Wait times for general surgery in BC: Moving beyond measurement

Surgical wait times have been a central focus for health policy since the 2003 First Ministers' Accord on Health Care Renewal,[1] which allocated $34 billion for health care. The 2004 Accord and Ten-Year Plan to Strengthen Health Care[2] allotted $5.5 billion to the Wait Time Reduction Fund to improve access to surgery, track wait times, and develop prioritization tools. Subsequently, the 2005 Chaoulli decision[3] in Quebec raised public awareness of the potential for patient harm due to long waits for nonemergency surgery.

Five areas (cataracts, hip and knee arthroplasty, hip fracture repair, cardiac surgery, and radiation oncology) were designated surgical priority areas. Benchmarks of maximal acceptable waits were set to achieve "meaningful reductions."[2] Consequently, the surgical field was divided into have and have-not specialties competing for limited perioperative resources.

Despite increased funding and improved data collection, it has been difficult for data to be used meaningfully to drive resource allocation for surgery. This is especially true for nonprioritized areas like general surgery.

Canadian health policy on wait times since 1984
The 1984 Canada Health Act[4] structured health care responsibilities with the federal government setting national standards and individual provinces directly responsible to allocate spending to achieve these standards. This division of responsibility limited the federal role to tax collector, with provincial silos in which standards and data tracking differ.

Before 2004 wait-time information was limited to survey data. Between 2001 and 2010, 25% of survey patients reported a wait of 4 or more months for nonemergent surgery.[5,6] British Columbia, Alberta, Saskatchewan, and Ontario were the first provinces to set up provincial data tracking for surgical waits. These early registries lacked uniformity in inclusion criteria, wait definitions, and summary measures, resulting in an inability to make interprovincial comparisons until 2008–2009.[7]

Wait times measurement methodology and challenges
The BC Surgical Patient Registry (SPR) was created in 2008. The intent of SPR is to support surgical decision making and resource allocation by providing prioritization information.[8] The operating budget is $875 000 annually. While no data regarding the initial setup cost in 2003–2004 are available in the public domain, the experience of other provinces suggests a range between $2 and $11 million.[9,10] Wait-time definitions are summarized in Table 1. The SPR aggregates booking data from individual surgeon offices. Average wait times are calculated using the date of booking to the date of operation. This methodology understates the overall wait time and burden of waiting from a patient's perspective, particularly if delays occur before surgical consultation.

National evaluation of wait-times progress and current data gaps
Over the past decade there have been major improvements in the reporting of wait-time data for priority procedures, with all provinces publicly reporting wait times. While the crude number of procedures performed has increased, wait times in the last 3 years have remained virtually unchanged, and the percentage of procedures completed within benchmark times has decreased.[11] A comparison of BC's performance in relation to provincial targets and national benchmarks is summarized in Table 2.

Despite recommendations and independent efforts to create benchmarks for all specialties[12,13] there has been no federal reassessment in the last 10 years.[14] Tracking of waits for nonpriority specialties occurs independently within individual provinces. In 2013 national cancer surgery statistics were reported for the first time, though there are currently no national benchmarks. As of 2014, general surgery wait times are being tracked in seven provinces (except Newfoundland, Prince Edward Island, and Manitoba), though not reported nationally. It is impossible to make national comparisons about waits for general surgery.

Within BC wait time targets were developed across multiple specialties in 2010. Examples of common general surgery diagnoses and their associated wait-time target are summarized in Table 3. Every elective surgical booking is accompanied by a prioritization code that designates the target time from booking to surgical date, ranging from 2 to 26 weeks.

Status of wait times in BC
Overall BC's surgical wait times have not declined and performance is slipping. The 90% target set by the BC provincial government[15] is rarely met. In 2002–2003, 90% of patients received nonemergency procedures within 23 weeks, with a total of 206 000 procedures performed. Ten years later, while the number of non-emergency procedures performed per year increased marginally to 218 000, the 90th percentile wait had increased to 26 weeks. The overall percentage of nonemergency surgeries completed within target wait times in BC currently stands at 65% (2013–2014), down from 82% (2010–2011).[16]

Increases in wait times are partly due to the push from health authorities to expedite cases that have been waiting more than 52 weeks. This increases the calculated average wait based on current methodology. A secondary effect of this policy is that surgeons are discouraged from booking new, potentially more urgent, cases into elective time until the long waiters are addressed. From a patient's perspective, this makes the wait-list data difficult to interpret. While the reported wait for a procedure may be 4 weeks, access to the operating room is not linear, making the actual wait time difficult to predict. Patients who wait exceedingly long may suffer exacerbation of symptoms, requiring emergent or expedited surgery with downshifting of others still waiting.

The limitations in access to operating rooms results in large numbers of patients dropping off the wait list. In 2011–2012, despite 123 599 cases being completed, 20 852 patients dropped off the wait list (Table 4). The average time to drop-off was 42.8 weeks. Alarmingly almost two-thirds (63%) of the drop-offs came from the top four priority groups (wait target = 16 weeks). Of these 12% were priority one (wait target = 2 weeks) who had waited an average of 24.1 weeks (correspondence with L. Vertesi, previous executive director of BC Health Services Purchasing Organization, 17 April 2015). While drop-offs can occur for various reasons (e.g., death on wait list, requirement for emergency surgery, obtaining private or out-of-province procedures), the enormous proportion of patients exiting the wait list has unfortunately become a component of keeping the wait list in check.

General surgery wait times in BC
All available wait-time data for general surgery were obtained from the BC Surgical Patient Registry from April 2009 to April 2015. Tracking of percentage of cases meeting target was implemented in 2011. Yearly caseload and average wait times are summarized in Figure 1. General surgery caseloads for overall, cancer, and noncancer cases as well as their associated percentage meeting benchmark are summarized in Figure 2aFigure 2b, and Figure 2c respectively. Average waits for patients who have undergone procedures (cases completed) and those who remain waiting at the end of the fiscal year (cases waiting) are reported separately.

For cancer surgery, over the last 4 years the number of cases performed per year appears to have remained stable around 10 000 per year, while the percentage of cases completed within target decreased, from 80% in 2011–2012 compared with 73% in 2014–2015. Of the patients who were still waiting at the end of each fiscal year, the proportion who had waited beyond the target remained relatively stable, from 41% to 39%. For general surgery cases where cancer is not suspected, the proportion of cases completed within target increased from 48% to 54%, but this was accompanied by a concurrent increase in the proportion of still-waiting patients who waited beyond targets for their noncancer surgery from 32% to 38%.

Overall, there has been worsening in the status of wait times for general surgery procedures in British Columbia. Despite substantial financial investment and policy making, advances in measurement have not translated into meaningful reductions in wait times. Clinicians are striving to ensure that cancer patients receive surgery in a timely manner, resulting in ever-longer wait times for patients with non-oncological diagnoses. Going forward, funding and informatics must be leveraged simultaneously to drive strategies for improving surgical capacity.

An analysis of 20 OECD countries suggested that higher availability of doctors and number of acute care beds was significantly associated with decreased wait times.[17] A 2013 study cited decreased surgical resources as a significant reason that 16% of new subspecialist graduates in Canada were unable to find work in surgical disciplines.[18] In the same year the National Physician Survey found that 35% of Canadian general surgeons felt they had unsatisfactory access to the operating room.[19] This finding was echoed by a study on BC general surgeons, highlighting that the surgeon shortage in BC is primarily driven by a lack of available operating room time and resources.[20]

In December 2011 the federal government committed to an additional annual 6% increase in health transfers from 2014 to 2017.[21] In the current model of block funding for hospitals, provision of surgical care is a major cost centre to hospital and health authority budgets, which can reduce incentives to invest undirected funds toward perioperative care. Operating room closures over the holidays are an additional example of cost-avoidance strategies currently employed. Health care funding reform incorporating activity-based funding becomes not only a financial incentive, but also a necessary element for continuous and timely care delivery to surgical patients.

Activity-based funding
In activity-based funding (ABF) models, funds are allocated to hospitals based on the type and volume of services provided, adjusting for the complexity of the patient population.[22] The United States Medicare program was the first federally run program to adopt this model in 1983.The Canadian Senate Committee recommended implementation of ABF in 2002.[11]

Potentially ABF provides increased accountability of public funds, equity in fund distribution, and increased investment in capital. Given the focus on care delivery, ABF offers flexibility in setting priorities to suit community needs and creates an environment that encourages competition and collaboration to provide the best services. In an ideal system, ABF balances patient illness and complexity in order to equitably allocate resources.

Potential disadvantages include gaming of financial structures of ABF models to preferentially provide services to patients who maximize financial surplus or limiting access to patients whose care would result in costs exceeding the funding amount. ABF can contribute to uncontrolled increases in expenditure driven by increased activity. In order to mitigate potential downsides, careful monitoring is required to keep spending in check and prevent undermining of the principles of equitable access and quality care.

A generally consistent outcome following ABF implementation is a reduced length of hospital stay.[23,24] ABF is also associated with improved patient satisfaction from reduced wait times.[25] However, findings regarding cost efficiency are mixed[26-29] as a higher intensity of services tends to be used during shorter stays. Robust cross-country comparisons remain difficult due to variation between methods of costing, implementation, and measuring outcomes. A recent systematic review and meta-analysis summarized 65 studies from the US and Europe on ABF implementation between 1980 to 2012,[30] finding no increase in mortality or hospital readmission rates. There was an increase in discharge to post-acute care facilities, highlighting the need for ABF to be implemented as part of more global reform. The authors were not able to specify in which settings ABF may be beneficial or deleterious, emphasizing that ABF has to be tailored to the context of a given health region.

Ontario adopted a funding model incorporating ABF on 1 April 2012 under the umbrella of Health System Funding Reform (HSFR). For the 2015–2016 fiscal year HSFR will comprise 70% of the funding structure provided to hospitals, with the remaining 30% based on block funding; 30% of HSFR will be based on quality-based procedures using a "price X volume" approach.[31] Reimbursement structures will integrate quality measures of outcome including evidence-based reviews of best practice and cancer surgery benchmarks. Theoretically, this approach will lead to funding being allocated to hospitals according to actual need, more equitable service provision, and better value for money.

Activity-based funding in BC
In April 2010 the BC Ministry of Health allotted $250 million to launch its Patient Focused Funding initiative to reduce wait times and increase same-day surgical procedures. As a result, wait times for the top-10 day procedures decreased at Vancouver Acute over a 9-month period of wait list–drive intensive funding. This translated to a 24% reduction in the surgical wait list (1800 cases) as well as a 69% reduction in cases waiting over 1 year (900 cases) (oral and written communication with L. Vertesi, previous executive director of BC Health Services Purchasing Organization, 17 April 2015) (Figure 3). Though much promise was demonstrated, the ABF program was discontinued in 2013.

The early success of ABF observed in BC supports its reimplementation as a method to address the specific concerns regarding surgical wait times, but must be implemented in the context of global health reform. Isolated data tracking can lead to solutions that are not patient focused, as is in evidence with the large number of patients dropping off wait lists. Expansion of data tracking and quality-of-care measures should be integrated to ensure that isolated data tracking and ABF incentives are not accompanied by an associated decrease in patient access/experience and quality care. This approach is in keeping with the 2014 BC Ministry of Health report, which aims to complete a population needs–based funding model for BC, as well as implement a multi-dimensional funding strategy that will incorporate global, patient-focused funding, and ABF.[15]

For general surgery in BC the establishment of the BC Surgical Patient Registry and advances in wait-times tracking is a significant achievement. The ability to track a patient's journey through a complex system is laudable and must be continued. Moving forward, data tracking must be expanded to reflect surgical wait times across all specialties, track performance, and create a feedback system for tailored policy making to fit evolving needs within a surgical system that places the highest value on the patientís illness experience. BC is poised at an opportune time to use activity-based funding strategies to deliver quality care to the right patient at the right time.

The authors would like to acknowledge Dr Les Vertesi for contributing his expertise in wait-list management in BC, for provision of previously unpublished data, and for manuscript revision.


This article has been peer reviewed.


1.    Government of Canada. First ministers' accord on health care renewal, 2003. Accessed 13 Nov 2013. www.scics.gc.ca/CMFiles/800039004_e1GTC-352011-6102.pdf.
2.    Health Canada. First ministers' meeting on the future of health care 2004: A 10-Year Plan to Strengthen Health Care, 2004. Accessed 14 May 2014. www.hc-sc.gc.ca/hcs-sss/delivery-prestation/fptcollab/2004-fmm-rpm/index....
3.    Supreme Court of Canada. Chaoulli v. Quebec (Attorney General), 2005. Accessed 25 Feb 2015. www.canlii.org/en/ca/scc/doc/2005/2005scc35/2005scc35.html.
4.    Government of Canada. The Canada Health Act, 1985. Accessed 10 Feb 2015. laws-lois.justice.gc.ca/eng/acts/c-6/fulltext.html.
5.    Health Council of Canada. How do Canadians rate the health care system. Results from the 2010 Commonwealth Fund international health policy survey, 2010.  Accessed 13 Nov 2013. www.healthcouncilcanada.ca/rpt_det.php?id=122.
6.    Organization for Economic Cooperation and Development. Health at a glance 2011: OECD indicators, 2011. Accessed 13 Nov 2013. www.oecd-ilibrary.org/sites/health_glance-2011-en/06/08/index.html?itemI....
7.    Canadian Institute for Health Information. Health care in Canada, 2012: A focus on wait times, 2012. Accessed 13 Nov 2013. secure.cihi.ca/free_products/HCIC2012-FullReport-ENweb.pdf.
8.    British Columbia Ministry of Health. BC Surgical Patient Registry communications backgrounder, 2012. Accessed 13 Nov 2013. www.phsa.ca/Documents/Surgical-Services/SPRCommunicationsBackgrounderJun....
9.    Collum J. Saskatchewan Surgical Waitlist Registry. Accessed 17 Apr 2015. sl.infoway-inforoute.ca/downloads/JoAnn_Collum_-_Saskatchewan's_Surgical_Wait_Times_Registry.pdf
10.    Nova Scotia Health. Provincial Surgery Project fact sheet, 2009. Accessed 17 Apr 2015. www.pcha.nshealth.ca/pdf_files/nr_surgery_project_092509.pdf.
11.    Canadian Institute for Health Information. Wait times for priority procedures in Canada, 2013. Accessed 27 Feb 2015. secure.cihi.ca/free_products/wait_times_2013_en.pdf.
12.    Standing Senate Committee on Social Affairs, Science, and Technology. Time for transformative change: A review of the 2004 health accord, 2012. Accessed 27 Feb 2015. www.parl.gc.ca/content/sen/committee/411/soci/rep/rep07mar12-e.pdf.
13.    Wait Time Alliance. Time to close the gap: Report card on wait times in Canada, 2014. Accessed 15 Nov 2014. www.waittimealliance.ca/wp-content/uploads/2014/06/FINAL-EN-WTA-Report-C....
14.    Wait Time Alliance. Time Out! Report card on wait times in Canada, 2011. Accessed 15 Nov 2014. www.waittimealliance.ca/media/2011reportcard/WTA2011-reportcard_e.pdf.
15.    British Columbia Ministry of Health. Wait time targets, 2007. Accessed 27 Feb 2015. www.health.gov.bc.ca/swt/overview/waittime_targets.html.
16.    British Columbia Ministry of Health. Setting priorities for the BC health system, 2014. Accessed 20 Feb 2015. www.health.gov.bc.ca/library/publications/year/2014/Setting-priorities-B....
17.    Organisation for Economic Co-operation and Development. Explaining wait times variations for elective surgery across OECD countries. Accessed 13 Nov 2014. www.oecd.org/els/health-systems/17256025.pdf.
18.    Royal College of Physicians and Surgeons of Canada. Royal college report on physician employment, 2013. Accessed 17 Jan 2015. www.royalcollege.ca/portal/page/portal/rc/common/documents/policy/employ....
19.    National Physician Survey. Results for surgical specialists, Q3b, 2013. Accessed 14 Nov 2014. nationalphysiciansurvey.ca/wp-content/uploads/2013/09/2013-SUR-EN-Q3b.pdf.
20.    Hwang H, Karimuddin AA. Dividing the pie into smaller slices: A qualitative and quantitative analysis of the general surgery workforce in British Columbia, 1992ñ2012. BCMJ 2013;55:26-32. 
21.    Parliament of Canada. The Canada health transfer: Changes to provincial allocations, 2011. Accessed 14 Nov 2014. www.parl.gc.ca/Content/LOP/ResearchPublications/2011-02-e.htm#a6.
22.    University of British Columbia Centre for Health Services and Policy Research. Activity-based funding (ABF), 2014. Accessed 27 Feb 2015. healthcarefunding2.sites.olt.ubc.ca/files/2014/03/White-Paper-ABF.pdf.
23.    O'Reilly J, Busse R, Hakkinen U, et al. Paying for hospital care: The experience with implementing activity-based funding in five European countries. Health Econ Policy Law 2012;7:73-101.
24.    Moreno-Serra R, Wagstaff A. System-wide impacts of hospital payment reforms: Evidence from Central and Eastern Europe and Central Asia. J Health Econ 2010;29:585ñ602. 
25.    Organisation for Economic Co-operation and Development. Towards high-performing health systems: Summary report, 2004. Accessed 27 Feb 2015.  www.oecd.org/dataoecd/7/58/31785551.pdf.
26.    Bjorn E, Hagen TP, Iversen T, et al. The effect of activity-based financing on hospital efficiency: A panel data analysis of DEA efficiency scores 1992 - 2000. Health Care Manag Sci 2003;6:271-283.
27.    Linna M, Hakkinen U, Peltola M, et al. Measuring cost efficiency in the Nordic hospitals--A cross-sectional comparison of public hospitals in 2002. Health Care Manag Sci 2010;13:346-357.
28.    Kittelsen S, Magnussen J, Sarheim AK, et al. Hospital productivity and the Norwegian Ownership Reform--A Nordic comparative study. Health Economics Research Programme at the University of Oslo 2008; pp. 1-25. Accessed 25 Feb 2015. www.hero.uio.no/ publicat/2008/2008_10.pdf.
29.    Street A, Duckett S. Are waiting lists inevitable? Health Policy (Amsterdam) 1996;36:1-15. Accessed 25 February 2015. http://www.ncbi.nlm.nih. gov/pubmed/10157818.
30.    Palmer KS, Agoritsas T, Martin D, et al. Activity-based funding of hospitals and its impact on mortality, readmission, discharge destination, severity of illness, and volume of care: A systematic review and meta-analysis. PLoS ONE 2012;9:e109975.
31.    Ontario Ministry of Health and Long-Term Care. Health system funding reform, 2015. Accessed 12 Mar 2015. www.health.gov.on.ca/en/pro/programs/ecfa/funding/hs_funding.aspx.


Dr Chan is a resident in general surgery at the University of British Columbia. Dr Hwang is a clinical instructor in the UBC Department of Surgery and a staff surgeon at the Vernon Jubilee Hospital. Dr Karimuddin is a clinical assistant professor in the UBC Department of Surgery and a staff general and colorectal surgeon at St. Paul's Hospital.

T. Chan, MHsc, MD,, Hamish Hwang, MD, FRCSC, FACS, Ahmer A. Karimuddin, MD, FRCSC. Wait times for general surgery in BC: Moving beyond measurement. BCMJ, Vol. 57, No. 8, October, 2015, Page(s) 341-348 - Premise.

Above is the information needed to cite this article in your paper or presentation. The International Committee of Medical Journal Editors (ICMJE) recommends the following citation style, which is the now nearly universally accepted citation style for scientific papers:
Halpern SD, Ubel PA, Caplan AL, Marion DW, Palmer AM, Schiding JK, et al. Solid-organ transplantation in HIV-infected patients. N Engl J Med. 2002;347:284-7.

About the ICMJE and citation styles

The ICMJE is small group of editors of general medical journals who first met informally in Vancouver, British Columbia, in 1978 to establish guidelines for the format of manuscripts submitted to their journals. The group became known as the Vancouver Group. Its requirements for manuscripts, including formats for bibliographic references developed by the U.S. National Library of Medicine (NLM), were first published in 1979. The Vancouver Group expanded and evolved into the International Committee of Medical Journal Editors (ICMJE), which meets annually. The ICMJE created the Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals to help authors and editors create and distribute accurate, clear, easily accessible reports of biomedical studies.

An alternate version of ICMJE style is to additionally list the month an issue number, but since most journals use continuous pagination, the shorter form provides sufficient information to locate the reference. The NLM now lists all authors.

BCMJ standard citation style is a slight modification of the ICMJE/NLM style, as follows:

  • Only the first three authors are listed, followed by "et al."
  • There is no period after the journal name.
  • Page numbers are not abbreviated.

For more information on the ICMJE Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals, visit www.icmje.org

BCMJ Guidelines for Authors

Leave a Reply