1. Leadership. Knowledge. Community. The Patient Journey - Progress 2008 Symposium: CCS Benchmarks for Access to Cardiovascular Services and Procedures:

2. Leadership. Knowledge. Community.2 The 7 Access to Care Subgroups SubgroupChair Specialist consultation and non- invasive tests Dr. Merril Knudtson Nuclear cardiologyDr. Rob Beanlands Emergent and urgent situationsDr. Blair O’Neill Revascularization and other cardiac surgeries Dr. David Ross Dr. Michelle Graham Heart failure clinicsDr. Heather Ross Electrophysiology servicesDr. Chris Simpson RehabilitationDr. Bill Dafoe

3. 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

4. Leadership. Knowledge. Community.4 The Cardiovascular Continuum of Care Onset of symptoms Non-invasive testing General practitioner Specialist consult Emergency department or 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 5 Total Patient Wait Time = PERIOD 1 + 2 + 3 + 4 + 5 PERIOD 2 Secondary prevention and rehabilitation Non-invasive testing Subspecialist consult Chronic Disease Management Programs

5. Leadership. Knowledge. Community.5 The Patient’s Perspective Wait-time IntervalMax (wks) Symptom onset to Family PhysicianUnknown Family Physician to Cardiologist6 Cardiologist to Angiogram6 Angiogram to Cardiac Surgeon 6* Cardiac Surgeon to Bypass Surgery Bypass Surgery to Rehabilitation4 Total Wait Time for the Patient22 In some jurisdictions, both wait periods are included in the measured interval.

6. Leadership. Knowledge. Community.6 CCS ACCESS TO CARDIOVASCULAR CARE RECOMMENDED WAIT TIME TARGETS SubgroupEmergencySemi-urgentScheduled Specialist consultation/ non-invasive tests < 24 hours Urgent SU < 1 week < 4 weeks < 6 weeks Nuclear cardiology < 24 hours < 3 days < 14 days Echocardiography < 24 hours < 7 days < 30 days Emergent and urgent revascularizations NSTEACS < 48 STEMI < 24 Urgent SU Urgent SU < 7 days < 14 days < 6 weeks Revascularization and other cardiac surgeries < 24 hours Urgent SU < 7 days < 2-4wks < 6 weeks Heart failure disease management clinics < 24 hours Urgent SU < 1-2 wks < 4 wks < 6 – 12 weeks Electrophysiology services <1-3 days Urgent SU < 2 weeks <4-6 wks < 3 months Rehabilitation < 3 days < 7 days < 30 days

7. Leadership. Knowledge. Community.7 Preconsultation Testing and Info The 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.

8. Leadership. Knowledge. Community.8 Improving Access to Specialists Cardiology

9. Leadership. Knowledge. Community.9 The CCS National Survey on Access to Care at Tertiary Cardiac Care Centres Summer 2007 – Summary Results

10. 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

11. 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%)

12. Leadership. Knowledge. Community.12 Response Rate by Province 2 31 4 5 1 17 1 00 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

13. 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”

14. Leadership. Knowledge. Community.14 How would you rate access to cardiac care at your centre? 8 of 17 rated access as “excellent” or “very good” 15 of 17 have been monitoring wait times for > 5 years

15. Leadership. Knowledge. Community.15 Does your cardiac care centre have wait time targets for: YesNoNot offered Monitor only N/ATotal Cath1201114 Angioplasty1111114 Cardiac surgery9211114 Hospital transfers84113 Permanent pacemaker66214 Catheter ablation642214 ICDs642214 5 centres had wait time targets for Initial specialist consultation, echocardiography, cardiac nuclear imaging, CHF clinic, electrophysiologist consultation, CRT and cardiac rehabilitation

16. Leadership. Knowledge. Community.16 What was the basis for establishing the targets that you have? CCS benchmarks adopted in centres in BC, Alberta, Quebec and Nova Scotia. All 5 centres using provincial benchmarks are in Ontario and Quebec.

17. Leadership. Knowledge. Community.17 How would you rate your cardiac care centre’s commitment to setting access targets? “Low” or “Little or no” reported in Manitoba and Ontario.

18. Leadership. Knowledge. Community.18 Prior to this survey, how would you describe your awareness of the CCS benchmarks? The CCS benchmarks have been well communicated among the survey respondents.

19. Leadership. Knowledge. Community.19 How would you describe the level of awareness among professional (medical, clinical and administrative) staff? The CCS benchmarks are not as well known among other medical, clinical and administrative staff. 38% rated “fair” or “poor”

20. 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

21. 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

22. 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”

23. 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

24. 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 start0

25. 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? Most respondents (71%) gave a grade of “Fair”.

26. 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