Survey of Access to GastroEnterology in Canada : The SAGE wait times program

1Dalhousie University, Halifax, Nova Scotia; 2University of Calgary, Calgary, Alberta; 3McMaster University, Hamilton, Ontario; 4McGill University, Montreal, Quebec; 5Kelowna General Hospital, Kelowna, British Columbia; 6Centre hospitalier de l’Université de Montréal, Montreal, Quebec; 7University of British Columbia, Vancouver, British Columbia; 8University of Alberta, Edmonton, Alberta; 9Regina General Hospital, Regina, Saskatchewan; 10University of Manitoba, Winnipeg, Manitoba; 11Intestinal Health Institute, Markham, Ontario; 12South Shore Regional Hospital, Bridgewater, Nova Scotia; 13Canadian Association of Gastroenterology, Oakville; 14University of Toronto and St Michael’s Hospital, Toronto, Ontario Correspondence: Dr Desmond Leddin, Dalhousie University, Division of Gastroenterology, Room 912, Victoria Building, Victoria General Hospital Site, 1278 Tower Road, Halifax, Nova Scotia B3H 2Y9. Telephone 902-473-7833, fax 902-473-4406, e-mail desmond.leddin@dal.ca Received for publication October 13, 2009. Accepted October 23, 2009 Assessment of wait times pertaining to specialist referrals remains a key method for determining the availability of health care in Canada. Previous studies indicating excessive wait times for a variety of specialties (1,2) have prompted government organizations to establish benchmarks for medically acceptable wait times in a number of medical fields (3). The federal Wait Time Alliance, of which the Canadian Association of Gastroenterology (CAG) is a member, has sought to reduce wait times for health care across Canada (4). The benchmarks for gastroenterology (time to consultation or procedure, if indicated) that were developed at a 2005 consensus conference are that emergency cases should be seen within 24 h, urgent cases should be seen within two weeks, semi-urgent cases should be seen within two months and routinely scheduled cases should be seen within six months (Table 1) (4,5). oriGinAl ArTiClE

A previous audit of wait times in gastroenterology in Canada -the Practice Audit in GastroEnterology (PAGE) program -was performed almost four years ago (6).Conducted between January and October 2005, the PAGE program documented median wait times from referral to consultation and/or procedure for patients with digestive diseases.A comparison of the real-world wait times in gastroenterology reported in PAGE and the consensus recommended wait times (5) found that the total wait times across seven indications exceeded published recommendations in 51% to 88% of cases, including both urgent and nonurgent cases (7).
One of the key factors affecting wait times in gastroenterology is the actual number of specialists available.A work force analysis conducted in 2007 found that there were 1.83 gastroenterologists per 100,000 population in Canada compared with almost twice that in the United States (3.9 per 100,000) and France (3.48 per 100,000) (8).Furthermore, as the population of Canada continues to shift toward an older mean age, the greater prevalence of acute and chronic health concerns in older patients will further increase the demand for services.This will undoubtedly create a greater negative impact on already long wait times if no additional resources are allocated and/or services are not redesigned.
The aim of the present study was to survey and report the national wait times for specialist gastroenterology care, and to examine change over time, if any, from the previous assessment (ie, PAGE) conducted in 2005.

METHODS
The CAG National Office managed all administrative aspects of the program.A special advisory committee (DL, EJI, CF, CR) with expertise in gastroenterology care, was integrally involved in all aspects of the program, including concept development, practice audit logistics management, data reporting and data analysis.

Participants
Physicians who specialize in digestive diseases (adult and pediatric gastroenterologists, and internists specializing in gastroenterology) were informed in advance of the survey through mailed announcements to CAG members and provincial gastroenterology organizations, as well as through advertisements in monthly e-newsletters, and notices published in The Canadian Journal of Gastroenterology and posted on the CAG Web site.Gastroenterologists or internists who were not CAG members were identified through the Canadian Medical Directory and also invited to participate.The CAG also liaised with the provincial and regional gastroenterology physician societies to encourage them to advertise and promote the program to their memberships.Physicians were encouraged to register their intent to participate with the CAG National Office using e-mail, telephone or fax.
Physicians were asked to provide personal demographic data and anonymous information on at least five new consecutive clinic patients (consults) and five consecutive procedure patients who had not had a previous procedure for the same indication.Only new referrals were included.Patients who were seen for urgent or nonurgent same-day consultation and procedure (C&P) were included and analyzed separately.Patients presenting to the emergency room were excluded.

Questionnaire
The Survey of Access to GastroEnterology (SAGE) questionnaire was developed by an advisory committee with expertise in gastroenterology, education, clinical research and previous national audit projects.It was designed to provide a snapshot of wait times related to 18 selected indications based on the Canadian consensus on medically acceptable wait times for digestive health care (5) as well as an 'other' write-in category.After review of the 'other' indications, many were found to relate to surveillance of colon cancer or colon polyps -these were grouped into indication 20, while those remaining became indication 19 (other, most of which were biliary in nature).Some items included in the questionnaire were similar to those collected in a previous survey conducted in 2005.New items were added to evaluate changes in the scope of practice that had occurred since 2005 and to apply to a broader sample of the provider population.Physicians were first asked to answer eight demographic questions describing their practice (Table 2), then to provide data for consecutive new patients (Table 3) seen during the week of November 17 to 21, 2008 (or, alternatively, weeks November 10 to 14 or November 24 to 28, 2008).Information was collected using a commercial online survey Web site (www.surveymonkey.com) or single-page fax form available in English or French.To ensure that the questionnaire was understandable, it was administered to a small convenience sample of physicians before the final survey date.

Ethics review
In the present survey, patient identifiers were not collected (ie, patient names and their information remained anonymous), no patient intervention was involved, only aggregate results were subsequently reported and, overall, minimal data were collected.Although these factors do not neccesitate an ethics review, this quality assurance/practice audit program was approved by a central ethics committee (Institutional Review Board, August 2008).Separate ethics approval was obtained in Alberta.

High likelihood of cancer based on imaging or physical examination
Severe and/or rapidly progressive dysphagia or odynophagia

Data analysis
An independent data analysis was conducted and statistical support was provided by the Division of Gastroenterology at McMaster University (Hamilton, Ontario) (YC).Statistical analyses, performed using SAS version 9.2 (SAS Institute Inc, USA), generated the following wait time durations: 1.The wait time to consultation: Time from the patient's first referral to the digestive health care provider until the consultation; 2. The wait time to procedure: Time from the patient's first consultation with the digestive health care provider until the completion of the digestive disease procedures or tests; and 3.The total wait time: Time from the patient's first referral to the digestive health care provider until completion of the procedures or tests.Total wait time is available only for patients who had both a consult and a procedure.Data for patients undergoing same-day C&P were analyzed separately.Data from the 2005 PAGE survey were re-analyzed to provide analyses of new patients only and same-day C&P.
Wait times are presented as medians with 95% CIs.Statistical comparisons with data from the PAGE program were performed using Wilcoxon's rank-sum test.

Overall wait times
Data on 1824 consultations, 741 procedures and 436 sameday C&Ps were collected.Nationally, the median wait times to consultation and to procedure were 92 days (95% CI 87 to 97 days) and 50 days (95% CI 45 to 55 days), respectively, while the median total wait time for both was 155 days (95% CI 143 to 164 days) (Table 4).These wait times were significantly longer than those reported in the 2005 PAGE survey (P<0.05)(Table 4).The median total wait time for patients who received same-day C&P was also significantly longer in the SAGE versus PAGE survey (P<0.05).Consultation, procedure and total wait times were significantly longer in teaching hospitals than in community-based practices (P<0.05)(Table 4).However, there was no significant difference in median total wait times by practice type for patients who received same-day C&P (113 days versus 87 days).

Wait times according to indication
Median wait times according to the primary indication are shown in Table 5.There were very small numbers of patients for some indications -those with fewer than 10 patients were not analyzed.As expected, longer wait times were encountered for patients receiving screening colonoscopy and those referred for surveillance of previous colon cancer or colon polyps (Table 5).The shortest wait times occurred for those receiving separate or same-day C&P for 'cancer likely based on imaging or physical examination', severe or rapidly progressing dysphagia or odynophagia, documented iron-deficiency anemia, or dyspepsia with alarm symptoms.
When analyzing the change in wait times from PAGE to SAGE, seven indications provided national data for comparison: poorly-controlled reflux/dyspepsia, with no alarm symptoms; dyspepsia with alarm symptoms; clinical features of significant, active inflammatory bowel disease; chronic diarrhea or chronic constipation; documented iron-deficiency anemia; positive fecal occult blood test; and cancer likely based on imaging or physical examination (Table 5).SAGE total wait times were numerically greater than PAGE data for five of the seven indications and greater than same-day C&P wait times for all seven indications.In patients with 'cancer likely based on imaging or physical examination', median wait times across all four categories (time to consult, time to procedure, total wait time and same-day C&P) were significantly longer in SAGE than in PAGE.The median time to consult was significantly longer for patients with 'poorly-controlled reflux/dyspepsia with no alarm symptoms', 'chronic diarrhea or chronic constipation', and 'documented iron-deficiency anemia'.The median total wait time was significantly longer for patients with 'chronic diarrhea or chronic constipation', and the median wait time for same-day C&P was also significantly longer for patients with 'documented iron-deficiency anemia'.

DiSCUSSiON
Assessment of current wait times for health services across specialties is critical to assist in planning for future health needs in Canada.The SAGE provides timely and much needed data that reflect current practices in gastroenterology health care delivery across Canada.It was undertaken with minimal survey burden to the specialist during a typical work week, thereby providing representative data to update and compare with data acquired during the PAGE survey (6).These surveys provided data necessary to track trends, and advocate for improved human and technical resources, and examined the issues behind excessive wait times, with the goal of improving wait times and patient access to gastroenterology services in Canada.SAGE offered an improved survey system (more efficient and less costly) than the method used in PAGE.The survey methodology provided a means to capture wait time data that should be applicable to other specialist groups and also allowed for the assessment of wait time trends over intervals of years.
The Fraser Institute's 2006 national waiting list survey (1) identified the median wait times to consult in 12 specialties in Canada.The median time to consult reported in SAGE was 92 days (13.1 weeks) -a figure that was exceeded by only four specialties (plastic surgery, ophthalmology, orthopedic surgery and neurosurgery) in the Fraser Institute's survey.
Similar to the results of the PAGE survey, median total wait times continue to exceed consensus recommended maximal wait time targets (Table 1) (5), even among patients who underwent same-day C&P.The only exception was for chronic gastroesophageal reflux disease referred for screening endoscopy.Indeed, not only are established targets being exceeded, but the trend over time is toward still longer median wait times (5,6).Clearly, timely access to health care specialists requires improvement.
While we have documented that wait times are excessive, we are unable to establish the reasons for failing to meet the recommended targets.Wait times represent a balance between service demands and the available resources needed to meet those demands.We can speculate on several possible reasons for the observed shortfall.We know that the number of Canadian gastroenterology specialists relative to the general population is low compared with some other countries (8).This would suggest a need for more human resources for gastroenterology specialists.It is also possible that Canadian primary care physicians are referring patients to a gastroenterologist at higher rates relative to their counterparts elsewhere.We cannot determine whether Canadian gastroenterology specialists are working more or less efficiently than those in other countries.In particular, we cannot assess whether they have sufficient access to endoscopic facilities and are using these facilities appropriately.
There is evidence that these factors are important determinants of access.A United States cohort study (9) of 498 consecutive wait-listed patients referred to an endoscopy practice found 28% to be inappropriately referred according to published guidelines for appropriate colonoscopy indications.A United Kingdom survey (10) of referred patients (n=598) wait-listed for follow-up regarding colorectal polyps found that only 14.8% of cases were being followed up according to guidelines.The majority of patients (78% of low-risk patients and 55% of intermediate-risk patients) had received or were waiting for a colonoscopy too soon or too frequently according to guideline recommendations.In a United Kingdom survey of 3549 patients currently waiting for a colonoscopy (11), implementation of guidelines led to reductions in wait time for diagnostic colonoscopy from 12 to four weeks for urgent, and from 40 to 15 weeks for routine referrals.Appropriate physician and patient education, provision of validated referral tools and monitoring of adherence to screening practices may liberate some of the time needed to improve patient access to gastroenterologists in Canada.
Compared with the community-based settings, the significantly longer median wait times in teaching hospitals suggest that increasing the number of independent, stand-alone clinics could potentially reduce gastroenterological wait times.Alternatively, the patients seen in teaching hospitals may require different, more time-intensive care or the competing demands of an academic practice may limit patient access to referral centres.
The SAGE has several limitations.Not all eligible physicians participated in the survey and, therefore, bias may have been introduced by physicians who were too busy (may have had longer wait times), were not comfortable sharing their personal or patient data, or were worried that the data may negatively impact their ability to practice.However, we estimate that more than 40% of physicians performing gastroenterology procedures (226 of an estimated 550 in Canada [8]) participated in the present survey, making it a highly representative sample.In addition, because physicians were given the option to remain anonymous, concerns over sharing data should have been avoided.The survey was conducted during one specific week, while this has the benefit of providing a snapshot of wait times at a particular moment, unknown factors during the week in question could have skewed the results.The data do not reflect wait times for those specializing in liver diseases only, which may be associated with longer wait times.Although wait times were self-reported by physicians, there was no reason to suspect differential reporting in 2008 compared with 2005.In the present paper, we did not examine the 75th or other percentiles of wait times -75th percentiles can provide valuable information because they indicate wait times for 25% of the patients who wait the longest.

SUMMARy
The SAGE provides a snapshot of access to gastroenterology services by Canadians in 2008.Compared with an earlier survey conducted in 2005 (PAGE), wait times have not improved and have, in fact, become longer.In both surveys, wait times for many indications exceeded consensus conference recommended targets.Future research should attempt to examine the causes of the increase in wait times so that appropriate strategies can be developed to improve patient access.The goal is to provide timely access to high-quality digestive health services across Canada.We have established a methodology for measurement of point-of-access care wait times that is applicable to other groups.
Bright red rectal bleeding Documented iron-deficiency anemia One or more positive fecal occult blood tests Chronic viral hepatitis Stable dysphagia (not severe) Poorly controlled reflux/dyspepsia Chronic constipation or chronic diarrhea New-onset change in bowel habits Chronic, unexplained abdominal pain Confirmation of a diagnosis of celiac disease (antibody test) Within six months Chronic gastroesophageal reflux disease for screening endoscopy Screening colonoscopy Persistent (>6 months) unexplained abnormal liver enzyme tests Data are adapted from reference 5

TAblE 2 Survey of Access to GastroEnterology (SAGE) -clinician demographics
□ Part-time: If part-time, what percentage of time do you work? 9. What percentage of your work week is spent in clinical care?Please round to the nearest 10% 10.Have you limited new patient referrals because of the length of your wait list?□ No □ Yes

TAblE 3 Survey of Access to GastroEnterology (SAGE) -patient information
□ Cancer likely based on imaging or physical examination (18) □ Other (write in diagnosis) (19) 3. On what date was the patient FIRST referred to you for this indication?4. On what date did you CONSULT with the patient regarding this indication?□ Same-day consult and procedure (check here then enter procedure date in question 5) □ Consult date not applicable □ Consult date, if different from procedure date 5. What is the date you performed a procedure (eg, endoscopy, liver biopsy, etc) for the patient for this indication?