Waiting to see the specialist: patient and provider characteristics of wait times from primary to specialty care

Wait times in Canada have focused on the time from seeing a specialist physician to having either an investigation or procedure, with the goal of improving access for a select number of health services such as cataract surgeries, cancer surgeries, cardiac procedures, hip and knee replacements and CT and MRI testing [1‐4]. However, the wait times from a patient’s perspective included steps in care before they see a specialist physician or undergo an advanced diagnostic test. In fact, patients may face the greatest wait-related risk at the earlier stages of care before the disease has been fully characterized [5]. A patient’s pathway of care includes access to primary care, the wait time from a family physician (FP) referral to a visit with a specialist or the receipt of an investigation, the wait time from seeing the specialist to having a surgical procedure and the wait time where information from the specialist visit or surgical procedure is received back to the FP [6, 7].

Patient socioeconomic status has been associated with less access to specialist care [8‐14] and lower wait times [15]. Women and older patients are less likely to be referred for some specialist care [16‐18]. Referral patterns for specialty care have been associated with practice locations and types of physician payment models [19‐23]. Patient comorbidity has been associated with wait times for surgical procedure [24], but it has not been well examined for specialist referrals. There is little information about what patient or provider factors are associated with primary care wait times.

A Commonwealth survey of primary care physicians practicing in eleven countries found three-quarters of Canadian FPs reported long waits for specialist consultation and procedures [25]. Canada ranked 7th out of seven industrialized countries on timeliness of care, which included measures of wait times to and from primary care [26, 27]. Currently in Canada, the only information on wait times from FP to specialists comes from patient or provider surveys [28‐32]. However, data from these surveys are not objective measures and they are subject to response (with often less than 30% response rates) and recall bias.

Increasingly in Canada, electronic medical records (EMRs) are being used by FPs in their clinical practices, with enough uptake of EMR use to begin the process of developing methods for primary care research including the measurement of wait times [33‐36]. However, extracting complete and accurate referral information from existing EMRs is challenging and similar work at a provincial or federal level is lacking [37‐39].

Across Canada, administrative data have been used extensively to determine population level primary care performance [40‐42]. It can describe care across health care sectors from physician offices to emergency room and inpatient care to community health care resources. However, administrative data are limited in its detail on what happens with a clinical encounter. EMR data do contain more detailed clinical information, but may not capture all encounters across health care sectors [34, 39]. The linking of FP EMR data with administrative data provides the detail needed to describe the overall picture of the referral pathway between primary and specialty-based health care.

The objectives for this study were: 1) to calculate the wait times from when a referral is made by a FP to when a patient sees a medical or surgical consultant, and 2) to examine patient and provider factors related to these wait times.

There were 54 family physicians who participated in EMRALD as of 2008. A comparison of these 54 FPs to all FPs in Ontario, Canada is provided in Table 1. EMRALD FPs were located throughout Ontario. However, EMRALD FPs compared to all FPs in Ontario were younger, more likely to be female, a Canadian medical graduate and more likely to participate in a patient enrolment model. There was a higher proportion of EMRALD FPs from rural locations.

We determined the median wait times from FP referral to seeing a specialist were from 5 to 11 weeks and the 75th percentile wait times from 9 to 33 weeks. With a few exceptions, patient factors were not consistently associated with wait times from primary care to having a specialist consultation visit. Similarly, FP practice size, FP sex and type of FP primary care enrolment model were not consistently associated with wait times. For many specialist physician types, FP practice location was associated with wait times from primary care.

Our wait times estimates are similar to published studies which are based on specialist physician self reports [31, 54, 55]. However, our measures of wait times for both medical and surgical specialists are greater than the 5 week and 2 week median wait times for non-urgent or urgent referrals previously reported for all specialist physicians together in Ontario in the National Physician Survey (NPS) report [32]. A comparison to NPS data is difficult because it includes all medical and surgical specialists together and we looked at specific specialist types. We also did not separate out urgent and non-urgent referrals. The NPS also rated accessibility to specialist types with a tendency for some medical specialists (psychiatry) to have a lower proportion of very good and excellent access than some surgical specialists (general surgery and ENT). The NPS estimates are based on physician opinions and may not in fact represent the reality of wait times from the patients’ perspective.

Our wait time measures are based on actual claims in the health care system. What differentiates EMRALD from other primary care EMR data sources in Canada is that it includes the entire FP EMR record and it is linked to the Ontario health administrative data. We were able to link over 80% of the EMR FP referrals to a physician claim. We limited our specialist visit claim to include a full consultation visit. Some of our FP EMR referrals may be for a reassessment visit and therefore were not linked to a full consultation claim. EMR mental health referrals had a low proportion linked to a psychiatrist claim. Many mental health referrals are made to non-physician providers such as psychologists or social workers who do not appear in the physicians claim data. For all patients, a certain proportion of referrals to specialist may be cancelled or result in a no show. This proportion may be higher for psychiatric referrals. Further work looking into the content of mental health referrals, including referrals for specific diagnoses, in currently underway.

We found that wait times from primary care to either medical or surgical specialist visits are not consistently related to patient factors. Other studies have found specialist visits and referrals rates to be associated with SES and comorbidity in Ontario [8, 9]. Specialist physicians tend to triage referrals based on their urgency. However, urgency of the referral was not well documented and therefore not assessed in this study. The specific disease is likely to also dictate the urgency of a referral. For example, seeing a cardiologist for unstable angina would be more urgent than advice on better blood pressure management. Further determination of wait times for specific diseases or condition is needed.

Practice location is the most consistent influence on wait times. Busier practices may have higher referral rates and therefore longer wait times. As seen in other studies comparing patients seen in different primary care delivery models, differences were seen in wait times to specialists between capitation-based primary care models compared to other models [14]. Further work examining FPs participating in models which include health care providers may explain some of these differences. For example, FPs who work in practices which include physiotherapists or sport medicine therapists, may manage most of their musculoskeletal conditions thereby referring fewer patients and then have shorter wait times to orthopedics or rheumatology. While physician gender and age are associated with referrals rates in Ontario [8], they are not associated consistently related to wait times.

The Wait Time Alliance in Canada has recommended benchmarks for a select number of conditions or investigations [4]. For example non-urgent hip and knee replacement should be done within 10 months after seeing an orthopedic surgeon. However, it is important to get an understanding of the wait time from primary care. FPs need to be able to manage patients, with various levels of complexity, prior to having the opinion or diagnostic information from a specialist physician. Prolonged wait times to see a specialist physician will potentially change the burden of care for some patients from specialty care to primary care [56]. In Canada, more FPs belong to newer primary care delivery models, many of which include other health care providers [44]. If wait times become increasingly long, primary care delivery models will need to be structured to support the care of more complex patients. For example, if the wait to see an orthopedic surgeon or pain specialist is too long, then primary care practice may want to include physiotherapists who can address some aspects of patient care. If certain health care regions have longer wait times than deemed acceptable, local programs assisting in access to either outside regional care or access to other health care providers would be helpful with the regional planning of services.

Study limitations: We included a convenience sample of community based FPs, with a higher proportion practicing in rural locations. As FP practice location is related to wait times, further work which includes a larger sample of FPs needs to be undertaken. In our study we look at all types of referrals to specialists and we did not examine specific diseases or conditions. For example, it is likely the wait time to for more acute or unstable conditions would be faster than less serious conditions. We were not able to assess the priority or urgency of the referral. Finally the quality of the referral, including information contained in the letter and accompanying test results, was not assessed in this study.

Wait times from primary care to specialty care are longer than those reported by physician surveys in Ontario, Canada with median waits from 33 to 76 days and 75th percentiles of 63 to 231.5 days. Wait times from primary to specialty care need to be included in the calculation of surgical and diagnostic wait time benchmarks in Canada. Patient factors and most physician factors do not seem to be consistently associated with wait times, except for FP practice location and practice size.