1. 1 Wait Time Information in Priority Areas: Definitions

2. Background In 2004, Canada’s first ministers agreed to work towards reducing wait times for five priority areas: cancer treatment, cardiac care, diagnostic imaging, joint replacement and sight restoration. CIHI was mandated to collect wait times information and monitor provincial progress in meeting benchmarks. Since 2004, CIHI and the provinces have collaboratively worked towards the development of indicators and public wait times reporting for five priority procedures and two diagnostic imaging procedures. 2

3. Background In 2005, the Comparable Indicators of Access Sub Committee (CIASC) developed a pan-Canadian definition for wait time measurement which was adopted by the federal/provincial/territorial ministries. The definition of start date for wait time measurement was defined as follows: “Waiting for a health service begins with the booking of a service, which is when the patient and the appropriate physician agree to a service, and the patient is ready to receive it.” The definition of finish date for wait time measurement was defined as follows: “Waiting for a service ends when the patient receives the service, or the initial service in a series of treatments or services.” 3

4. Procedures for which wait times information is currently being reported Hip replacement Knee replacement Hip fracture repair Cataract Coronary artery bypass graft (CABG) Radiation therapy MRI CT Cancer surgery (breast, bladder, colorectal, lung and prostate) IV chemotherapy (collection targeted for 2016) 4

5. Procedures for which wait times information is being considered for future reporting Diagnostic imaging wait times (PET scan and ultrasound) Emergency department (ED) wait times Specialists wait times 5

6. Reporting for hip replacement As of 2010, the following definition and population have been applied to CIHI’s reporting for hip replacement surgery wait times: Definition The number of days a patient waited, between the date when the patient and the appropriate physician agreed to a total hip replacement surgery and the patient was ready to receive it, and the date the patient received a planned total hip replacement surgery. Benchmark Within 26 weeks (182 days) Time frame April 1 to September 30, annually Population Includes those age 18 and older Includes all total hip replacements (primary and revision); bilaterals count as a single wait For all priority levels Excludes emergency cases Excludes elective partial hip replacements and hip-resurfacing techniques Excludes days when the patient was unavailable Decisions/rationale The inclusion of bilateral hip replacements, patients younger than age 18, and/or out-of-province patients are not material to the reported wait times for hip replacements. These are not reported as exceptions for provinces that are unable to remove these cases from their data. Provinces continue to work towards removing “patient unavailable” days from reported wait times. This will continue to be an area of variation which CIHI will note. 6

7. Reporting for knee replacement As of 2010, the following definition and population have been applied to reporting for knee replacement surgery wait times: Definition The number of days a patient waited, between the date when the patient and the appropriate physician agreed to a total knee replacement surgery and the patient was ready to receive it, and the date the patient received a planned total knee replacement surgery. Benchmark Within 26 weeks (182 days) Time frame April 1 to September 30, annually Population Includes those age 18 and older Includes all total knee joint replacements (primary and revision); bilateral joints count as a single wait For all priority levels Excludes emergency cases Excludes knee-resurfacing techniques Excludes days when the patient was unavailable Decisions/rationale The inclusion of bilateral knee replacements, patients younger than age 18 and out-of-province patients are not material to the reported wait times for knee replacements. These will not be reported as exceptions for provinces that are unable to remove these cases from their data. Provinces continue to work towards removing “patient unavailable” days from reported wait times. This will continue to be an area of variation which CIHI will note. 7

8. Reporting for hip fracture repair As of 2010, the following definition and population have been applied to reporting for hip fracture repair wait times: Definition 1. Measured from the time of first registration at an emergency department with hip fracture (index admission) to the time when hip surgery was received. AND/OR 2. Measured from the time of first inpatient admission with hip fracture (index admission) to the time when hip surgery was received. Benchmark Within 48 hours Time frame April 1 to September 30, annually Population Ages 18 and older Discharge from an acute care institution Admission category recorded as emergent/urgent (if wait from first inpatient admission) Excludes in-hospital hip fractures Decisions/rationale In-hospital hip fractures are excluded as the time of the fracture or start of wait is not known. 8

9. Reporting for cataract surgery As of 2010, the following definition and population have been applied to reporting for cataract surgery wait times: Definition The number of days that patients waited, between the date when the patient and the appropriate physician agreed to a cataract surgery and the patient was ready to receive it, and the date the patient received a planned cataract surgery. Benchmark Within 16 weeks (112 days) Time frame April 1 to September 30, annually Population Ages 18 and older For first eye only; bilateral cataract removal counts as a single wait For all priority levels Excludes emergency cases Excludes days when the patient was unavailable Reviewed April 19, 2011 Decisions/rationale CIHI will note the cases that have been included in which a procedure has been performed on the second eye. There is no universal definition for high-risk cataract surgery procedures across provinces, hence, they are not consistent across jurisdictions. CIHI will note where high-risk patients are included. Inclusion of out-of-province patients is not material to the reported wait times for cataract surgery. These are not reported as exceptions for provinces that are unable to remove these cases from their data. Provinces continue to work towards removing “patient unavailable” days from reported wait times. This will continue to be an area of variation which CIHI notes. Rationale for inclusion of first eye only: Provincial start times for the wait for cataract surgery for the second eye vary (booking date, DTT, time of first surgery). About 40% of all cataract surgery procedures involve the second eye. Taken together, including this wait will likely materially affect reported waits. 9

10. Reporting for coronary artery bypass graft surgery (CABG) As of 2011, the following definition and population have been applied to reporting for bypass surgery wait times: Definition The number of days that patients waited, between the date when the patient and the appropriate physician agreed to a coronary artery bypass graft (CABG) and the patient was ready to receive it, and the date the patient received a planned CABG. Benchmark Within 2 to 26 weeks (14 to 182 days), depending on how urgently care is needed. Time frame April 1 to September 30, annually Population Includes those age 18 and older Includes Isolated CABG only For all priority levels Excludes emergency cases Excludes days when the patient was unavailable Decisions/rationale The inclusion of out-of-province patients and those younger than age 18 is not material to the reported wait times for bypass surgery. Inclusion of these patients will not be reported as an exception. Provinces continue to work towards removing “patient unavailable” days from reported wait times. This will continue to be an area of variation which CIHI notes. 10

11. Reporting for radiation therapy As of 2011, the following definition and population will apply to reporting for radiation therapy wait times: Definition The number of days that patients waited, between the date the patient is “ready to treat” and the date of the first radiation therapy treatment. Benchmark Within 4 weeks (28 days) of patient being ready to treat Time frame April 1 to September 30, annually Population Includes adults (those age 18 and older) All referrals to start or initiate radiation treatment All priority levels and all cancer types rolled up Excludes days when the patient was unavailable Includes oncology planning time Reviewed April 19, 2011 Provinces that include radiation treatments other than external beam are noted in the exceptions. Decisions/rationale Pediatrics and emergency patients are included as their inclusion is not material to the reported wait times for radiation therapy. The inclusion of these patients will not be reported as an exception for those provinces that do report in this manner. All referrals to start or initiate treatment may include patients who have had previous radiation treatment for the same or other cancers, patients who have metastases from a previous cancer and/or palliative patients. Provinces that include radiation treatments other than external beam will be noted in the exceptions. 11

12. Reporting for CT and MRI scans As of 2010, the following definition and population have been applied to reporting for CT and MRI wait times: Definition The number of days that patients waited, between the date the order/requisition is received and the date of the date the patient received the scan. Time frame April 1 to September 30, annually Population Includes adults (those age 18 and older) Includes diagnostic scans (may be inpatient and/or outpatient) For all priority levels Excludes routine follow-up scans Excludes mammography screening and prenatal screening Decisions/rationale The inclusion of emergency patients is not material to the reported wait times for diagnostic imaging. These will not be reported as an exception. Routine follow-up scans are material to reported wait times as they comprise between10% and 15% of all cases and typically might occur at a six-month or annual cycle and would contribute to long “waits” if left in. Several provinces are able to identify routine follow-up scans via a flag in their databases. For those unable to identify follow-ups, CIHI will note this as an exception. Mammography screening and prenatal screening will not be included in the population and will be noted in the population. 12

13. Reporting for general cancer surgery As of 2014, the following definition and population will apply to reporting for cancer surgery wait times: Definition The number of days that patients waited, between the date when the patient and the appropriate physician agreed to a cancer surgery and the patient was ready to receive it, and the date the patient received a planned cancer surgery. Time frame April 1 to September 30, annually Population Includes all surgeries for proven and suspected cancers All surgeries for palliative patients are included All cancer surgery for new and recurrent/metastatic cancers will be included Excludes days when the patient was unavailable Excludes patients who received a biopsy as the sole procedure Excludes patients on neo-adjuvant therapy Excludes emergency cases Decisions/rationale Suspected cases are included because a pathology report may not be completed before surgery and data collection limitations do not allow for accurate collection of pathology results. Surgical treatment for palliative patients and recurrent cancers are included because it competes for operating room time the same as newly diagnosed cancer patients. Provinces unable to exclude biopsies as a sole procedure will be noted in the exceptions. 13

14. Reporting for breast cancer surgery In addition to the general exclusions for cancer surgery, the following definition and population will apply to reporting for breast cancer surgery wait times: Population Includes all mastectomies, resections, excisions and lumpectomies for proven or suspected cases of cancer. Includes breast and sentinel node biopsies when combined with surgeries listed above for patients that have a proven or suspected cancer. Excludes BRCA 1 and 2 mutations. Excludes breast reconstruction surgery unless done in the same operating room session. Decisions/rationale Treatment for BRCA 1 and 2 mutations are considered to have different needs than those with suspected or confirmed cancer and are therefore excluded. Provinces unable to BRCA 1 and 2 mutations will be noted in the exceptions. Reconstruction cases will be excluded for the same reason noted in the previous bullet. However if provinces are unable to remove these cases, they are not likely to materially affect the waits and no provincial exception will be noted. 14

15. Reporting for bladder cancer surgery In addition to the general exclusions for cancer surgery, the following definition and population will apply to reporting for bladder cancer surgery wait times: Population Includes resections (partial or complete) of the bladder with or without fulguration. Includes cystectomy with or without ileal conduit for proven or suspected cases of cancer. Excludes cystoscopy as a diagnostic procedure. 15

16. Reporting for colorectal cancer surgery In addition to the general exclusions for cancer surgery, the following definition and population will apply to reporting for colorectal cancer surgery wait times: Population Includes all resections of the colon by incision or scope performed in an operating room (large intestine including cecum, ascending, transverse, descending and sigmoid) and rectum (does not include small intestine) for proven or suspected cases of cancer. Includes iliostomy/colostomy for proven or suspected cancer. Excludes closure of iliostomy/colostomy. Excludes cancer of the stomach or small intestine. Excludes diagnostic scopes. 16

17. Reporting for lung cancer surgery In addition to the general exclusions for cancer surgery, the following definition and population will apply to reporting for lung cancer surgery wait times: Population Includes thoractotomies for suspected or proven cancer with resection (partial or complete) of lung(s). Excludes bronchoscopies/mediastinoscopies. Decisions/rationale Bronchoscopy/mediastinoscopy for diagnosis was excluded as most lung cancer is diagnosed using various diagnostic imaging modalities. 17

18. Reporting for prostate cancer surgery In addition to the general exclusions for cancer surgery, the following definition and population will apply to reporting for prostate cancer surgery wait times: Population Includes complete resection of the prostate for proven or suspected cases of cancer. Includes pelvic node dissection. Excludes trans-urethral resection of the prostate. Decisions/rationale Includes pelvic node dissection, as it is part of determining the treatment pathway for patients with less differentiated tumors. 18

19. Reporting for IV chemotherapy (collection targeted for 2016) Ready to treat to first treatment*: The wait time for IV chemotherapy treatment is the number of calendar days a patient waited, between the date the patient is ready to treat and the date of the first IV chemotherapy treatment (day 1, cycle 1). Referral-to-consult: The number of days a patient waited, between the date the referral from family physician or specialist was received and the date the patient was seen by an oncologist for the first time. Consult-to-treatment: The number of days a patient waited, between the date the patient sees the oncologist for the first time and the date of the first IV chemotherapy treatment. Summary measures: 50th percentile, 90th percentile Body sites: Breast, colorectal, lung * It was agreed that the “RTT to first treatment” wait time will be the common starting point when provinces are ready to begin collecting and reporting. 19

20. Reporting for IV chemotherapy (collection targeted for 2016) Population Ages 18 and older Includes IV chemotherapy only Only includes first dose of IV chemotherapy treatment for both patients with a new diagnosis of cancer and recurrent cancer Includes planning time Excludes supportive and hormonal therapy Excludes multiple rounds Excludes emergency patients who have a life threatening condition or require immediate assessment and treatment Excludes inpatient cases Excludes patient unavailable days 20

21. IV chemotherapy: Patient pathway 21 Planning time: Defined as all activities that occur prior to treatment and that are part of the system response such as: patients waiting for IV PICC line or Portacath insertion, a chemo chair, approval of medications, and alternative options for treatment, among others. Patient caused delays are not part of the planning time definition and are excluded (if known) from the wait time calculation.

22. PET scan and ultrasound wait times 22

23. PET and ultrasound wait times indicator Definition The number of days a patient waited from the date the order/requisition was received to the date the patient received the positron emission tomography (PET)/ultrasound scan. Summary measure The summary measures for PET scan and ultrasound wait times will be 50th percentile and 90th percentile. Population Includes those age 18 and older Excludes obstetrics Excludes routine follow-ups Excludes emergency patients Decisions/rationale Obstetrics scans are typically scheduled for set times so these patients do not “wait” for their scan Follow-up appointments are typically scheduled. Some provinces are unable to separate out routine follow-ups. There is a high proportion of no-shows and rescheduled appointments across all of the provinces; given the large volume of scans, it is not possible to delete patient unavailable days as with other priority procedures. However, most provinces are able to adjust the wait times data by removing the names of patients who initiate delays, and those who are currently unable to do so agree in principle that they should be removed. Provinces will move towards excluding patients who reschedule their appointment. Where this is not possible, an exception will be noted. 23

24. Emergency department wait times 24

25. ED wait time indicators Definitions Time of Physician Initial Assessment (TPIA): The time interval between the earlier of triage date/time or registration date/time* and date/time of physician initial assessment Time to Disposition (TtoD): The time interval between the earlier of triage date/time or registration date/time* and the disposition date/time (as determined by the main service provider) Time Waiting for Inpatient Bed (TWIB): The time interval between the disposition date/time (as determined by main service provider) and the date/time patient left ED for admission to an inpatient bed or operating room ED Length Of Stay (LOS): The time interval between the earlier of triage date/time or registration date/time* and one of the following times: date/time patient left ED for admitted or transferred patients or disposition date/time for all other visit dispositions Summary measures The summary measures for ED wait times will be 50th percentile and 90th percentile. Population May be reported for all patients, by triage level or by visit disposition. Inclusions/exclusions * Depending on the acuity of the case or hospital procedures, triage may occur before registration; therefore, the earlier of these two events is used as the starting point. If either Triage Time or Registration Time is unknown (time = 9999), the other can be used as a proxy. TPIA is not calculated for patients registered but left without being seen or triaged and patients triaged but left before further assessment. TtoD is not calculated for patients registered but left without being seen or triaged. TWIB is only calculated for patients admitted into reporting facility as inpatient (CCU or OR or to another unit). 25

26. Key events characterizing an ED visit Emergency Department Length of Stay (ED LOS) = Records with the stated Visit Disposition are excluded from the calculation. Admitted Left ED ED LOS incorporates TWIB if the patient is admitted (VD = 06, 07), or an equivalent duration if waiting for transfer (VD = 08, 09). VD = 01– 05,07–15 VD = 01– 06,08–15 Disposition Disposition is the end point for ED LOS if the patient is neither admitted (VD = 06, 07) nor transferred (VD = 08, 09) Time to Disposition (TtoD) VD = 02 Time waiting for inpatient bed (TWIB) — CCU and OR Time waiting for inpatient bed (TWIB) — other unit PIA Arrival Registration/triage Time to Physician Initial Assessment (TPIA) VD = 02,03 26

27. Data elements for Time to Initial Physician Assessment Data elementDefinition Date/Time of PIA (Physician Initial Assessment) The date/time* the physician (first physician) first assessed the patient. Triage Date/Time The calendar date/time when the patient is triaged in the ED. Note the following Canadian Association of Emergency Physicians (CAEP) guideline: Triage should occur prior to registration. Triage Level The initial triage level (adult — CTAS; pediatric — PCTAS) for the patient on this visit. The triage level was developed by CAEP and applicable to patients seen in EDs. Date/Time of Registration/Visit The date/time when the patient presents for services to any ambulatory care functional centre and is officially registered as a patient. * Format for “date” is year/month/day ; for “time,” the format is hours and minutes. 27

28. Data elements for Time to Disposition Data elementDefinition Visit Disposition Admitted into reporting facility as an inpatient to CCU or OR directly from an ambulatory care visit functional centre Admitted into reporting facility as an inpatient to another unit of the reporting facility directly from the ambulatory care visit functional centre Transferred to another acute care facility directly from an ambulatory care visit functional centre (including another acute care facility with entry through ED) Transferred to another non–acute care facility directly from an ambulatory care visit functional centre (for example, stand-alone rehabilitation or stand-alone mental health facility) Death after arrival — patient expires after initiation of the ambulatory care visit Death on arrival — patient is dead on arrival at the ambulatory care service Intra-facility transfer to day surgery Intra-facility transfer to the ED Intra-facility transfer to a clinic 28

29. Data elements for Time to Disposition Data elementDefinition Disposition Date/Time The date/time* the main service provider makes the decision about the patient’s disposition Notes The best available marker for the Disposition Date is the date when the service provider issues the disposition order or request. It is the end point for an ED and/or day surgery visit. When Disposition Date is unknown and the patient is admitted, record the date/time the patient left the ED. * Format for “date” is year/month/day ; for “time,” the format is hours and minutes. 29

30. Specialist care wait times 30

31. Specialist care wait time indicator Definition The number of days between the date the referral was received in the specialist’s office and the date the patient was seen by a specialist. Summary measure The summary measures for specialist care wait times will be 50th percentile and 90th percentile. Population Includes those age 18 and older Includes new referrals (new referrals occur when a referral letter is generated by a general practitioner or other specialist) Excludes patient unavailable days Excludes emergency cases and in-hospital referrals 31

32. 32 Thank you!