Improving Patient Care and the Health Care System

Access to care has been a challenge that many patients have had to face. Joanne only had an achy knee when she let her family doctor know of her concern. By the time she was given an appointment to see an orthopaedic surgeon her ache had progressed to the point she could barely walk up and down stairs. Needless to say her overall condition deteriorated due to her mobility issues.  The McCaig Institute explores ways of reducing wait times, improving diagnostics and treatment pathways, so that those that need the care now are able to receive the care they need.

Reducing Wait Times in Shoulder Surgery

Orthopaedic surgeon Richard Boorman, MD runs his clinic out of the University of Calgary Sport Medicine Centre where wait times for shoulder surgery can be long. Boorman and his team identified that a high percentage of patients with chronic full thickness rotator cuff tears referred to him and his colleagues had not undergone appropriate non-operative treatment before opting for surgery.  His clinical research involved the development of a comprehensive non-operative treatment program of education, pain management, physiotherapy, and home exercises.  The study follows non-surgery and surgery patients for two years to measure performance and identify any differences.  Seventy five percent of the referred patients from the waiting list for surgery got better following the comprehensive non-operative treatment program and did not require a surgical procedure. 

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Improving the Health Care System

Osteoarthritis (OA) currently affects 1 in 8 Canadians and within one generation (30 years) 1 in 4 Canadians is expected to have OA (Arthritis Alliance of Canada, 2011). Given the alarming increase in the prevalence of this disease, the increasing cost of health care and the diminished financial capacity of the health care system to support quality health care, policy makers and service planners in Canada face the challenge of making decisions that balance the needs of the patients with escalating costs. Until now, there have been no reliable and validated tools that Alberta Health Services (AHS) policy makers and services planners could use to properly inform these decisions. 

To address this need, Deborah Marshall, PhD has formed a collaborative partnership with AHS, the Bone Joint Health Strategic Clinical Network (BJHSCN), the Alberta Bone and Joint Health Institute (ABJHI) and other academic researchers. With funding from Canadian Institute of Health Research (CIHR), the Arthritis Society, and AIHS Osteoarthritis Team grant, this team has created a computer model to study patient flow, resource utilization and wait times along the continuum of care. The system dynamics modeling  will allow health care policy makers and providers to make informed decisions on the most effective and efficient way to allocate resources and deliver care to patients with hip and knee osteoarthritis (OA). This tool allows us to estimate the burden of OA across the care continuum (from self-management, through to diagnosis, surgery and rehabilitation). It also forecasts future demands for OA health services planning and determines what resources will be needed to improve access, effectiveness and efficiency of OA healthcare services to meet the target performance.  Using provincial data on disease characteristics as well as information on health services utilization by patients diagnosed with OA, Dr. Marshall has been able to identify critical bottle-necks in the health care system. She is now examining potential solutions that can be implemented along the OA care path continuum in order to make the system as a whole work more efficiently. Marshall explains, “our focus is on closing the gap between the current system of care and the desired system of integrated care for OA delivered by the right people at the right time.” This will ultimately result in improved access to care and improved quality of care, for patients with hip and knee OA.

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One study Marshall is involved with is comparing hip resurfacing rates to total hip replacement (arthroplasty). Failure rates are measured and recommendations are made to clinicians and health policy makers worldwide regarding the comparative risks. Her team also looks at  resource use and costs to inform the development of a new evidence-based centralized referral process for arthritis in Alberta. In another study the eReferral system is reviewed for elective hip and knee total joint replacements from primary care to specialist. 

Treatment choices in rheumatoid arthritis are complex and involve a trade-off of risks and benefits. Marshall's research help inform treatment recommendations.  At any one time Marshall's team undertakes a number of studies reviewing patient outcomes and providing recommendations to health policy makers.

Deborah Marshall was awarded a five-year renewal of her Canada Research Chair position in Health Services and Systems Research.  Marshall’s group is currently developing a similar model for the rheumatoid arthritis care pathway. She was recently awarded two CIHR grants ($500,000 each) to improve health care delivery to patients with OA. 

Reality check: the cost-effectiveness of removing body checking from youth ice hockey.

Sarah Lacny has researched the effects of body checking in hockey with principal investigators Deborah Marshall, PhD and Carolyn Emery, PhD.  Hockey Canada has recently raised the age at which body checking is allowed from the Pee Wee level (ages 11-12 years) to Bantam (ages 13-14 years). This decision was made after studies demonstrated that injury rates in Pee Wee leagues in which body checking was allowed were 3 times greater than leagues that did not allow body checking. In addition to physical consequences, injuries placed an economic burden on both the healthcare system and families who bear the costs that are not covered by the healthcare system.

To better understand the economic implications associated with body checking, Sarah examined the cost–effectiveness of disallowing body checking in Pee Wee hockey in Alberta. 

She compared injury rates and costs incurred by injured players during the 2007-2008 Pee Wee hockey season in Alberta, where body checking was allowed, and Quebec, where body checking was not allowed. Sarah and her team of researchers found that, in addition to significantly higher injury rates, resulting healthcare costs were 2.5 times greater in Alberta than Quebec.

They demonstrated that implementing a policy that does not allow body checking in Pee Wee hockey is cost-saving (associated with fewer injuries and lower costs) compared to policies that allows body checking. These findings may better inform Hockey Canada and other organizations responsible for developing body checking policies in youth hockey.