jeremy hurst, employment and social affairs directorate, oecd, and luigi siciliani, university of...
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Jeremy Hurst, Employment and Social Affairs Directorate, OECD,
and Luigi Siciliani, University of York
European Health ForumGastein, 6-9 October 2004
Workshop 3a: Improving health system performance: new evidence from international research
CAN EXCESSIVE WAITING TIMES FOR ELECTIVE SURGERY BE ELIMINATED?
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Excessive waiting times for elective surgery
A puzzling phenomenon– About half of OECD countries report having
problems – about half do not (including many with universal, public, health coverage)
– Policies to tackle excessive waiting times (>3 to 6 months) often end in disappointment
– It is the biggest public complaint about the health system in a number of countries but surveys of people actually waiting suggest they are not very worried by waits of up to 3-6 months (except for cardiovascular?)
– Can excessive waiting be eliminated?
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Scope of OECD project on waiting times
Involved 12 countries with waiting time problems– Australia, Canada, Denmark, Finland, Ireland, Italy, the Netherlands, New
Zealand, Norway, Spain, Sweden, the United Kingdom Also looked at 8 countries without waiting time
problems– Austria, Belgium, France, Germany, Japan, Luxembourg, Switzerland, and
the United States
Focussed on 10 elective procedures, such as hip replacement and cataract surgery
Collected data on surgery rates, waiting times, capacity etc.
Collected information on policies
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Main questions addressed
What are the causes of variations in waiting times?
What policies are most effective in tackling excessive waiting times (>3-6 months)?
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The waiting time phenomenon
GP as-sessment
Wait. list(stock)
Surgeonassessment
Publicprocedureperformed
additionsinflow
treatmentsoutflow
Privateprocedureperformed
leakage
Private electivetreatment
Emergency surgicaltreatment
referrals
ReturntoGP
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Main findings: data on waiting times
Large variations in waiting times for 10 procedures among countries reporting waiting time problems
The UK usually has the highest waiting times Only scraps of evidence for a few countries
not reporting waiting time problems They confirm waiting is very short in these
countries
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Main findings: data on surgery rates
Rapid increase in elective surgery rates over time (e.g. +64% in England in the 1990s)
Large variations in surgery rates between countries (e.g. more than threefold for 6 procedures, 10 fold for hysterectomy)
Countries reporting waiting time problems generally have lower rates of surgery than countries not reporting waiting time problems
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Hip replacement rates and waiting times
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Econometric results 1) 8 waiting time countries
– Lower waiting times with:• More physicians and beds• Higher public and total health expenditure (new)• A higher proportion of day cases (some models) (new)• A higher proportion of elderly (some models) (new)
2) 12 countries with waiting and 8 without– Lower probability of waiting with:
• More specialists and beds• Higher public and total health expenditure (new)• A higher proportion of elderly (new)• Fee-for-service remuneration of specialists (new)• Weak constraints on hospital activity (some models) (new)
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Review of policies for tackling excessive waiting (1)
Supply side policies– Increase expenditure and/or capacity
• High benefit, high cost, takes time
– Increase productivity (e.g. by activity related payments; more day surgery)
• High benefit, medium cost (?), takes time
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Different supply policies, Denmark and England Rates of coronary revascularistion
procedures,, 1990-2000
0
20
40
60
80
100
120
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000
Pro
ced
ure
s / 1
0000
0 p
op
ula
tio
n
PTCA - DenmarkPTCA - EnglandCoronary bypass - DenmarkCoronary bypass - England PTCA -
Denmark
PTCA - England
CABG - Denmark
CABG - England
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Different supply policies, Median waiting times for coronary revascularisation
procedures, Denmark and England, 1991-2001
0
20
40
60
80
100
120
140
160
180
200
1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001
Med
ian
wai
tin
g t
ime
(day
s)
PTCA - DenmarkPTCA - EnglandCoronary bypass - DenmarkCoronary bypass - England CABG - England
PTCA - England
PTCA - Denmark
CABG - Denmark
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Denmark: Development in waiting time and number of operations for the 18 specific operations
(inpatients)
18
19
20
21
22
23
24
25
26
27
28
Jan FebMarAprMayJun JulAugSepOctNovDecJanFebMarAprMayJun JulAugSepOctNovDecJan FebMarAprMayJun JulAugSepOctNovDec
2000 2001 2002
52,000
54,000
56,000
58,000
60,000
62,000
64,000
66,000
Mean waiting time Activity
Waiting time in weeks
Number of operations
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Review of policies for tackling excessive waiting (2)
Demand side policies– Clinical prioritization
• should increase efficiency and equity
– Manage demand (raise clinical thresholds) as in New Zealand (nobody on waiting list . 6 months)
• Some benefit (does not increase surgery rate and can be seen as increasing ‘waiting to join the waiting list’), low cost, quite quick to implement?
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Review of policies for tackling excessive waiting (3)
Policies aimed directly at waiting times and mixed policies– Maximum waiting time targets
• Like squeezing a balloon; can clash with clinical priorities, but cheap to implement?
– Mixed policies• Best buy?
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160
50
100
150
200
250
Jun-96Dec-96Jun-97Dec-97Jun-98Dec-98Jun-99Dec-99Jun-00Dec-00
Wai
tin
g t
ime
(day
s)
Mean waiting
Mean waiting time for patientson the list (Insalud, Spain)
0
50000
100000
150000
200000
250000
300000
350000
400000
450000
500000
Jun-
96
Dec-
96
Jun-
97
Dec-
97
Jun-
98
Dec-
98
Jun-
99
Dec-
99
Jun-
00
Dec-
00
Nu
mb
er Total activity
Public activity (normal)
Public activity (extra hours)
Private activity
Surgical treatments
provided (Insalud, Spain)
Mixed policies, Spain
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Towards solving the puzzles
Why international variations in waiting times?– Surgical capacity differs– Surgical productivity probably differs– Incentives to form queues differ
Why do policies to tackle excessive waiting times often end in disappointment?– Demand is increasing rapidly through time– There may be backlogs in demand– lower waiting acts like a price to encourage higher demand
Why is the public so alarmed by waiting when patients are less worried?– an inescapable aspect of public opinion or poor
communication?
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Conclusions
Yes: excessive waiting for elective surgery can be eliminated.
Tentatively: mixed policies = best buy– Capacity– Productivity/efficiency– Management of demand
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More information:
www.oecd.org/health
www.oecd.org/healthmin2004
www.oecd.org/health/healthdata