The 2012 SAGE wait times program: Survey of Access to GastroEnterology in Canada

BACKGROUND:

Periodically surveying wait times for specialist health services in Canada captures current data and enables comparisons with previous surveys to identify changes over time.

METHODS:

During one week in April 2012, Canadian gastroenterologists were asked to complete a questionnaire (online or by fax) recording demographics, reason for referral, and dates of referral and specialist visits for at least 10 consecutive new patients (five consultations and five procedures) who had not been seen previously for the same indication. Wait times were determined for 18 indications and compared with those from similar surveys conducted in 2008 and 2005.

RESULTS:

Data regarding adult patients were provided by 173 gastroenterologists for 1374 consultations, 540 procedures and 293 same-day consultations and procedures. Nationally, the median wait times were 92 days (95% CI 85 days to 100 days) from referral to consultation, 55 days (95% CI 50 days to 61 days) from consultation to procedure and 155 days (95% CI 142 days to 175 days) (total) from referral to procedure. Overall, wait times were longer in 2012 than in 2005 (P<0.05); the wait time to same-day consultation and procedure was shorter in 2012 than in 2008 (78 days versus 101 days; P<0.05), but continued to be longer than in 2005 (P<0.05). The total wait time remained longest for screening colonoscopy, increasing from 201 days in 2008 to 279 days in 2012 (P<0.05).

DISCUSSION:

Wait times for gastroenterology services continue to exceed recommended targets, remain unchanged since 2008 and exceed wait times reported in 2005.     

General anesthetic versus light sedation: Effect on pediatric endoscopy wait times

BACKGROUND:

Wait times are an important measure of health care system effectiveness. There are no studies describing wait times in pediatric gastroenterology for either outpatient visits or endoscopy. Pediatric endoscopy is performed under light sedation or general anesthesia. The latter is hypothesized to be associated with a longer wait time due to practical limits on access to anesthesia in the Canadian health care system.

OBJECTIVE:

To identify wait time differences according to sedation type and measure adverse clinical outcomes that may arise from increased wait time to endoscopy in pediatric patients.

METHODS:

The present study was a retrospective review of medical charts of all patients <18 years of age who had been assessed in the pediatric gastroenterology clinic and were scheduled for an elective outpatient endoscopic procedure at McMaster Children’s Hospital (Hamilton, Ontario) between January 2006 and December 2007. The primary outcome measure was time between clinic visit and date of endoscopy. Secondary outcome measures included other defined waiting periods and complications while waiting, such as emergency room visits and hospital admissions.

RESULTS:

The median wait time to procedure was 64 days for general anesthesia patients and 22 days for patients who underwent light sedation (P<0.0001). There was no significant difference between the two groups with regard to the number of emergency room visits or hospital admissions, both pre- and postendoscopy.

CONCLUSIONS:

Due to the lack of pediatric anesthetic resources, patients who were administered general anesthesia experienced a longer wait time for endoscopy compared with patients who underwent light sedation. This did not result in adverse clinical outcomes in this population.     

Current status of core and advanced adult gastrointestinal endoscopy training in Canada: Survey of existing accredited programs

OBJECTIVE:

To determine the current status of core and advanced adult gastroenterology training in Canada.

METHODS:

A survey consisting of 20 questions pertaining to core and advanced endoscopy training was circulated to 14 accredited adult gastroenterology residency program directors. For continuous variables, median and range were analyzed; for categorical variables, percentage and associated 95% CIs were analyzed.

RESULTS:

All 14 programs responded to the survey. The median number of core trainees was six (range four to 16). The median (range) procedural volumes for gastroscopy, colonoscopy, percutaneous endoscopic gastrostomy and sigmoidoscopy, respectively, were 400 (150 to 1000), 325 (200 to 1500), 15 (zero to 250) and 60 (25 to 300). Eleven of 13 (84.6%) programs used endoscopy simulators in their curriculum. Eight of 14 programs (57%) provided a structured advanced endoscopy training fellowship. The majority (88%) offered training of combined endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasonography. The median number of positions offered yearly for advanced endoscopy fellowship was one (range one to three). The median (range) procedural volumes for ERCP, endoscopic ultrasonography and endoscopic mucosal resection, respectively, were 325 (200 to 750), 250 (80 to 400) and 20 (10 to 63). None of the current programs offered training in endoscopic submucosal dissection or natural orifice transluminal endoscopic surgery.

CONCLUSION:

Most accredited adult Canadian gastroenterology programs met the minimal procedural requirements recommended by the Canadian Association of Gastroenterology during core training. However, a more heterogeneous experience has been observed for advanced training. Additional studies would be required to validate and standardize evaluation tools used during gastroenterology curricula.     

Access to specialist gastroenterology care in Canada: comparison of wait times and consensus targets

BACKGROUND: Monitoring wait times and defining targets for care have been advocated to improve health care delivery related to cancer, heart, diagnostic imaging, joint replacements and sight restoration. There are few data on access to care for digestive diseases, although they pose a greater economic burden than cancer or heart disease in Canada. The present study compared wait times for specialist gastroenterology care with recent, evidence-based, consensus-defined benchmark wait times for a range of digestive diseases. METHODS: Total wait times from primary care referral to investigation were measured for seven digestive disease indications by using the Practice Audit in Gastroenterology program, and were benchmarked against consensus recommendations. RESULTS: Total wait times for 1903 patients who were undergoing investigation exceeded targets for those with probable cancer (median 26 days [25th to 75th percentiles eight to 56 days] versus target of two weeks); probable inflammatory bowel disease (101 days [35 to 209 days] versus two weeks); documented iron deficiency anemia (71 days [19 to 142 days] versus two months); positive fecal occult blood test (73 days [36 to 148 days] versus two months); dyspepsia with alarm symptoms (60 days [23 to 140 days] versus two months); refractory dyspepsia without alarm symptoms (126 days [42 to 225 days] versus two months); and chronic constipation and diarrhea (141 days [68 to 264 days] versus two months). A minority of patients were seen within target times: probable cancer (33% [95% CI 20% to 47%]); probable inflammatory bowel disease (12% [95% CI 1% to 23%]); iron deficiency anemia (46% [95% CI 37% to 55%]); positive occult blood test (41% [95% CI 28% to 54%]); dyspepsia with alarm symptoms (51% [95% CI 41% to 60%]); refractory dyspepsia without alarm symptoms (33% [95% CI 19% to 47%]); and chronic constipation and diarrhea (21% [95% CI 14% to 29%]). DISCUSSION: Total wait times for the seven indications exceeded the consensus targets; 51% to 88% of patients were not seen within the target wait time. Multiple interventions, including adoption of evidence-based management guidelines and provision of economic and human resources, are needed to ensure appropriate access to digestive health care in Canada. Outcomes can be evaluated by the 'point-of-care', practice audit methodology used for the present study.     

Treating the right patient at the right time: Access to echocardiography in Canada

The Canadian Cardiovascular Society is the national professional society for cardiovascular specialists and researchers in Canada. In the spring of 2004, the Canadian Cardiovascular Society Council formed the Access to Care Working Group ('Working Group') to use the best science and information available to establish reasonable triage categories and safe wait times for access to common cardiovascular procedures. The Working Group decided to publish a series of commentaries to initiate a structured national discussion on this important issue, and the present commentary proposes recommended wait times for access to echocardiography. 'Emergent' echocardiograms should be performed within 24 h, 'urgent' within seven days and 'scheduled' (elective) within 30 days. A framework for a solution-oriented approach to improve access is presented.     

Treating the right patient at the right time: Access to cardiac catheterization, percutaneous coronary intervention and cardiac surgery

The Canadian Cardiovascular Society Access to Care Working Group was formed with a mandate to use the best science and information available to establish reasonable triage categories and safe wait times for common cardiovascular services and procedures through a series of commentaries. The present commentary discusses the rationale for access benchmarks for cardiac catheterization and revascularization procedures for patients with stable angina, and access benchmarks for cardiac catheterization and surgery for patients with valvular heart disease. Literature on standards of care, wait times and wait list management was reviewed. A survey of cardiac centres in Canada was performed to develop an inventory of current practices in identifying and triaging patients. The Working Group recommends the following medically acceptable wait times for access to cardiac catheterization: 14 days for symptomatic aortic stenosis and six weeks for patients with stable angina and other valvular disease. For percutaneous coronary intervention in stable patients with high-risk anatomy, immediate revascularization or a wait time of 14 days is recommended; six weeks is recommended for all other patients. The target for bypass surgery in those with high-risk anatomy or valve surgery in patients with symptomatic aortic stenosis is 14 days; for all others, the target is six weeks. All stakeholders must affirm the appropriateness of these standards and work continuously to achieve them. There is an ongoing need to continually reassess current risk stratification methods to limit adverse events in patients on waiting lists and assist clinicians in triaging patients for invasive therapies.     

Improving access in gastroenterology: The single point of entry model for referrals

In 2005, a group of academic gastroenterologists in Calgary (Alberta) adopted a centralized referral intake system known as central triage. This system provided a single point of entry model (SEM) for referrals rather than the traditional system of individual practitioners managing their own referrals and queues. The goal of central triage was to improve wait times and referral management. In 2008, a similar system was developed in Edmonton at the University of Alberta Hospital (Edmonton, Alberta). SEMs have subsequently been adopted by numerous subspecialties throughout Alberta. There are many benefits of SEMs including improved access and reduced wait times. Understanding and measuring complex patient flow systems is key to improving access, and centralized intake systems provide an opportunity to better understand total demand and system bottlenecks. This knowledge is particularly important for specialties such as gastroenterology (GI), in which demand exceeds supply. While it is anticipated that SEMs will reduce wait times for GI care in Canada, the lack of sufficient resources to meet the demand for GI care necessitates additional strategies.     

Effect of the implementation of a program to improve referrals by primary care on appropriateness and wait times in endoscopic examinations

Introduction

Within a program to improve referrals by primary care (PC) in Ourense (Spain), we implemented practice guidelines on dyspepsia and rectal bleeding. Our aim was to evaluate the reasons for referral to endoscopy, the appropriateness of these referrals, and wait times.

Material and methods

We performed a retrospective cohort study in the Ourense health area between February 2009 and January 2010. The endoscopies performed with the indications of dyspepsia and rectal bleeding requested directly from PC were compared with those referred initially to specialist care (SC). The reasons for the referral, the priority of the endoscopy, compliance with the protocol, endoscopic finding and the wait time from referral were gathered.

Results

During the period analyzed, 158 upper gastrointestinal endoscopies (SC: 121; PC: 37) and 243 colonoscopies (SC: 193; PC: 50) were performed with the indications of dyspepsia and rectal bleeding. Among endoscopies, 34.5% and 77.7% were requested with high priority from PC and SC, respectively (p < 0.001). The criteria for referral were met in 86.5% of upper gastrointestinal endoscopies and in 82% of colonoscopies requested from PC. No differences were found in endoscopic findings. The median wait time from referral was lower in upper gastrointestinal endoscopy (PC: 105 ± 5.5 days, SC: 174 ± 17.8 days; p: 0.003) and colonoscopies (PC: 101 ± 11.8 days, SC: 187 ± 9.6 days; p < 0.001) referred from PC.

Conclusions

The use of the program for improved referrals by PC reduces wait times. The examinations requested complied with the indications.     

Improving Access to Eye Care: Teleophthalmology in Alberta, Canada

Backround

Diabetic retinopathy in Alberta and throughout Canada is common, with a prevalence up to 40% in people with diabetes. Unfortunately, due to travel distance, time, and expense, a third of patients with diabetes do not receive annual dilated eye examinations by ophthalmologists, despite universal health care access. In an effort to improve access, a teleophthalmology program was developed to overcome barriers to eye care. Prior to clinical implementation, teleophthalmology technology was clinically validated for the identification of treatable levels of diabetic retinopathy.

Method

Patients undergoing a teleophthalmology assessment underwent stereoscopic digital retinal photographs following pupillary dilation. Digital images were then packaged into an encrypted password-protected compressed file for uploading onto a secure server. Images were digitally unpackaged for review as a stereoscopic digital slide show and graded with a modified Early Treatment Diabetic Retinopathy Study algorithm. Reports were then generated automatically as a PDF file and sent back to the referring physician.

Results

Teleophthalmology programs in Alberta have assessed more than 5500 patients (9016 visits) to date. Nine hundred thirty patients have been referred for additional testing or treatment. Approximately 2% of teleophthalmology assessments have required referral for in-person examination due to ungradable image sets, most commonly due to cataract, corneal drying, or asteroid hyalosis.

Conclusions

In Alberta and throughout Canada, many patients with diabetes do not receive an annual dilated eye examination. Teleophthalmology is beneficial because patients can be assessed within their own communities. This decreases the time to treatment, allows treated patients to be followed remotely, and prevents unnecessary referrals. Health care costs may be reduced by the introduction of comprehensive teleophthalmology examinations by enabling testing and treatment to be planned prior to the patient''s first visit.     

窄带成像技术普通内镜诊断大肠肿瘤的价值

目的探讨窄带成像技术普通内镜（NBI）诊断大肠肿瘤的临床价值。方法 2012年6月至2012年8月行常规内镜和NBI普通内镜检查的患者225例,对发现的大肠新生性病变记录腺管开口形态,将NBI内镜诊断和病理组织学诊断结果进行对比分析,并比较NBI内镜与常规内镜在鉴别肿瘤性和非肿瘤性病变的敏感性、特异性和准确性。结果 NBI普通内镜对腺管开口类型的判断接近病理水平,鉴别病变是否为肿瘤的敏感性、特异性、准确率分别为93.6%,91.7%和93.0%,显著高于常规内镜（P〈0.01）。结论 NBI普通内镜能较准确判断病变的性质,为鉴别是否为肿瘤性病变的更有效的内镜方法。     

成人腹型过敏性紫癜的临床和内镜特征

目的探讨成人腹型过敏性紫癜的临床特点与内镜表现，为该病早期诊断提供依据。方法对32例成人腹型过敏性紫癜的临床特点与内镜表现进行回顾分析。结果32例患者均有腹部绞痛，腹痛部位多变而不固定，症状严重而腹部体征轻微，59．4％的患者伴恶心、呕吐，50％的患者有呕血、便血，大便潜血全部阳性，25％患者血尿淀粉酶升高，腹痛发生后2～10d出现下肢紫癜。内镜检查可见胃肠黏膜充血、水肿、出血点、糜烂、溃疡，以十二指肠、回肠末段、回盲部和升结肠黏膜病理改变最严重，食管黏膜正常。临床和内镜的误诊率分别为87．5％和85．7％。解痉剂和抗酸药物治疗无效，糖皮质激素有效。结论腹型过敏性紫癜患者的胃肠黏膜广泛散在大小不一的出血点和雪花状多发性溃疡。临床表现无特异性，腹痛剧烈而部位多变、腹部体征轻微，是其临床特点之一。     

Laboratory diagnosis of syphilis: A survey to examine the range of tests used in Canada

Laboratory diagnosis of syphilis has undergone major changes in the past decade with the introduction of immunoassays and recombinant Treponema pallidum antigens as screening tools for syphilis infection. To address this change in laboratory practice, a national syphilis laboratory working group was established with members from the Public Health Agency of Canada, provincial public health laboratories across the country as well as sexually transmitted infection researchers, clinicians and epidemiologists. This working group aims to examine how the use of newer immunoassays will affect syphilis diagnosis, surveillance and disease management. To provide a baseline for this work, an e-mail survey was conducted in the fall of 2009 to determine current laboratory practices for syphilis diagnosis in Canada. The most commonly used tests were rapid plasma reagin, enzyme immunoassay, T pallidum passive particle agglutination, venereal disease research laboratory, fluorescent treponemal antibody absorption, line immunoassay and polymerase chain reaction with 92%, 36%, 32%, 20%, 12%, 12% and 12% of the responding laboratories reporting using these tests, respectively. The ultimate goal of this working group will be to update laboratory guidelines for the diagnosis of syphilis, and to identify syphilis surveillance and research priorities in Canada.     

A comparison of hospital and nonhospital colonoscopy: wait times, fees and guideline adherence to follow-up interval

BACKGROUND:

Although colonoscopy is increasingly performed in nonhospital facilities, studies to date examining differences between colonoscopy services in hospital and nonhospital settings have been limited, in large part, to administrative databases.

OBJECTIVES:

To describe the experiences of patients receiving colonoscopy in hospital and nonhospital settings, and to compare these settings with respect to wait times and recommended follow-up interval to the next colonoscopy.

METHODS:

A postal survey of 2000 patients, 50 to 70 years of age, from an urban academic family practice was conducted. Most recent colonoscopy was classified as either occurring in a hospital or nonhospital setting. Multivariable logistic regression analysis was used to examine the association among wait times, follow-up intervals and patient factors with respect to colonoscopy setting.

RESULTS:

Patients who underwent their most recent colonoscopy outside of a hospital were more likely to be men (P=0.01) and to have undergone more than one previous colonoscopy (P=0.02). For patients with a normal screening colonoscopy and no family history of colorectal cancer or polyps, nonhospital clinics less often recommended a 10-year follow-up interval (OR 0.13 [95% CI 0.04 to 0.47]). Reported wait times at nonhospital clinics were shorter for patients receiving screening colonoscopy (OR 2.11 [95% CI 1.28 to 3.47]), but not for symptomatic patients (OR 1.74 [95% CI 0.88 to 3.43]). For individuals attending nonhospital clinics, 10% were referred from a hospital by the same specialist performing the procedure; 31.7% reported paying a fee.

CONCLUSION:

Nonhospital clinics were far less likely to adhere to guidelines regarding follow-up intervals for low-risk patients. Given the implications for both health care costs and patient safety, further study is needed to determine the cause of this disparity.     

胶囊内镜在小肠出血诊断中的效价分析

目的分析胶囊内镜检查在小肠出血诊断中的效价，并与传统检查方法进行比较。方法将怀疑小肠出血住院患者分为两组：A组58例，为1998年至2005年问行传统检查患者；B组93例，为2002年5月至2005年1月间行胶囊内镜检查患者。通过统计两组的诊断率、特异性治疗率、检查费用和其他相关累计费用，分析传统检查和胶囊内镜检查的成本效果比及综合成本效果比情况，并进行敏感性检验。结果A组和B组对小肠出血病因的诊断率分别为22．4％（13／58）及86％（80／93），总检查费用分别为133750元及790500元。仅从检查成本效果比分析，B组（9881．3元／例）略优于A组（10288．5元／例）。此外，由于B组的诊断率显著高于A组（P=0．001），而根据诊断结果指导的特异性治疗率B组高于A组（49．5％比12．1％），即B组能更有效终止和节省因病因不能明确而反复就诊、检查、支持治疗和住院等费用。故经调整后的综合成本效果比B组（9881．3元／例）明显优于A组（从1个月的16361．5元至5年以上的97424．0元／例），即随着时间的推移，A组比B组每例多花费6480．2～87542．7元，是B组的1．7～9．9倍。结论对于经胃镜、结肠镜检查阴性而疑有小肠出血的患者，尽早选择胶囊内镜检查比反复进行传统检查更经济实用。     

血液透析五年以上成人永久性血管通路患者生存质量与血流量的相关因素分析

目的研究永久性血管通路在五年以上透析后血流量大小对患者生存质量的影响。方法选择永久性血管通路透析五年以上患者88例,其中实验组为血管通路血流量≤300 mL/min患者45例,对照组为血管通路血流量在300～500 mL/min患者43例,两组患者均采用常规透析,并对两组患者并发症、血红蛋白、尿素氮、血肌酐、白蛋白、残余肾功能等生存质量因素进行分析。结果透析后,实验组尿素氮和血肌酐水平高于对照组(24.87±7.97 mmol/L和675±232μmol/L比17.34±9.53 mmol/L和368±243μmol/L;P<0.05),实验组血红蛋白水平(70.62±12.03 g/L)低于对照组(76.03±13.05 g/L;P<0.05),两组白蛋白水平无明显差异(P>0.05)。实验组残余肾功能降低了90.9%,明显高于对照组的36.4%。在对狭窄治疗后再狭窄机会以及血液再通时的流速比较中发现实验组明显差于对照组(P<0.05)。结论永久性血管通路进行透析且血管通路血流量≤300 mL/min的患者在透析过程中应当注意身体机能的变化,在适当的时机应调整透析方案,增加透析频率和对并发症的预防,提高患者...