Cutbacks

Alberta approves private clinics

Protestors failed to stop Alberta’s controversial legislation that regulates the contracting out of surgical services to private, for-profit clinics. Bill 11, the Health Care Protection Act became law in mid-May after Premier Ralph Klein invoked closure on debate in the legislature. The bill not only drew fire from opponents across the country but also divided physicians and had protesters describing Klein as "a fascist." CMAJ 2000;162(11):1606-7.

Deciding how long is long enough

Reducing the time that patients spend in hospital is seen as one way to control health care costs, but determining just what is an appropriate time to spend in a hospital for a particular ailment is not always straightforward. Researchers applied three tools — the ISD (Intensity of service, Severity of illness, Discharge screens), the MCAP (Managed Care Appropriateness Protocol) and the AEP (Appropriateness Evaluation Protocol) — to the retrospective review of 75 patients admitted to an acute cardiology service. Each case was also reviewed by a panel of cardiologists. The overall agreement between the tools and the panel was poor, suggesting that the tools have only a low level of validity when compared with a panel of experts. The authors suggest this raises serious doubt as to whether they should be used at all. CMAJ 2000;162(13):1809-13.

An accompanying editorial cautions that utilization review is not going away and advises physicians and researchers to work together to improve the methodology. CMAJ 2000;162(13):1824-5.

ER alternative: urgent care centers

Urgent Care Centers offer emergency room services without the long wait. Since the first center appeared in 1989, about 24 others have sprung up across Canada. They offer complete emergency room services, but don’t accept ambulances. Physicians at two Ottawa centers are trying to form a national association. CMAJ 2000:162(7):1037-8 .

Freeing up the ER for real emergencies

Inappropriate use of emergency departments is a large problem for hospital staff trying to provide care for those who need it most. A study of emergency room use at St. Paul’s Hospital in downtown Vancouver, found that 24 patients visited the emergency department a total of 616 times during the course of one year. The authors report that in addition to physical ailments, heavy users of emergency rooms also often have social or psychological problems.

In an attempt to ease the problem of patients blocking emergency rooms with conditions that could be treated in the community setting, the authors devised a care plan for frequent users. Through the involvement of social workers, emergency and family physicians, psychiatric nurses and community care providers, the same patients made a total of only 175 visits in the year after the program was implemented. CMAJ 2000;162(7):1017-20.

Hospital downsizing and health care use

In a study of British Columbia hospitals, researchers analysed the shifts in health care use by elderly people and found that even though the number of short-stay hospital beds fell by 30% in the five years prior to 1997 and the average length of hospital stays declined by 12.9%, the large drops had little impact on these patients. For example, even though elderly patients in BC spent far less time in acute and extended-stay beds because of the cuts (27.3% and 14.4%, respectively), the health impact on these patients was negligible. "Overall changes in health care use were small, which suggests that the repercussions of the decline in acute care services for elderly people have been minimal," the authors report. CMAJ 2000;163(4):397-401.

An accompanying commentary describes the consistency of these results with others and contrasts them with media reports of crisis and suffering. The author concludes that "Bed closures have not made it tougher for sick elderly patients to get into hospital. Claims to the contrary are false." CMAJ 2000;163(4):411-2.

Is scarcity of resources a valid legal defence?

Physicians may blame cutbacks when their patients encounter difficulties receiving medical treatment, but the law could well hold them accountable for the standard of care their patients receive — a standard that hasn’t changed despite cuts in funding and resources. The decline in health care resources is opening a new area of potential legal liability for physicians. CMAJ 2000;162(6):880.

Private MRI clinics flourish in Quebec

Twenty-five radiologists from McGill University in Montreal launched a private medical imaging centre, joining similar clinics in Alberta, British Columbia and Quebec. Slated to open in December 2000, the $5-million, state-of-the-art clinic was to include a $2-million MRI machine. In Montreal, the waiting period for an MRI scan at the city’s eight public facilities ranges from two weeks to 14 months. CMAJ 2000;163(10):1326.

The waiting-list shuffle

There is a disturbing chasm between widely held views and the research evidence about waiting lists in Canada according to a group of researchers.

The authors attribute this gap to confusion over terminology, differences in measures and methods, and a lack of awareness about management approaches. They also contend that frequently offered solutions such as introducing a two-tiered system and allocating additional funding are not supported by evidence. The authors conclude that Canada needs a better infrastructure of information about waiting lists and their management. CMAJ 2000; 162(9):1305-10.

An accompanying editorial contends that information and management defects are almost always prematurely diagnosed as financial shortages. They conclude that: "The waiting-list ‘nonsystem’ in Canada is a classic case of forced decision-making in the absence of good management information. There is a surfeit of nonstandardized data and a dearth of usable, policy-oriented information about waiting lists." CMAJ 2000; 162(9):1297-1300.

Waiting for coronary artery bypass surgery

Patients awaiting coronary artery bypass grafting (CABG) in Ontario are at much greater risk of death than the general population. However, the authors of a new study conclude patients awaiting CABG in Ontario are at similar or decreased vital risk when compared with thousands of other patients living with coronary artery disease.

In an attempt to benchmark the burden of delayed care on patients, a group of researchers determined the vital risk among people waiting for CABG in Ontario and compared it with the risk in the general population and among people living with coronary artery disease. The authors report that among 21,220 patients awaiting CABG, there were 82 preoperative deaths over a median followup of 18 days and the standard mortality rate was 2.92 (95% confidence limit 2.29-3.55). Among 21,220 matched six-month survivors of an acute myocardial infarction, there were 663 deaths over a median follow up of 185 days and the standard mortality rate was 3.84 (95% confidence limit 3.54-4.14). CMAJ 162(6):775-9.

An accompanying editorial discusses how mortality rate studies like this one can be meaningfully interpreted without patient-level adjustments. CMAJ 162(6):794-5.

Copyright 2000 Canadian Medical Association or its licensors