Canadian Cardiovascular Society Access to Care Workshop proceedings and next steps

Abstract

On October 24, 2008, the Canadian Cardiovascular Society (CCS) Standing Committee on Access to Care invited clinical practitioners, researchers and administrators from across Canada to provide input on the CCS action plan for 2009/2010. The meeting provided an opportunity for stakeholders to identify initiatives under three CCS priority areas for action: collecting and reporting wait time data, improving systems to improve access, and establishing national networks. Building on the suggestions from this meeting, the Standing Committee drafted an action plan for 2009/2010. This plan includes a lead role for the CCS in facilitating consensus on pan-Canadian data standards and definitions, and using current resources and infrastructure. The CCS and its Standing Committee look forward to continuing to work with stakeholders to promote awareness and adoption of the benchmarks, and to undertake new initiatives that will provide insight into access to care issues along the continuum of care.

On October 24, 2008, the Canadian Cardiovascular Society (CCS) Standing Committee on Access to Care invited clinical practitioners, researchers and administrators from across Canada to a stakeholder meeting as a first step in seeking input on a proposed CCS action plan for 2009/2010. The CCS has a long-standing commitment to improving access to cardiovascular care and services for Canadians. This issue was identified as a strategic priority for 2007 to 2010. As well, the CCS’ commitment was formalized through the establishment of a Standing Committee on Access to Care in 2008 and, previously, through the development of pan-Canadian working groups to develop evidence-based wait time benchmarks and commentaries on access to cardiovascular care across the continuum (1).

The October 2008 meeting provided an opportunity for stakeholders to undertake a situational analysis and identify possible activities for each of the following three topics identified by the CCS as priority areas for action:

• Collecting and reporting wait time data;

• Improving systems to improve access; and

• Establishing national networks (eg, for sharing of best practices and for advocacy strategies).

The following article is a summary of stakeholder meeting discussions along with highlights of the CCS action plan on access to care that was subsequently developed and approved for 2009/2010.

PRIORITY AREA 1: COLLECTING AND REPORTING WAIT TIME DATA

The time is ripe for the development of systems to report and monitor access to cardiovascular care data. Access to care has been a key policy issue nationally and in many provinces for some time. Through its participation in the Wait Time Alliance, the CCS has taken a leadership role in the development and dissemination of, and advocacy for, the adoption of wait time benchmarks along the entire continuum of care as one tool for improving access to care for Canadians. This work has become even more relevant with the current financial meltdown, with provinces again trying to limit health care expenditures, combined with demographic projections of an aging population resulting in increased rates of heart disease and provider shortages due to an aging work force.

It was noted that significant investments are being made in the development, implementation and use of wait time information systems across the country. This interest in wait time data is also being fueled by a general desire for greater accountability in how health care dollars are spent. These investments have helped policy makers, clinicians and administrators understand the baseline performance in comparison with wait time benchmarks to determine where our existing investments in capacity are sufficient and where additional investments are required on a priority basis. The ongoing monitoring of wait times helps us to understand how effective our efforts to reduce wait times have been.

With fewer than 20 tertiary cardiac care centres in Canada, the scope of any initiative to define, collect and monitor hospital-based wait time data specific to key specialized cardiovascular care and services would be manageable. Meeting participants commented that such an initiative would be a very positive first step and would set the stage for a more comprehensive database that would monitor a more complete patient journey through our complex systems.

However, despite the commitment of policy makers, clinicians and administrators to more effectively manage wait times, there are still many obstacles to overcome. Existing data sources are fragmented, with no common definitions and a proliferation of data systems with only a local or, at best, regional scope. The processes for data collection and analysis in the 13 different political jurisdictions are parallel, but are neither coordinated nor aligned. Privacy legislation further complicates the ability to collect and share data. Another major barrier continues to be the limited funding made available for collaborative, interjurisdictional projects.

One recent step in the direction of developing a national body to lead federally funded initiatives that will encourage interjurisdictional sharing and collaboration is the Canadian Heart Health Strategy and Action Plan (CHHS-AP). In developing a national strategy for the cardiovascular health of Canadians, the CHHS-AP identified timely access to care and services as the topic of two of its six theme working groups. A third working group addressed the need for better information systems.

PRIORITY AREA 2: IMPROVING SYSTEMS TO IMPROVE ACCESS

The second priority area discussed at the stakeholder meeting focused on how to improve the systems needed to enhance the delivery of cardiovascular care and services. Participants indicated that, unfortunately, there is limited understanding or documentation of best practices in managing access to care along the continuum. For example, despite the recent investments in the collection of wait time data, there are still limited data available on how long patients wait for the first consultation with a family physician or with a cardiologist. Too often still, wait lists are maintained by individual providers, with no mechanism for interprovider comparisons. This fragmented approach to data collection provides no means to understand patient flow or to develop strategies to redirect patients to shorter lists.

It was noted that the CCS and other members of the Wait Time Alliance were planning to launch a National Physician Diary Study in the new year to focus on the collection of actual, nonurgent patient wait time data, including the point from referral by a general practitioner or family physician through to the initial cardiology consult. Meeting participants suggested that the CCS should approach the College of Family Physicians of Canada to solicit interest in a joint commentary paper that could build on data from the National Physician Diary Study. This collaboration would provide an opportunity to highlight challenges and issues that need to be addressed to help meet the heart health needs of Canadians.

At the other end of the continuum that includes access to multidisciplinary team care, meeting participants indicated there is a poor understanding of the proportion of patients who should be or who are actually referred for rehabilitation and secondary prevention services or heart failure care after treatment, or of how long referred patients wait for these services. For the coming year, it was suggested that the CCS consider launching a collaborative survey with the Canadian Association of Cardiac Rehabilitation to collect this information and report on access to cardiovascular rehabilitation services.

PRIORITY AREA 3: ESTABLISHING NATIONAL NETWORKS

The third priority theme discussed at the meeting was originally articulated as establishing national networks, such as those for sharing of best practices and for advocacy strategies. However, during small working group discussions, the focus shifted to the development of a national network to facilitate and encourage the tracking of aggregate medical and health data, and quality indicators. It was noted that the cardiovascular community is already coming together to develop these networks.

At the time of the stakeholder meeting, it was expected that the impending release of the CHHS-AP would provide Canadians with a comprehensive plan to improve the heart health of our citizens through prevention and, when disease presented, to manage the disease along the entire continuum of care. Over a period of two years, this initiative drew on the perspectives and experience of a 29-member steering committee, the deliberations of six themed working groups consisting of 11 to 15 members, and consultations with 1500 stakeholders. The CCS was one of the lead organizations involved in the development of the CHHS-AP and was an active participant in working group discussions.

As well, the Cardiac Care Network and the Canadian Institute for Health Information are spearheading a national initiative to develop quality indicators for in-hospital cardiovascular care. The possible opportunity for the CCS to facilitate cardiovascular community input to the development of these indicators was highlighted.

NEXT STEPS AND CCS ACTION PLAN FOR 2009/2010

A sincere thank you was extended to the meeting participants for their thoughtful input and suggestions on priorities and potential activities for the CCS for the coming year. It was noted that the interest and investment across Canada in managing medical wait times, and the growing interest in chronic disease prevention and management will continue to keep access to cardiovascular care and services on the political agenda for many years. It is equally important to ensure that the health care community continues to build its understanding of the challenges and opportunities for improving access to care for Canadians.

As a follow-up to the October 2008 stakeholder meeting, the CCS Standing Committee on Access to Care considered the suggestions made at the meeting and drafted an action plan for 2009/2010 that was subsequently approved by the CCS Council and aligned with the CHHS-AP. This plan includes a lead role for the CCS in facilitating consensus on pan-Canadian data standards and definitions, and using current resources and infrastructure. The imperative for such an initiative and the benefits it would yield were outlined in the CHHS-AP, which was officially launched on February 24, 2009 (2,3). The CCS looks forward to engaging stakeholder and expert input in developing and carrying out this important initiative, and advocating for financial support. The CCS will also consider its contribution to the Cardiac Care Network/Canadian Institute for Health Information quality indicators initiative, and is well positioned to coordinate input from the cardiovascular community.

Additionally, the CCS plans to continue its membership in and involvement with the Wait Time Alliance, for which the Canadian Medical Association provides the secretariat. This includes participation in the spring release and report card of results from the February and March 2009 National Physician Diary Study and survey (4). At the time of writing this paper, preliminary findings from the 40 community cardiologists and electrophysiologists who responded to the opinion section of the survey, indicated that wait times in their specialty had increased by 49% in the past five years and that their outlook for the next five years suggests no major change. Further details will be officially released once available.

As well, some of the wait time issues identified by community cardiologists in the National Physician Diary Study will shed light on issues that can be addressed in a joint commentary paper with the College of Family Physicians of Canada on nonurgent patient access to the specialist consult, although response rates from the study were too low to be reported in a meaningful way. A national survey and report on access to cardiac rehabilitation, in collaboration with the Canadian Association of Cardiac Rehabilitation and as suggested at the October 2008 stakeholder meeting, is also planned for the coming year.

The development of wait time benchmarks along the continuum of cardiovascular care was a major and successful first step toward improved and more equitable access to cardiovascular care across our country. The CCS and its Standing Committee look forward to continuing to work with stakeholders in the coming year to promote awareness and adoption of the benchmarks, and to embark on several new initiatives that provide more insight into access to care issues along the continuum of care.