit dialling (RDD) sampling frame of telephone numbers.

In order to produce reliable estimates at the national and provincial levels, in particular for the estimates of waiting times, a subsample of about 34,000 CCHS respondents was targeted in total for 2005. The subsample was selected using a stratified random sampling technique. The total number of respondents is 33,539. The number of respondents and response rates are provided in Table 1.

It should be noted that the CCHS aims at producing reliable estimates at the health region level, and the HSAS at the national and provincial levels.

Following the collection and processing of the data, the respondents’ records were weighted in order to reflect the sampling and non-response that occurred in the CCHS. Weights were also adjusted to demographic projections by age group and province.

Analytical methods
Weighted distributions and frequencies were produced. Weighted median waiting times were calculated for specialist visits, non-emergency surgery and selected diagnostic tests. Partial or item non-responses accounted for less than 5% of the totals in most analyses; records with item non–responses were excluded from the calculations. The bootstrap technique was used to estimate the variance and confidence intervals to properly account for the complex survey design. This technique fully adjusts for the design effects of the survey. Confidence intervals were established at the level of p = 0.05. For counts, ratios and percentiles estimates, pairwise differences between 2003 and 2005 were deemed statistically significant based on a two-tailed test with p < 0.05. Where multiple proportions were tested, the significance levels were adjusted using the Bonferroni method.

Results
Waiting for care remains the number one barrier to access
While most individuals who accessed a specialized service did not experience any difficulties – some did. (Table 2) Approximately 11% of those 15 years of age or older (2.8 million Canadians) visited a medical specialist in 2005 - among them, 19% reported that they faced difficulties accessing care. Approximately 6% (1.6 million) reported that they had non-emergency surgery - among them, 13% reported that they had difficulty accessing care. Similarly, 9% of the population 15 years and older (2.2 million Canadians) accessed selected diagnostic tests – among them, 13% reported difficulties accessing care.

Those who reported difficulties were asked about the types of barriers they faced. As in previous surveys, waiting too long for care was cited as the number one barrier among those who experienced difficulties. (Table 3) Among those who experienced difficulties accessing a specialist consultation, 68% indicated that waiting was the problem followed by 32% who indicated that they had difficulties getting an appointment.

Among those who had difficulties accessing non-emergency surgery, 66% indicated that it was because they had to wait too long. Over one in five individuals reporting difficulties indicated that they experienced difficulties getting an appointment, a rate similar to 2003 results.

Similarly, among those with difficulties accessing diagnostic tests such as an MRI or CT scan, 59% reported that they waited too long to get an appointment and 36% reported that they waited too long to get the test. The results are similar to those reported in 2003.

Median waiting times remain unchanged at the national level – some differences were noted at the provincial level
In 2005, the median waiting time was about 4 weeks for specialist visits, 4 weeks for non-emergency surgery, and 3 weeks for diagnostic tests. (Table 4, Table 5, Table 6)

Nationally, median waiting times remained stable between 2003 and 2005 – but there were some differences at the provincial level for selected specialized services.

Median waiting times for non-emergency surgery were reduced by half in Quebec from almost 9 weeks in 2003 to 4 weeks in 2005. For diagnostic tests, median waiting times in Newfoundland and Labrador rose significantly from 2 weeks in 2003 to 4 weeks in 2005 and in British Columbia median waits rose from 2 weeks to 3 weeks.

Most patients received specialized services within 3 months
The proportion of patients who waited less than 1 month to receive care ranged from 40% for those accessing non-emergency surgery to 56% among those who received a diagnostic test. (Chart 1; Table 7) The proportion waiting between 1 and 3 months ranged from 33% for diagnostic tests to 41% for specialists visits and non-emergency surgery. The proportion waiting longer than 3 months ranged from 10% for diagnostic tests to 19% for non-emergency surgery. The distribution of waiting times was similar between 2003 and 2005.

Approximately 40% of individuals receiving cardiac and cancer related surgery received care within one month (42%). (Table 8). Approximately one in five (19%) of those receiving joint replacements or cataract or other eye surgery received care within one month.

While most reported waiting times as acceptable – some deemed their waits unacceptably long and some experienced adverse effects
Waiting for care is not inherently problematic but may be considered so when patients experience adverse effects (K.D. Kelly et al. 2001), (H.C. Brownlow et al. 2001), (I.N. Ackerman et al. 2005), (H. Hadjistavropoulos et al. 2001) and/or feel they have simply waited too long for care. The proportion of patients who felt that their waiting time was unacceptable was highest among those who waited for specialist visits (29%) and diagnostic tests (21%) and lowest among those who waited for non-emergency surgery (16%) (Chart 2 ; Table 9) even though individuals are more likely to wait longer (i.e. > 3 months) for non-emergency surgical care compared with other specialized services (Table 7). This points to potential differences regarding thresholds for unacceptable waits across different specialized services – i.e. Canadians appear to be more willing to wait longer for surgery than for a visit to the specialist.

Approximately 18% of individuals who visited a specialist indicated that waiting for the visit affected their life compared with 11% and 12% for non-emergency surgery and diagnostic tests respectively. (Table 10) Most of those who were affected reported that they experienced worry, stress and anxiety during the waiting period: ranging from 49% among those whose lives were affected by waiting for non-emergency surgery to 71% among those affected by waiting for a diagnostic test. (Table 11) Between 38% and 51% of individuals waiting for specialist services experienced pain and close to 36% of those who were affected by waiting for non-emergency surgery indicated that they experienced difficulties with activities of daily living. Approximately 28% of those who were affected by waiting for a diagnostic test indicated that it resulted in worry, stress and anxiety for their friends and family.

Limitations
There are several limitations to the data and the analysis presented in this report. The data are based on self-reported information for both service needs and difficulties accessing services over a 12-month period; as such, the information may be subject to recall bias and has not been clinically validated. To reduce reporting error due to recall bias, questions repeatedly referred to services used in the last 12 months.

Reliable estimates at the national and provincial levels could not be produced for all the variables, given that, in some cases, very few individuals may actually need services or experience difficulties and the survey sample may be too small to detect sufficient cases needed to generate reliable estimates.

There are also several limitations to the HSAS data relating to estimates of waiting times for specialist services. Waiting time estimates are retrospective and included only those who completed their waiting periods and received care. The data do not reflect the waiting times of those still waiting at the time of the survey. Respondents could report waiting times in days, weeks or months, and many may have rounded their waiting times. For these reasons, direct comparisons of waiting time estimates presented in these tables with estimates based from other sources, such as waiting time registries, health administrative data and physician reports, should be made with extreme caution.

Conclusions/Discussion
Statistics Canada continues to provide information regarding patients’ experiences accessing care at the national and provincial levels. The results for 2005 indicate that waiting for care remains the number one barrier for those having difficulties accessing care. Median waiting times for all specialized services have remained relatively stable between 2003 and 2005 at 3 to 4 weeks, depending on the type of care. There were some differences noted in selected provinces. Most individuals continue to report that they received care within 3 months.

Similarly, patients’ views about waiting for care have remained fairly stable between 2003 and 2005. While 70 to 80 percent indicated that their waiting time was acceptable – there continues to be a proportion of Canadians who feel they are waiting an unacceptably long time for care.

The Canadian Community Health Survey provides valuable information regarding patients’ experiences waiting for care. These data will be further explored to better understand the factors associated with long waits and adverse experiences while waiting for specialized services.

Glossary
Diagnostic test: MRI, CT scan or angiography requested by a physician to determine or confirm a diagnosis; does not include X-rays, blood test, etc.

Non-emergency surgery: Booked or planned surgery provided on an outpatient or inpatient basis; does not refer to surgery provided through an admission to the hospital emergency room as a result of, for example, an accident or life-threatening situation.

Specialist visits: Visit with a medical specialist to obtain a diagnosis for a new illness or condition; does not include specialist visits for ongoing care for a previously diagnosed condition.

Specialized services: Services including specialist visits for a new illness or condition, non-emergency surgery other than dental surgery, and selected diagnostic tests (non-emergency MRIs, CT scans, and angiographies).

Waiting times
Specialist visit: Time between when individuals and their doctor decided that they should see a specialist and the day of the visit.

Non-emergency surgery: Time between when individuals and their surgeon decided to go ahead with the surgery and the day of surgery.

Diagnostic tests: Time between when individuals and their doctor decided to go ahead with the test and the day of the test.
 
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In 2005, the median waiting time was about 4 weeks for specialist visits, 4 weeks for non-emergency surgery, and 3 weeks for diagnostic tests. (Table 4, Table 5, Table 6)
 
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In 2005, the median waiting time was about 4 weeks for specialist visits, 4 weeks for non-emergency surgery, and 3 weeks for diagnostic tests. (Table 4, Table 5, Table 6)
至少不是某人随口讲的“否则一般慢性病等几年都没人理“。
 
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回复: 关于加拿大医疗服务等候时间长短政府和民众看法不一,请看研究文章

新闻报道:

Wait times vary for patients first treated at ERs
Updated Thu. Oct. 18 2007 2:30 PM ET

CTV.ca News Staff

Wait times for beds at acute care hospitals vary greatly in cases when a patient has first been treated at an emergency department, finds a new study.


Outside Quebec, 60 per cent of overall patients admitted to an acute care hospital -- for reasons other than childbirth -- first visited an emergency department (EDs), says the Canadian Institute for Health Information (CIHI), which compiled the report.


The report found that in 2005 half of all patients admitted to hospital through Canada's EDs waited 1.7 hours or less for a bed once a doctor made the decision to admit.


The 10 per cent of patients with the shortest waits were transferred immediately while the 10 per cent with the longest waits didn't get a bed until 15.1 hours or more.


"Those patients are being cared for but in an ideal system they would be transferred in a more timely manner to the in-patient side of the system," CIHI's Greg Webster told CTV's Canada AM on Thursday.


Every year, Canadians make more than 14 million visits to EDs with more than one million patients subsequently being admitted to hospital, says the CIHI.


The study was based on 277 hospitals, outside of Quebec, that each collected wait time data in a similar way.


In 2005, 4 per cent of patients admitted to EDs waiting more than 24 hours for acute care beds.


"These patients tended to be older and have multiple health problems. They also had longer average lengths of stay in hospital after leaving the ED," the report found.


The study also found factors such as time of day, the day of the week and the month of the visit affected wait times.


In large community and teaching hospitals, ED bed wait times were typically longer during the day, on weekdays and from November to March.


Further, patients at small community hospitals waited less than those who went to larger community and teaching hospitals.


"What we can see is that there may be some ways in terms of how the services are being organized within the health care system that are contributing to these wait times," said Webster.


"In some cases it may be the actual capacity of the hospital, in other instances there may be opportunities to improve the management of the beds within the hospital."



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Please Add Comments(8)

Donna McClure
On Jan. 31st. of this year, I had a bad fall on icy stairs. I waited 91/2 hours in Emergency, without even something for the dreadful pain caused by 2 compression fractures in thoracic spine! My Doctor told me to go to X-Ray first, and he added to the requistion that I was to be treated ASAP. However, this was forgotten!


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Robin McCabe
More Info is needed on how they calculate wait time. A few years ago my Father waited 3 days in Emergency for surgery to his broken hip. I have waited 3 hours in emergency waiting room with my child before a nurse even takes our name.


--------------------------------------------------------------------------------

ance
I think wait times for any scarce medical service in Canada are like the flip of a coin.

A recent example: In the small (60,000 people) Alberta city I live in there is only one dermatologist.

My daughter, who has a serious skin disorder can wait up to 6 months between appointments for the treatment that keeps the condition under control. The initial visit for evaluation also took 6 months.

A friend has a couple of moles that by her own admission were not yet a problem but she wanted to get on the list to be seen.

She flashed these moles at her family doctor last week and got an immediate (2 weeks later) appointment.

Who decides how long you wait? It appears the right doctor (or the right lie or exageration about a patient's condition??)can circumvent even the longest waiting list with access for something trivial.

Don't anyone bother with the speach about "moles can become cancerous", these were emphatically not even close to being at that point.

Does anyone double check when a doctor says "this person must see a specialist immediately"?

Is there ever any punitve response to such obvious doctor assisted queue jumping?




--------------------------------------------------------------------------------

Michele
This maybe a bit off topic but how long have we heard about doctor shortages? If more medical spots where opened then, we would have more doctors available now and more Canadians could have a family doctor. I know of to many bright Bsc. studets turned down from med school because of lack of spots. Why would the medical associations not recommend more med spaces. You would think 'someone' want us to keep having doctor shortages.


--------------------------------------------------------------------------------

Mike B.
The problem isn't in the emergency department, even if it looks that way. Most emergency departments have expanded, opening more beds. The real problem is that the hospitals aren't opening more beds on the floors. So a person that gets admitted to the hospital gets stuck in emerg because there is no bed in the hospital for them. At times emerg docs are examining patients in hallways because all the beds in emerg are full with admitted patients. Why do you think response times for ambulances are long? They can't unload their patients so they end up getting stuck in emerg. Hire more nurses, open up beds in the hospitals. That'll help solve the wait times in emerg.


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J.C.
I feel it is not the medical staff at fault but the non-medical persons are the ones who should be fired. From the hospital Administrator to all non-medical staff feel that they are untouchable and are so ARROGANT, they can treat in-patients in EDS like cattle and have no feelings for those who are seriously hurt or the elderly who are very sick.
The receptionists need to remember they to will get old and need the same facilities that they are now employed in.
So come on Ontario Government, CLEAN HOUSE OF THESE LAZY JERKS IN OUR HOSPITALS. Then we will have better service in our ED's


--------------------------------------------------------------------------------

LorGrand
Although there has been some waiting time, both my husband and myself - are very satisfied with the treatment we did receive: both in ER and in our hospital stays. Patients with the greatest need, are taken care of first; and, that is as it should be. Langley Memorial Hospital rates very high on my list of 'caring' hospitals.


--------------------------------------------------------------------------------

Chris
I had 2 incidents in a hospital over the past 5 years, both times I was treated almost immediately. The biggest promblem is that people that are not needing EMERGENCY services abuse the system. People STOP going to the hospital if you have a cold, or small ache. It is for EMERGENCIES. People who abuse the ER should be fined. Make them pay for their stupidity !!!


--------------------------------------------------------------------------------
 
N

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回复: 关于加拿大医疗服务等候时间长短政府和民众看法不一,请看研究文章

The report found that in 2005 half of all patients admitted to hospital through Canada's EDs waited 1.7 hours or less for a bed once a doctor made the decision to admit.
 

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回复: 关于加拿大医疗服务等候时间长短政府和民众看法不一,请看研究文章

谢谢英格兰的资料,不过俺觉得你把紧急和普通搞混了。对于ER,加拿大医院处理得相当不错,但是对于普通的,长期的,比如慢性鼻炎,慢性胃炎之类不危害生命的案子,轮侯时间相当长。不瞒你说,多伦多2006年很著名的中国移民因病无法忍受最后自杀(愿她安息)的案情,俺就是此案直接目击证人之一。她的病,就是因为最开始医生处理慢,延误时间过长,才从普通肿瘤恶化为癌变。期间病情恶化升级一次,才给在诊断一次。每次仪器诊断做化验都排期1~2个月,时间就是这么给耽误了。知道最开始,医生给她开的什么药么?只有止痛药!!!到了晚期才发现是癌变!不管医院再怎么当作紧急案件积极治理,都回天无术。结果是她不堪忍受病痛,在家结束了自己的生命。所以你的统计资料再怎么官方,对于慢性病的轮侯时间过长这一事实,完全没有谈及。而俺亲眼所见的生命消失,却完全可以颠覆这一报告~~
 
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回复: 关于加拿大医疗服务等候时间长短政府和民众看法不一,请看研究文章

谢谢英格兰的资料,不过俺觉得你把紧急和普通搞混了。对于ER,加拿大医院处理得相当不错,但是对于普通的,长期的,比如慢性鼻炎,慢性胃炎之类不危害生命的案子,轮侯时间相当长。不瞒你说,多伦多2006年很著名的中国移民因病无法忍受最后自杀(愿她安息)的案情,俺就是此案直接目击证人之一。她的病,就是因为最开始医生处理慢,延误时间过长,才从普通肿瘤恶化为癌变。知道最开始,医生给她开的什么药么?只有止痛药!!!到了晚期才发现是癌变!不管医院再怎么当作紧急案件积极治理,都回天无术。结果是她不堪忍受病痛,在家结束了自己的生命。所以你的统计资料再怎么官方,对于慢性病的轮侯时间过长这一事实,完全没有谈及。而俺亲眼所见的生命消失,却完全可以颠覆这一报告~~

在我印象中,有一个人是因为无法承担药费,出院后自杀的. 不知道我们说的是不是同一个人.
 

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在我印象中,有一个人是因为无法承担药费,出院后自杀的. 不知道我们说的是不是同一个人.

俺认识他们全家人,买有一栋半独立物。经济虽不是大富,但治病的前还是有的。所以无法出医药费只是个幌子,她丈夫说的并不完全是实情。真实情况,俺还是不想说了,毕竟逝者已去~~

Bruce你相信加拿大真的会有无钱看病致死么?
 
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俺认识他们全家人,买有一栋半独立物。经济虽不是大富,但治病的前还是有的。所以无法出医药费只是个幌子,她丈夫说的并不完全是实情。真实情况,俺还是不想说了,毕竟逝者已去~~

Bruce你相信加拿大真的会有无钱看病致死么?

她丈夫说的不是真的, 大家又怎么能相信你呢? 你前两天狡辩"眼镜",音犹在耳,今天你的话,我不信. 除非你把从前狡辩的东西吃回去.
 

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她丈夫说的不是真的, 大家又怎么能相信你呢? 你前两天狡辩"眼镜",音犹在耳,今天你的话,我不信. 除非你把从前狡辩的东西吃回去.

你信不信,俺一点都不在乎。俺只希望你能够用良心说话,而不是带着你的眼镜,坚持所谓的政见。

所以请你回答俺,到底加拿大有没有人,会因为没有钱治病而去世?
 
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你信不信,俺一点都不在乎。俺只希望你能够用良心说话,而不是带着你的眼镜,坚持所谓的政见。

所以请你回答俺,到底加拿大有没有人,会因为没有钱治病而去世?
政府不负担药费, 那么就是会出现这个现象. 虽然可能比例非常低,但是一定会有.
 

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政府不负担药费, 那么就是会出现这个现象. 虽然可能比例非常低,但是一定会有.

谢谢Bruce。那么请问对于重病,危及生命的病,在如上面的这种非常情况下,没有了治病的医疗费,加拿大政府会像中国医院那样,不交钱不给药么?
 
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谢谢Bruce。那么请问对于重病,危及生命的病,在如上面的这种非常情况下,没有了治病的医疗费,加拿大政府会像中国医院那样,不交钱不给药么?
如果你严重了,住院全免费. 出院后,药费自理. 这就是现状吧. 如果说社会其他救助机构, 我不是太清楚. 如果单纯讲政府,就是不负责这部分药费.
 

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如果你严重了,住院全免费. 出院后,药费自理. 这就是现状吧. 如果说社会其他救助机构, 我不是太清楚. 如果单纯讲政府,就是不负责这部分药费.

那就是说在加拿大,根本没有低收入人士药费豁免这一政策了。如果没有钱,病死都没人救了~~

谢谢Bruce老师。看来是俺对加拿大的医疗体制理解有误,得去重新审视这一体系了。
 
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如果你严重了,住院全免费. 出院后,药费自理. 这就是现状吧. 如果说社会其他救助机构, 我不是太清楚. 如果单纯讲政府,就是不负责这部分药费.
B专家还在GOGO呢殴?:wdb24::wdb24::wdb24:

加拿大医疗服务等候时间长短政府和民众的看法的学说---是在耍嘴皮子殴...:wdb8::wdb18::wdb7::wdb7::wdb7:

真正在加拿大看病的病人才是最有发言权的说呢!:wdb18::wdb18::wdb18:

一年甚至几年都不去医院看病的年纪轻的人只会找资料,GOGO来的东东来说说事儿殴.:wdb16::wdb5::wdb26::wdb15::wdb4:



说中国医疗必加拿大好,民主精英们一准儿出来辩论呢!:wdb19::wdb19::wdb19:

加拿大的医疗就是好,:wdb20::wdb20:什么病也看不了:wdb5::wdb5::wdb5:
着急抱怨无人理,:wdb8::wdb8::wdb8:有病的小命一条等着报销殴,等着报销嘿嘿.:wdb10::wdb10::wdb10:好好好好.:wdb24::wdb24::wdb24:
 
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回复: 关于加拿大医疗服务等候时间长短政府和民众看法不一,请看研究文章

B专家还在GOGO呢殴?:wdb24::wdb24::wdb24:

加拿大医疗服务等候时间长短政府和民众的看法的学说---是在耍嘴皮子殴...:wdb8::wdb18::wdb7::wdb7::wdb7:

真正在加拿大看病的病人才是最有发言权的说呢!:wdb18::wdb18::wdb18:

一年甚至几年都不去医院看病的年纪轻的人只会找资料,GOGO来的东东来说说事儿殴.:wdb16::wdb5::wdb26::wdb15::wdb4:



说中国医疗必加拿大好,民主精英们一准儿出来辩论呢!:wdb19::wdb19::wdb19:

加拿大的医疗就是好,:wdb20::wdb20:什么病也看不了:wdb5::wdb5::wdb5:
着急抱怨无人理,:wdb8::wdb8::wdb8:有病的小命一条等着报销殴,等着报销嘿嘿.:wdb10::wdb10::wdb10:好好好好.:wdb24::wdb24::wdb24:

你这种博士连资料也不会找。只会XXXXX。
 
N

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回复: 关于加拿大医疗服务等候时间长短政府和民众看法不一,请看研究文章

谢谢英格兰的资料,不过俺觉得你把紧急和普通搞混了。对于ER,加拿大医院处理得相当不错,但是对于普通的,长期的,比如慢性鼻炎,慢性胃炎之类不危害生命的案子,轮侯时间相当长。不瞒你说,多伦多2006年很著名的中国移民因病无法忍受最后自杀(愿她安息)的案情,俺就是此案直接目击证人之一。她的病,就是因为最开始医生处理慢,延误时间过长,才从普通肿瘤恶化为癌变。期间病情恶化升级一次,才给在诊断一次。每次仪器诊断做化验都排期1~2个月,时间就是这么给耽误了。知道最开始,医生给她开的什么药么?只有止痛药!!!到了晚期才发现是癌变!不管医院再怎么当作紧急案件积极治理,都回天无术。结果是她不堪忍受病痛,在家结束了自己的生命。所以你的统计资料再怎么官方,对于慢性病的轮侯时间过长这一事实,完全没有谈及。而俺亲眼所见的生命消失,却完全可以颠覆这一报告~~
In 2005, the median waiting time was about 4 weeks for specialist visits, 4 weeks for non-emergency surgery, and 3 weeks for diagnostic tests. (Table 4, Table 5, Table 6)
 

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