Post on 25-Dec-2015
transcript
Leadership. Knowledge. Community.
The Patient Journey - Progress 2008 Symposium: CCS Benchmarks for Access to Cardiovascular Services and Procedures:
Leadership. Knowledge. Community.2
The 7 Access to Care Subgroups
Subgroup Chair
Specialist consultation and non-invasive tests
Dr. Merril Knudtson
Nuclear cardiology Dr. Rob Beanlands
Emergent and urgent situations Dr. Blair O’Neill
Revascularization and other cardiac surgeries
Dr. David RossDr. Michelle Graham
Heart failure clinics Dr. Heather Ross
Electrophysiology services Dr. Chris Simpson
Rehabilitation Dr. Bill Dafoe
Leadership. Knowledge. Community.3
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
Leadership. Knowledge. Community.4
The Cardiovascular Continuum of CareOnset of
symptoms
Non-invasive testing
General practitioner
Specialist consult
Emergency departmentor hospital admission
Therapeutic procedure (e.g., surgery, angioplasty, pacemaker, ICD, ablation)
Invasive and/or non-invasive
testing
Rehabilitation
PERIOD 1
PERIOD 3
PERIOD 4
PERIOD 5Total Patient Wait Time = PERIOD 1 + 2 + 3 + 4 + 5
PERIOD 2
Secondary preventionand rehabilitation
Non-invasive testing Subspecialist
consult
Chronic Disease Management Programs
Chronic Disease Management Programs
Leadership. Knowledge. Community.5
The Patient’s PerspectiveWait-time Interval Max (wks)
Symptom onset to Family Physician Unknown
Family Physician to Cardiologist 6
Cardiologist to Angiogram 6
Angiogram to Cardiac Surgeon6*
Cardiac Surgeon to Bypass Surgery
Bypass Surgery to Rehabilitation 4
Total Wait Time for the Patient 22
In some jurisdictions, both wait periods are included in the measured interval.
Leadership. Knowledge. Community.6
CCS ACCESS TO CARDIOVASCULAR CARE RECOMMENDED WAIT TIME TARGETS
Subgroup EmergencyEmergency Semi-urgentSemi-urgent ScheduledScheduled
Specialist consultation/ non-invasive tests
< 24 hours< 24 hours Urgent SUUrgent SU
< 1 week < 4 < 1 week < 4 weeksweeks
< 6 weeks< 6 weeks
Nuclear cardiology < 24 hours< 24 hours < 3 days< 3 days < 14 days< 14 days
Echocardiography < 24 hours< 24 hours < 7 days< 7 days < 30 days< 30 days
Emergent and urgent revascularizations
NSTEACS < 48NSTEACS < 48
STEMI < 24STEMI < 24
Urgent SUUrgent SU
< 7 days < 14 days< 7 days < 14 days
< 6 weeks< 6 weeks
Revascularization and other cardiac surgeries
< 24 hours< 24 hours Urgent SUUrgent SU
< 7 days < 2-4wks< 7 days < 2-4wks
< 6 weeks< 6 weeks
Heart failure disease management clinics
< 24 hours< 24 hours Urgent SUUrgent SU
< 1-2 wks < 4 wks< 1-2 wks < 4 wks
< 6 – 12 weeks< 6 – 12 weeks
Electrophysiology services
<1-3 days<1-3 days Urgent SUUrgent SU
< 2 weeks <4-6 wks< 2 weeks <4-6 wks
< 3 months< 3 months
Rehabilitation < 3 days< 3 days < 7 days< 7 days < 30 days< 30 days
Leadership. Knowledge. Community.7
Preconsultation Testing and InfoThe 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.
Leadership. Knowledge. Community.8
Improving Access to SpecialistsImproving Access to Specialists
Cardiology
Leadership. Knowledge. Community.9
The CCS National Survey onAccess to Care
at Tertiary Cardiac Care Centres
• Summer 2007 – Summary Results
Leadership. Knowledge. Community.10
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
Leadership. Knowledge. Community.11
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%)
Leadership. Knowledge. Community.12
Response Rate by Province
0%
20%
40%
60%
80%
100%
Re
sp
on
se
ra
te
BC AL SK MN ON * PQ NB NS NL Canada
2
3 1
45
1
17
1
0 0
11 academic, 2 community, and 4 regional centres responded 13 respondents were Chiefs of Cardiology
•1 tertiary and 3 community and centres responded in Ontario
Leadership. Knowledge. Community.13
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”
Leadership. Knowledge. Community.14
How would you rate access to cardiac care at your centre?
0 2 4 6 8
Poor
Fair
GoodVery
Excellent
Number of respondents
8 of 17 rated access as “excellent” or “very good”15 of 17 have been monitoring wait times for > 5 years
Leadership. Knowledge. Community.15
Does your cardiac care centre have wait time targets for:
Yes No Not offered
Monitor only
N/A Total
Cath 12 0 1 1 14
Angioplasty 11 1 1 1 14
Cardiac surgery 9 2 1 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
5 centres had wait time targets for Initial specialist consultation, echocardiography, cardiac nuclear imaging, CHF clinic, electrophysiologist consultation, CRT and cardiac rehabilitation
Leadership. Knowledge. Community.16
What was the basis for establishing the targets that you have?
0 2 4 6 8
Not spec ified
Centre-spec ific
Combination
Provinc ial benchmarks
CCS benchmarks
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.
Leadership. Knowledge. Community.17
How would you rate your cardiac care centre’s commitment to setting access targets?
0 2 4 6 8 10
Little or no
Low
Good
Strong
Very strong
Number of responses
“Low” or “Little or no” reported in Manitoba and Ontario.
Leadership. Knowledge. Community.18
Prior to this survey, how would you describe your awareness of the CCS benchmarks?
0 1 2 3 4 5 6
N/A
Poor
Fair
Good
Very good
Excellent
Number of responses
The CCS benchmarks have been well communicated among the survey respondents.
Leadership. Knowledge. Community.19
How would you describe the level of awareness among professional (medical, clinical and administrative) staff?
0 1 2 3 4 5 6
N/A
Poor
Fair
Good
Very good
Excellent
Number of responses
The CCS benchmarks are not as well known among other medical, clinical and administrative staff. 38% rated “fair” or “poor”
Leadership. Knowledge. Community.20
Barriers to the adoption of access targets for a broad range of CV services and procedures, in order of importance/ significance
1. Lack of human resources
2. Lack of funding
3. Lack of physical resources
4. Lack of infrastructure
5. Liability concerns for physicians and administrators
6. No or low awareness of the CCS benchmarks
7. Not perceived as a priority at this time
Leadership. Knowledge. Community.21
Key individuals and groups whose support is necessary for the adoption of benchmarks for the full continuum of care, in order of significance:
1. Medical leadership within hospitals
2. Minister or Deputy Minister of Health
3. Hospital administrators
4. Medical leadership within academic institutions
5. Ministry or Minister of Health staff
6. Staff at regional or local health authorities
7. Medical leadership within the community
Leadership. Knowledge. Community.22
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”
Leadership. Knowledge. Community.23
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
Leadership. Knowledge. Community.24
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
Leadership. Knowledge. Community.25
What grade would you give to governments for how well they have meaningfully addressed wait times for CV over last 2 years?
0
2
4
6
8
10
12
Nu
mb
er
of
rep
on
de
nts
Fail Poor Fair Good Excellent
Most respondents (71%) gave a grade of “Fair”.
Leadership. Knowledge. Community.26
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