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Access to health care services in Canada
Waiting times for specialized services (January to December 2005)
Waiting for care has been and continues to be a major issue in the health care sector. Recently provincial and federal ministries of health have adopted a range of policies and strategies to address lengthy waits for care. In 2004, First Ministers agreed to develop a 10-year plan to improve access and reduce waiting times in several key areas including hip and knee replacements and cataract surgery. The plan called for the establishment of benchmarks for medically acceptable waiting times with regular reporting to track progress towards these targets(Health Canada. 2004). In an effort to improve the state of information and to meet reporting requirements, several provincial jurisdictions have developed wait time registries to provide up to date information on waiting for procedures (Ministry of Health, B.C. n.d.), (Alberta Health and Wellness. n.d.), (Ministry of Health and Long-Term Care, Ontario. n.d.), (Nova Scotia Department of Health. n.d.).
Statistics Canada has been reporting on patients’ experiences waiting for care, including how long they wait, since the introduction of the Health Services Access Survey (HSAS) in 2001(C. Sanmartin et al. 2001), (C. Sanmartin et al. 2003). This survey was designed to provide national and provincial level estimates of patients’ experiences accessing health care services including waiting times for specialized services. The survey has now been incorporated into the Canadian Community Health Survey and currently represents the only national level information on waiting times. Preliminary results from the first 6 months of data collection were reported in January 2006. In this report, we provide updated results on patients’ experiences waiting for care based on the full 12 months of data for 2005.
The report is based on a sub-sample of the 2005 Canadian Community Health Survey (CCHS). It represents approximately 98% of the population of Canadians aged 15 and older living in private dwellings in the 10 provinces. Excluded from this report are residents of the three territories, those living on Indian reserves or Crown lands, residents in institutions, full-time members of the Canadian Forces, and residents of certain remote regions. The data were collected by personal and telephone interviews between January and December 2005.
Since the respondents are a subsample of the CCHS, the same multiple sample frames of this parent survey apply. The CCHS uses the area frame designed for the Canadian Labour Force Survey (LFS). The sampling plan of the LFS is a multistage stratified cluster design in which the dwelling is the final sampling unit. The CCHS also uses two types of telephone frames: list frames and a random digit dialling (RDD) sampling frame of telephone numbers.
In order to produce reliable estimates at the national and provincial levels, in particular for the estimates of waiting times, a subsample of about 34,000 CCHS respondents was targeted in total for 2005. The subsample was selected using a stratified random sampling technique. The total number of respondents is 33,539. The number of respondents and response rates are provided in Table 1.
It should be noted that the CCHS aims at producing reliable estimates at the health region level, and the HSAS at the national and provincial levels.
Following the collection and processing of the data, the respondents’ records were weighted in order to reflect the sampling and non-response that occurred in the CCHS. Weights were also adjusted to demographic projections by age group and province.
Weighted distributions and frequencies were produced. Weighted median waiting times were calculated for specialist visits, non-emergency surgery and selected diagnostic tests. Partial or item non-responses accounted for less than 5% of the totals in most analyses; records with item non–responses were excluded from the calculations. The bootstrap technique was used to estimate the variance and confidence intervals to properly account for the complex survey design. This technique fully adjusts for the design effects of the survey. Confidence intervals were established at the level of p = 0.05. For counts, ratios and percentiles estimates, pairwise differences between 2003 and 2005 were deemed statistically significant based on a two-tailed test with p < 0.05. Where multiple proportions were tested, the significance levels were adjusted using the Bonferroni method.
Waiting for care remains the number one barrier to access
While most individuals who accessed a specialized service did not experience any difficulties – some did. (Table 2) Approximately 11% of those 15 years of age or older (2.8 million Canadians) visited a medical specialist in 2005 - among them, 19% reported that they faced difficulties accessing care. Approximately 6% (1.6 million) reported that they had non-emergency surgery - among them, 13% reported that they had difficulty accessing care. Similarly, 9% of the population 15 years and older (2.2 million Canadians) accessed selected diagnostic tests – among them, 13% reported difficulties accessing care.
Those who reported difficulties were asked about the types of barriers they faced. As in previous surveys, waiting too long for care was cited as the number one barrier among those who experienced difficulties. (Table 3) Among those who experienced difficulties accessing a specialist consultation, 68% indicated that waiting was the problem followed by 32% who indicated that they had difficulties getting an appointment.
Among those who had difficulties accessing non-emergency surgery, 66% indicated that it was because they had to wait too long. Over one in five individuals reporting difficulties indicated that they experienced difficulties getting an appointment, a rate similar to 2003 results.
Similarly, among those with difficulties accessing diagnostic tests such as an MRI or CT scan, 59% reported that they waited too long to get an appointment and 36% reported that they waited too long to get the test. The results are similar to those reported in 2003.
Median waiting times remain unchanged at the national level – some differences were noted at the provincial level
Nationally, median waiting times remained stable between 2003 and 2005 – but there were some differences at the provincial level for selected specialized services.
Median waiting times for non-emergency surgery were reduced by half in Quebec from almost 9 weeks in 2003 to 4 weeks in 2005. For diagnostic tests, median waiting times in Newfoundland and Labrador rose significantly from 2 weeks in 2003 to 4 weeks in 2005 and in British Columbia median waits rose from 2 weeks to 3 weeks.
Most patients received specialized services within 3 months
The proportion of patients who waited less than 1 month to receive care ranged from 40% for those accessing non-emergency surgery to 56% among those who received a diagnostic test. (Chart 1; Table 7) The proportion waiting between 1 and 3 months ranged from 33% for diagnostic tests to 41% for specialists visits and non-emergency surgery. The proportion waiting longer than 3 months ranged from 10% for diagnostic tests to 19% for non-emergency surgery. The distribution of waiting times was similar between 2003 and 2005.
Approximately 40% of individuals receiving cardiac and cancer related surgery received care within one month (42%). (Table 8). Approximately one in five (19%) of those receiving joint replacements or cataract or other eye surgery received care within one month.
While most reported waiting times as acceptable – some deemed their waits unacceptably long and some experienced adverse effects
Waiting for care is not inherently problematic but may be considered so when patients experience adverse effects (K.D. Kelly et al. 2001), (H.C. Brownlow et al. 2001), (I.N. Ackerman et al. 2005), (H. Hadjistavropoulos et al. 2001) and/or feel they have simply waited too long for care. The proportion of patients who felt that their waiting time was unacceptable was highest among those who waited for specialist visits (29%) and diagnostic tests (21%) and lowest among those who waited for non-emergency surgery (16%) (Chart 2 ; Table 9) even though individuals are more likely to wait longer (i.e. > 3 months) for non-emergency surgical care compared with other specialized services (Table 7). This points to potential differences regarding thresholds for unacceptable waits across different specialized services – i.e. Canadians appear to be more willing to wait longer for surgery than for a visit to the specialist.
Approximately 18% of individuals who visited a specialist indicated that waiting for the visit affected their life compared with 11% and 12% for non-emergency surgery and diagnostic tests respectively. (Table 10) Most of those who were affected reported that they experienced worry, stress and anxiety during the waiting period: ranging from 49% among those whose lives were affected by waiting for non-emergency surgery to 71% among those affected by waiting for a diagnostic test. (Table 11) Between 38% and 51% of individuals waiting for specialist services experienced pain and close to 36% of those who were affected by waiting for non-emergency surgery indicated that they experienced difficulties with activities of daily living. Approximately 28% of those who were affected by waiting for a diagnostic test indicated that it resulted in worry, stress and anxiety for their friends and family.
There are several limitations to the data and the analysis presented in this report. The data are based on self-reported information for both service needs and difficulties accessing services over a 12-month period; as such, the information may be subject to recall bias and has not been clinically validated. To reduce reporting error due to recall bias, questions repeatedly referred to services used in the last 12 months.
Reliable estimates at the national and provincial levels could not be produced for all the variables, given that, in some cases, very few individuals may actually need services or experience difficulties and the survey sample may be too small to detect sufficient cases needed to generate reliable estimates.
There are also several limitations to the HSAS data relating to estimates of waiting times for specialist services. Waiting time estimates are retrospective and included only those who completed their waiting periods and received care. The data do not reflect the waiting times of those still waiting at the time of the survey. Respondents could report waiting times in days, weeks or months, and many may have rounded their waiting times. For these reasons, direct comparisons of waiting time estimates presented in these tables with estimates based from other sources, such as waiting time registries, health administrative data and physician reports, should be made with extreme caution.
Statistics Canada continues to provide information regarding patients’ experiences accessing care at the national and provincial levels. The results for 2005 indicate that waiting for care remains the number one barrier for those having difficulties accessing care. Median waiting times for all specialized services have remained relatively stable between 2003 and 2005 at 3 to 4 weeks, depending on the type of care. There were some differences noted in selected provinces. Most individuals continue to report that they received care within 3 months.
Similarly, patients’ views about waiting for care have remained fairly stable between 2003 and 2005. While 70 to 80 percent indicated that their waiting time was acceptable – there continues to be a proportion of Canadians who feel they are waiting an unacceptably long time for care.
The Canadian Community Health Survey provides valuable information regarding patients’ experiences waiting for care. These data will be further explored to better understand the factors associated with long waits and adverse experiences while waiting for specialized services.
Diagnostic test: MRI, CT scan or angiography requested by a physician to determine or confirm a diagnosis; does not include X-rays, blood test, etc.
Non-emergency surgery: Booked or planned surgery provided on an outpatient or inpatient basis; does not refer to surgery provided through an admission to the hospital emergency room as a result of, for example, an accident or life-threatening situation.
Specialist visits: Visit with a medical specialist to obtain a diagnosis for a new illness or condition; does not include specialist visits for ongoing care for a previously diagnosed condition.
Specialized services: Services including specialist visits for a new illness or condition, non-emergency surgery other than dental surgery, and selected diagnostic tests (non-emergency MRIs, CT scans, and angiographies).
Non-emergency surgery: Time between when individuals and their surgeon decided to go ahead with the surgery and the day of surgery.
Diagnostic tests: Time between when individuals and their doctor decided to go ahead with the test and the day of the test.