Transcript Leadership. Knowledge. Community. 2

The Patient Journey Progress 2008 Symposium:
CCS Benchmarks for Access
to Cardiovascular Services
and Procedures:
Leadership. Knowledge. Community.
The 7 Access to Care Subgroups
2
Subgroup
Chair
Specialist consultation and noninvasive tests
Dr. Merril Knudtson
Nuclear cardiology
Dr. Rob Beanlands
Emergent and urgent situations
Dr. Blair O’Neill
Revascularization and other
cardiac surgeries
Dr. David Ross
Dr. Michelle Graham
Heart failure clinics
Dr. Heather Ross
Electrophysiology services
Dr. Chris Simpson
Rehabilitation
Dr. Bill Dafoe
Leadership. Knowledge. Community.
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
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Leadership. Knowledge. Community.
The Cardiovascular Continuum of Care
Onset of
symptoms
Emergency department
or hospital admission
PERIOD 1
General
practitioner
Non-invasive
testing
Secondary prevention
and rehabilitation
PERIOD 2
Chronic Disease
Management Programs
Specialist
consult
Non-invasive
testing
PERIOD 3
Subspecialist
consult
Invasive and/or
non-invasive
testing
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Total Patient Wait Time =
PERIOD 1 + 2 + 3 + 4 + 5
PERIOD 4
Therapeutic procedure (e.g., surgery,
angioplasty, pacemaker, ICD, ablation)
PERIOD 5
Rehabilitation
Chronic
Disease Community.
Leadership.
Knowledge.
Management Programs
The Patient’s Perspective
Wait-time Interval
Max (wks)
Symptom onset to Family Physician
Unknown
Family Physician to Cardiologist
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Cardiologist to Angiogram
6
Angiogram to Cardiac Surgeon
Cardiac Surgeon to Bypass Surgery
Bypass Surgery to Rehabilitation
Total Wait Time for the Patient
6*
4
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In some jurisdictions, both wait periods are included in the measured interval.
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Leadership. Knowledge. Community.
CCS ACCESS TO CARDIOVASCULAR CARE
RECOMMENDED WAIT TIME TARGETS
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Subgroup
Emergency
Semi-urgent
Scheduled
Specialist consultation/
non-invasive tests
< 24 hours
Urgent
SU
< 1 week < 4 weeks
< 6 weeks
Nuclear cardiology
< 24 hours
< 3 days
< 14 days
Echocardiography
< 24 hours
< 7 days
< 30 days
Emergent and urgent
revascularizations
NSTEACS < 48
STEMI < 24
Urgent
SU
< 7 days < 14 days
< 6 weeks
Revascularization and
other cardiac surgeries
< 24 hours
Urgent
< 7 days
< 6 weeks
Heart failure disease
management clinics
< 24 hours
Urgent
< 1-2 wks
Electrophysiology
services
<1-3 days
Urgent
SU
< 2 weeks <4-6 wks
< 3 months
Rehabilitation
< 3 days
< 7 days
< 30 days
SU
< 2-4wks
SU
< 4 wks
< 6 – 12 weeks
Leadership. Knowledge. Community.
Preconsultation Testing and Info
The 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.
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Leadership. Knowledge. Community.
Improving Access to Specialists
Cardiology
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Leadership. Knowledge. Community.
The CCS National Survey on
Access to Care
at Tertiary Cardiac Care Centres
• Summer 2007 – Summary Results
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Leadership. Knowledge. Community.
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
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Leadership. Knowledge. Community.
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%)
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Leadership. Knowledge. Community.
Response Rate by Province
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Response rate
100%
1
1
1
80%
60%
40%
2
17
5
4
20%
0
0%
BC
AL
SK
0
MN
ON *
PQ
NB
NS
NL Canada
11 academic, 2 community, and 4 regional centres responded
13 respondents were Chiefs of Cardiology
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Leadership. Knowledge. Community.
•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”
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Leadership. Knowledge. Community.
How would you rate access to
cardiac care at your centre?
Excellent
Very
Good
Fair
Poor
0
2
4
6
8
Number of respondents
8 of 17 rated access as “excellent” or “very good”
15 of 17 have been monitoring wait times for > 5 years
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Leadership. Knowledge. Community.
Does your cardiac care centre have
wait time targets for:
Yes
No
Cath
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Angioplasty
Not
offered
Monitor
only
N/A
Total
0
1
1
14
11
1
1
1
14
Cardiac surgery
9
2
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
1
5 centres had wait time targets for Initial specialist consultation, echocardiography,
cardiac nuclear imaging, CHF clinic, electrophysiologist consultation, CRT and
15 cardiac rehabilitation
Leadership. Knowledge. Community.
What was the basis for establishing
the targets that you have?
CCS benchmarks
Provincial benchmarks
Combination
Centre-specific
Not specified
0
2
4
6
8
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.
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Leadership. Knowledge. Community.
How would you rate your cardiac
care centre’s commitment to setting
access targets?
Very strong
Strong
Good
Low
Little or no
0
2
4
6
8
10
Number of responses
“Low” or “Little or no” reported in Manitoba and Ontario.
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Leadership. Knowledge. Community.
Prior to this survey, how would you
describe your awareness of the CCS
benchmarks?
Excellent
Very good
Good
Fair
Poor
N/A
0
1
2
3
4
5
6
Number of responses
18
The CCS benchmarks have been well communicated among the
survey respondents.
Leadership. Knowledge. Community.
How would you describe the level of
awareness among professional (medical,
clinical and administrative) staff?
Excellent
Very good
Good
Fair
Poor
N/A
0
1
2
3
4
5
6
Number of responses
The CCS benchmarks are not as well known among other medical, clinical and
administrative staff. 38% rated “fair” or “poor”
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Leadership. Knowledge. Community.
Barriers to the adoption of access targets for a
broad range of CV services and procedures, in order
of importance/ significance
1.
2.
3.
4.
5.
6.
7.
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Lack of human resources
Lack of funding
Lack of physical resources
Lack of infrastructure
Liability concerns for physicians and administrators
No or low awareness of the CCS benchmarks
Not perceived as a priority at this time
Leadership. Knowledge. Community.
Key individuals and groups whose support is
necessary for the adoption of benchmarks for the
full continuum of care, in order of significance:
1.
2.
3.
4.
5.
6.
7.
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Medical leadership within hospitals
Minister or Deputy Minister of Health
Hospital administrators
Medical leadership within academic institutions
Ministry or Minister of Health staff
Staff at regional or local health authorities
Medical leadership within the community
Leadership. Knowledge. 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”
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Leadership. Knowledge. Community.
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
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Leadership. Knowledge. Community.
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
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Leadership. Knowledge. Community.
What grade would you give to governments
for how well they have meaningfully
addressed wait times for CV over last 2
years?
12
repondents
Number of
10
8
6
4
2
0
Fail
Poor
Fair
Good
Excellent
Most respondents (71%) gave a grade of “Fair”.
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Leadership. Knowledge. Community.
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
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Leadership. Knowledge. Community.