We read with considerable interest the article by Ivo Olivotto and colleagues outlining waiting times from abnormal breast screen to diagnosis for women attending organized screening programs.1 The authors' findings highlight the excessive waits that endanger patients' health and peace of mind.
However, there are 2 fundamental problems implicit in the authors' discussion. First, their description of diverse diagnostic practices highlights the lack of program control over standard diagnostic strategies. This reality is further evinced by the marked variability in observed waiting times within and between programs. It is difficult, if not impossible, to evaluate the significance of the queue when the very decisions to utilize medical services are themselves questionable. Therefore, a more logical sequence to this study would have been to focus on utilization strategies first and only thereafter turn to an investigation of queues.
Standardization of diagnostic pathways may reduce excessive waits if unnecessary referrals and duplication of tests are eliminated. Yet these measures alone will unlikely suffice in addressing the challenges of the queue for breast cancer evaluation. Hence, the second problem: Olivotto and colleagues focus on organizational reform strategies as solutions to lengthy delays in diagnosis. They cite the experiences in Sweden and the United Kingdom, where a host of organizational strategies and new care routines were invoked and the breast cancer workup was reallocated from the primary caregiver to the specialist. However, these reform strategies ultimately failed, ostensibly because of unchecked increases in utilization and limited funding availability.2,3,4 Ontario's experience in managing cardiac queues also illustrates that organizational efforts alone are insufficient to eliminate lengthy delays in service. Centralized triage approaches to cardiac services have not obviated the need for transient funding infusions during times of excessive backlogs —this despite the widespread use of explicit indicators of urgency for patients awaiting bypass surgery.5
The problem of excessive waits is a complex one. We must first disentangle and then standardize diagnostic pathways to allow for reasonable comparisons of quality and timeliness of care across jurisdictions. Only then might we suggest solutions with confidence. Ultimately, however, the principles comprising waiting-list management will likely remain the same: system-monitoring processes, explicit prioritization criteria and reasonable supply estimates (although flexibility in capacity should be maintained to meet transient fluctuations in demand).
The authors' study is a step in the right direction, but we are left waiting for a compelling destination to emerge from their work.
Signatures
Dalis L. Rotstein
Student Harvard University Cambridge, Mass.
David A. Alter
Scientist Institute for Clinical Evaluative Sciences Toronto, Ont.
References
- 1.Olivotto IA, Bancej C, Goel V, Snider J, McAuley RG, Irvine B, et al. Waiting times from abnormal breast screen to diagnosis in 7 Canadian provinces. CMAJ 2001;165(3):277-83. [PMC free article] [PubMed]
- 2.Cant PJ, Yu DSL. Impact of the ‘2 week wait’ directive for suspected cancer on service provision in a symptomatic breast clinic. Br J Surg 2000; 87:1082-6. [DOI] [PubMed]
- 3.Hanning M, Spangberg UW. Maximum waiting time: A threat to clinical freedom? Implementation of a policy to reduce waiting times. Health Policy 2000;52(1):15-32. [DOI] [PubMed]
- 4.Hanning M. Maximum waiting time guarantee — an attempt to reduce waiting lists in Sweden. Health Policy 1996;36:17-35. [DOI] [PubMed]
- 5.Naylor CD. Benchmarking the provision of coronary artery surgery. CMAJ 1998;158(9): 1151-3. [PMC free article] [PubMed]