We can cut waiting lists by cutting into fewer patients

[Guest guest]

We can cut waiting lists by cutting into fewer patients

By ANDRE PICARD

Thursday, September 2, 2004 - Page A15

http://www.theglobeandmail.com/servlet/ArticleNews/TPStory/LAC/20040902/HPICARD0\

2/TPHealth/

 

When the talk turns to waiting lists -- as it does often in political

circles these days -- there is an assumption that waits for surgery are

caused by inadequate resources.

 

If we only had more surgeons, more operating rooms and more money, the

thinking goes, we could clear up this pesky problem.

 

If only it were so simple.

 

Waiting lists occur for a multitude of reasons: Shortages of personnel,

poor management of resources, lack of co-ordination and co-operation,

and allocation of budgets.

 

A health system that strives to give equitable access to care but does

not have unlimited resources, such as Canada's publicly funded system,

must ration.

 

Rationing is often viewed as dirty word but, in reality, it means making

choices. Many of these are tough choices, particularly when it comes to

elective surgery. How much money do you allocate to hip replacements?

What about cataracts? Do we invest in an expensive new technology that

provides only marginal added benefit to patients? Do we limit the

creation of parallel, for-profit delivery to ensure equitable access?

 

Where the Canadian system often falls down is failing to make those

choices rationally, and in a manner that is transparent. That requires

leadership, clear vision, and good communication skills, not just money.

 

It also requires good research. It's easy to dismiss research as an

exercise in bureaucratic paper-shuffling and a delaying tactic. " Give us

more money and we'll fix the problem, " goes the rallying cry.

 

But when it comes to waiting lists, there is a disturbing lack of

information. In many cases, we don't know how many people are actually

waiting for a procedure because lists are rarely managed centrally. The

result is inconsistency and unfairness, which are often worse than the

wait itself.

 

Medically, we don't know when a wait becomes problematic. For example,

how long after prostate surgery should radiation treatment begin? A

couple of weeks allows some needed recovery time, but does six weeks

increase the risk of cancer recurrence?

 

And if the waiting time that is deemed acceptable is exceeded, what are

we going to do? Send patients to the United States for treatment?

Institute a system of penalties so health-care institutions shift their

priorities?

 

Waiting lists are not a simple issue to tackle, but they are a crucial

one. Eliminating -- or at the very least better managing -- waiting

lists will result in a better health system and better health care.

 

That is because waiting lists are symbolic of inefficiency.

 

There were a couple of stark reminders this week that, despite

cost-cutting, some startling inefficiencies remain.

 

A team of researchers from the University of Alberta and the University

of Calgary showed that almost half of carotid endarterectomies (an

operation to clear blocked arteries in the neck) are of questionable

value, and that 10 per cent of these surgeries are entirely

inappropriate and probably dangerous to patients.

 

A second study, conducted by Health Canada, found that the mastectomy

rate varies dramatically from one province to the next, which likely

means that hundreds, maybe even thousands, of women are having their

breasts removed unnecessarily.

 

These are but two examples, but there are many more. The vast majority

of tonsillectomies were dubious; lower back surgery, once the rage,

provided little pain relief in the long term; medically unjustified

hysterectomies, gall bladder removals, cesarean sections and cataract

operations are legion. More recently, some solid studies have shown that

surgery for arthritic knees is of no value, and that " active

surveillance " of some cancerous tumours is more effective than

surgically removing them.

 

These excesses occur because research that shows the value (or lack

thereof) of surgical procedures, and the modified clinical guidelines

that result, are often slow to be implemented. The breakthroughs you

read about in the daily newspaper are too slow to trickle out to the

real world.

 

No one wants to wait unduly long for surgery. But in our rush to solve

the waiting list problem, we cannot forget that surgeries that are

performed should always be necessary and useful.

 

Imagine if, like carotid endarterectomies, 10 per cent or more of a host

of surgical procedures were unnecessary. Correcting these problems would

not only save lives, but would also increase the time and resources

available for other surgeries. And a 10-per-cent increase might go a

long way toward clearing up waiting lists.

 

More important than the monetary savings is reducing harm to patients.

We owe it to every patient to get it right, to not perform useless or

marginally beneficial procedures.

 

Unnecessary surgery is not occurring out of malice. It is, most often,

the result of uncertainty and poor information. By investing in research

on the clinical effectiveness of procedures; by probing and exposing the

troubling regional disparities in care; by following up with better

dissemination of scientific information; and by monitoring physicians'

and surgeons' adherence to practice guidelines, we can greatly reduce

cases of needless surgery.

 

In our zeal to tackle waiting lists, we cannot lose sight of the fact

that more is not always better -- especially when a lot of blood and

scalpels are involved.