Research Evidence in the Federal Policy Process: A Wait Times Case Study Presentation to Centre for Health Economics and Policy Analysis, McMaster University January 21, 2009

2 Overview Role of research in federal health care policy process Case study: Wait Times Examples: Development of evidence-based common benchmarks National Wait Times Initiative Patient Wait Times Guarantee Pilot Project Fund Lessons for researchers (and policy makers)

3 Ideal policy process would be evidence-based at all stages… Data analysis Forecasts/predictions Scientific evidence Research studies Syntheses of research Best practices Evaluations Expert, professional opinions Develop/ Assess Option(s) Make Decision(s) Implement Public Accountability Evaluate Identify Issue(s)

4 …but evidence in policy process includes many elements Research and scientific evidence one factor in development of policy “evidence” base Different lines of evidence helpful at different times, different actors use and influenced by evidence in different ways Constraints and imperatives determine how, when, to what extent evidence used Political, legislative, jurisdictional, financial, timing

5 Federal role in health care policy process is constrained… Health Canada mandate broad: Regulation Health services for First Nations and Inuit Health promotion Generating and sharing knowledge and information Contributing to global health Support for health care system Provincial/territorial governments responsible for health care system delivery (except for specific populations) Federal support for provincial/territorial health care delivery Emphasis on policy development, monitoring and analysis Catalyst for health system innovation

6 …and impacts how the federal government uses evidence Consistent with federal roles and responsibilities Fund health care systems through transfers to provincial/territorial governments (and enforce Canada Health Act) Partner with provincial/territorial governments, stakeholders on health system innovation Strong federal knowledge broker role on health system innovation Formal structures to improve knowledge development and translation (CIHR, partnership with provincial/territorial governments for CIHI) Creating accessible information for broader audience

7 Case study: Wait Times 10-Year Plan to Strengthen Health Care (2004 Health Accord) included commitment to reduce acute care wait times Focus on five priority areas (cancer, cardiac, joint replacement, sight restoration, diagnostic imaging) Included commitments to: –establish common evidence-based benchmarks for medically acceptable wait times; and –set multi-year targets to meet benchmarks Complemented by National Wait Times Initiative (Budget 2005) $13 million over three years to develop and disseminate knowledge to address wait times Additional $1B in incremental funding (Budget 2007), in return for commitment that each province/territory would establish a Patient Wait Times Guarantee by 2010 Includes Patient Wait Time Guarantees Pilot Project Fund of up to $30 million over 3 years

8 Example: Development of evidence-based common benchmarks 2004 Health Accord provided significant new funding, imperatives to reduce patient wait times and improve wait times management Governments started by asking: What is an acceptable wait time? Benchmarks are “evidence-based goals that express the amount of time that clinical evidence shows is appropriate to wait for a particular procedure or diagnostic test” Not guarantees or legal obligations to individual patients Provided common foundation for accountability under the Accord, including establishment of multi-year targets

9 Example: Development of evidence-based common benchmarks (continued) Provincial/territorial governments established formal process with Canadian Institutes of Health Research; CIHR provided syntheses of available evidence Parallel input from other experts, e.g., Wait Time Alliance, comprised of Canadian Medical Association and medical societies; Western Canada Waiting List Project; Institute for Clinical Evaluative Sciences Federal role as catalyst: Championed inclusion of benchmarks in Accord Federal funding provided to support experts in process (e.g., Wait Time Alliance, CIHR) Federal Wait Times Advisor (mandate included: identify and continue to develop consensus on establishing evidence-based benchmarks)

10 In December 2005, provincial/territorial governments announced benchmarks* in four** of the five priority areas: *The benchmarks apply to non-emergency procedures ** Governments did not set a benchmark for diagnostic imaging, in large part because appropriate use of such technologies and evidence on acceptable wait times are under debate *** Cardiac bypass benchmarks are based on consensus opinion and existing best practices. A review of evidence informed the development of the other benchmarks Then there were benchmarks… CancerBreast cancer screening for women aged 50 to 69 Every two years Cervical cancer screening for women aged 18 to 69 Every three years after two normal tests Radiation therapy for cancerWithin four weeks of patient being ready to treat CardiacCardiac bypass surgery*** – based on patient’s level of urgency Level I: within 2 weeks; Level 2: within 6 weeks; Level 3: within 26 weeks Joint ReplacementsHip fracture fixation Hip replacement Knee replacement Within 48 hours Within 26 weeks Sight RestorationSurgery to remove cataractsWithin 16 weeks for patients at high risk

11 …but they are imperfect, from an evidentiary perspective Insufficient evidence for syntheses in all areas Timeframe set parameters, limited ability to develop new evidence Competing input from multiple sources, much of it based on clinical experience, not research No benchmark set for diagnostic imaging; benchmarks in other areas are starting point, do not cover all procedures

12 In the end, benchmarks more evidence “informed” than evidence “based” CIHR: benchmark wait time not more than 6 months, maximum reasonable wait for cataract surgery Based on review of research, found: > 6 months may result in decline in vision, could affect independence and mobility like driving, risk of falls On average, 2.5 months or less unlikely to have negative effect on health outcomes after surgery Individuals may be able to wait longer or shorter periods depending on vision, disabilities, ability to live independently, overall health Provincial/Territorial Benchmark: Surgery to remove cataracts – within 16 weeks for patients at high risk Wait Time Alliance: reviewed available evidence, clinical guidelines, consulted with medical practitioners Proposed benchmarks for cataract removal surgery according to urgency; based on expert consensus coordinated by the Canadian Ophthalmological Society, due to a lack of empirical data Emergent - N/A Urgent - Based on individual need Scheduled - 4 months

13 Lessons for researchers (and policy makers): Benchmarks CIHR-led knowledge translation process able to support evidence-based decisions on benchmarks because: Political commitment to investing in scientific evidence Credibility, accessibility of evidence provided Committed policymakers; “nimble” researchers Flexible and responsive research funding agency (Watson, D.E., Barer, M.L., and Matkovich, H.M “Wait Time Benchmarks, Research Evidence and the Knowledge Translation Process.” Healthcare Policy 2(3):56-62)

14 Lessons for researchers (and policy makers): Benchmarks (continued) Also an interesting case to examine because: 2004 Accord publicly acknowledged the need for benchmarks, set out a process and defined timeframe Collaborative effort – governments, researchers, clinicians, health stakeholders Lack of evidence informed development as much as evidence Established basis for future work Case provides insight into competing influences on health policy decisions, the impact of political momentum on policy process

15 Example: National Wait Times Initiative National Wait Times Initiative announced in 2005 to help advance 2004 Health Accord commitments Aim to complement and catalyze efforts of provincial/territorial governments by engaging stakeholders to contribute to improved wait times management and reduction Flexible enough to support more recent federal commitments on Patient Wait Times Guarantees Supports research, knowledge development and dissemination, consistent with federal role, to inform the development of policies, best practices, programs, and services Program has supported: policy research, options and advice; new approaches, models and best practices; networks/collaborative initiatives; new data collection methods and tools; and the development of guidelines and standards

16 Project: Strategy to address hip/knee replacement wait times Three-phased project with Bone and Joint Canada to address wait times for hip/knee replacement, through a continuum of care approach focused on access, quality, efficiency, and sustainability Consolidated evidence in up-to-date literature review Established national collaboration and networks involving clinical, administrative and government leadership Developed framework for core model of care Will develop tool kit and on-line resources to promote pan-Canadian up-take Processes to facilitate consensus on model and broader adoption, at national and regional levels Impacts: Model implemented in Alberta, Ontario, lessons learned shared in Nova Scotia resulting in smoother implementation New multi-sectoral partnerships to improve management of wait times for orthopaedic surgery Right mix of leadership, knowledge translation, networking and dissemination have catalyzed action

17 Example: Patient Wait Times Guarantee Pilot Project Fund Budget 2007 provided up to $30 million over three years to support pilot projects that will assist provincial/territorial governments in testing, advancing and establishing Patient Wait Times Guarantees Ten projects now underway in 8 provinces and territories, completed by March 31, 2010 Identifying and addressing policy and operational issues associated with establishing Guarantees Enabling testing of innovative approaches to lay the groundwork for Guarantees (e.g., the development of protocols to provide recourse options for patients) Encouraging collaboration and exchange of best practices amongst provincial/territorial governments Projects required to ensure transfer of knowledge and exchange of best practices; results, including evaluations, to be shared with other jurisdictions

18 Projects: Manitoba and Nova Scotia Government of Manitoba: Bridging General and Specialist Care: The Right Door, the First Time Testing Guarantees, including recourse, for referrals by general practitioners to specialists Covers seven practice areas, including cancer services, orthopaedics and ophthalmology Information technology systems will improve referral processes, aim to provide seamless, timely and appropriate care Objectives: shorter wait times, reductions in inappropriate referrals and elimination of unnecessary lab and diagnostic tests Government of Nova Scotia: Improving Access to Diagnostic Services Testing ways to improve access to diagnostic imaging services Objectives: improve the appropriate use of diagnostic imaging services, improve efficiencies in diagnostic imaging departments, and engage patients in choosing where and when they receive care

19 Lessons for researchers (and policy makers): NWTI and PWTG Pilot Project Fund Provincial/territorial responsibilities for design and delivery of health care services and federal role as knowledge broker provide opportunities for researchers and other experts Funder is not necessarily end-user of knowledge Opportunities for researchers to support later stages of policy process, potential for more immediate impact on outcomes than at front-end of process

20 Conclusion Impact of research (and researchers) for health care system in federal context largely indirect, but influential Knowledge translation is key, particularly in later stages of policy cycle and change management Don’t underestimate the role of momentum, aligning with priorities for policy development Need to be ready – equally true for policymakers and researchers Partnerships are crucial (formal and informal)