Skip to main content
Dr. Mark Swain

The Power of Partnership, Measurement, and Data: Countering the Challenge of Ballooning Specialist Referrals and Wait times

Daniel Rivera, Combined BScH/MSc Candidate, Life Sciences/Neuroscience

The January 16th Medical Grand Round was fortunate to host Dr. Mark Swain who is currently the Head of the Division of Gastroenterology and Hepatology at the University of Calgary.
 

Dr. Swain spoke of the power that partnerships and measurement played in his experience combatting ballooning wait times for GI specialist appointments in Calgary – a problem arising from ever-increasing demand amidst a limited amount of specialist availability.
 

Gastroenterology was amongst the most referred-to specialties in Calgary in the early 2010s, with wait times often as long as 2 years. Dr. Swain spoke of his intention to harness the power of measurement, which he was well acquainted with as a clinician-scientist, to combat this issue upon assuming the role of Division Head in 2012.
 

Key to success would be partnering with primary care physicians (PCPs). With many patients being referred to GI specialists without “red flags” such as weight loss, rectal bleeding, or anemia, significant strain was placed on the wait list. This led to frustration for PCPs, patients, and specialists alike. To combat this, Clinical Care Pathways were developed jointly with PCPs to help identify the most appropriate, evidence-based type of care given a patient’s clinical presentation. These were made publicly available to physicians and patient’s alike and can be found on the Calgary Division of Gastroenterology and Hepatology’s website so both parties are able to better understand the journey from primary care onwards regarding gastrointestinal symptoms.
 

Key to effective entry and utilization of a Clinical Care Pathway is, as Dr. Swain asserted, effective triage. In Calgary, GI Central Access and Triage (CAT) was established and allowed for priority to be placed on the sickest patients but also for patients with less urgent symptoms to be led on more appropriate clinical care paths. As many as 40% and 15% of patients reporting abdominal pain have indigestion (with or without gastric reflux) or irritable bowel syndrome, respectively. These disorders are often effectively remedied by lifestyle and dietary adjustment and are best handle by non-specialist care. Specialist care, it seems, may not always be the best, or most appropriate, care. Dr. Swain presented data showing that 84% of patients led to primary care via CAT had their symptoms effectively managed and the 16% who were re-referred to specialists did not present with urgent disorders or disease upon re-assessment. Data and measurement have come to show that smarter approaches to triage and referrals can lead to better outcomes for patients and halt increasing GI specialist referral.
 

But, strategic partnerships continued to form. Specialist LINK, which seeks to improve PCP and specialist communication was developed with the  Division of Gastroenterology and Hepatology, Primary Care Networks, and Alberta Health Services. Specialist LINK is available to all PCPs in Calgary via telephone and promises, upon a call, a call back from a GI specialist within 30 minutes to provide tele-advice and information on the Clinical Care Pathways. The benefits were rapidly recognized by PCPs handling GI symptoms, and this their patients, so much so that Specialist LINK has expanded to 23 specialties to date. Between 2014 and 2019, a 101% increase in the number of patients who avoided a specialist referral was achieved. When surveyed, 89% of PCPs were satisfied with the service and 80% felt better equipped with it. Data also shows that $1.2 million has been saved since between 2014-2019 with that amount projected to increase to $2.0 million in 2020. Measurement and data, again, have proven the effectiveness of strategic partnerships in countering stubborn clinical challenges.
 

Dr. Swain and other’s efforts show that partnering with all relevant stakeholders can result in the development of solutions to challenges, such as the wait time and referral crisis, that work for physicians and patients alike.
 

In our post-round discussion, Dr. Swain spoke to the TMED 801 class about how empowering data can be when shared with patients, reflecting on his experiences in hepatology. To provide patients with the appropriate, evidence-based care can profoundly quell the anxiety of experiencing distressing symptoms. Patients feel taken care of, whether the next healthcare step is what they had feared or different from what they expected. To take the right next step, rigorous measurement and data collection is necessary to not only empower the clinician, but also benefit the patient.
 

It was a pleasure to have Dr. Swain present at Medical Grand Rounds! Thank you for sharing your experience, insight, and time with all those who attended and, on behalf of the TMED 801 students, for the discussion that followed!

Comments

Name
Sophia Linton

Mon, 01/20/2020 - 10:27

Through developing the Clinical Care Pathways Dr. Swain said he learned a great deal from the RNs and NPs (who were essential in developing this program). In particular, he said he learned how to communicate better with his patients and to be more empathetic.

To all the MDs out there, what have you learned from your RNs and NPs and how have they improved your practice?

Name
Sophia Linton

This is a very great question! I noticed that Canadian Nurse Practitioner Initiative began in the mid-2000s - it would be interesting to see how their roles and integration in the clinic have developed

Name
Daniel Rivera

Name
Rachel Bentley

Mon, 01/20/2020 - 11:23

Hi Daniel. Great job summarizing the discussion with Dr. Swain. His talk showed an innovative and very successful solution to the ever-growing problem with specialist wait times. One thing that struck me in Dr. Swain's talk was the integration of many health care professionals, from nurse practitioners to health care policy experts, in designing and implementing their care pathways. You did a great job of emphasizing the role of partnerships in Dr. Swain's group's resounding success at reducing GI wait times, and their work is a prime example of how collaborations, such as that between the PCPs and GI specialists, can be highly beneficial. I was wondering if you had any thoughts on how these cross-disciplinary collaborations can lead to improvements in health care?

Name
Rachel Bentley

Thank you Rachel! I think that health care policy workers and NPs have a huge role to play in not only making what was put in place sustainable and successful, but improving and expanding the efforts to challenge common and stubborn clinical problems. I think that health care policy makers can certainly help develop policy and guidelines that support initiatives and their evaluation to make programs, such as the one Dr. Swain had spoke up, successful. To get things to change will certainly cost money, whether it be supporting research or implementing new services, and time, effort, and structural support, and health care policy makers can play a central role in helping see such initiatives be put in play in the real world through supporting them in these ways.

As for NPs, I think Dr. Swain said it best - they invaluable and are the best suited for a variety of things that specialists or primary care is not appropriate for. I think by working with them to better utilize them will not only address the common frustrations amongst their healthcare colleagues, but provide quicker access to the most appropriate care for patients.

Name
Daniel Rivera

Name
Quentin Tsang

Mon, 01/20/2020 - 11:34

Great summary Daniel! I had the pleasure of meeting Dr. Swain earlier in the week in a meeting at GIDRU where he shared his research on inflammation and changes in the brain. Only focusing on his basic science expertise, I had no idea that Dr. Swain pioneered such a valiant program to virtually eliminate wait times for routine GI referrals in Calgary. During our post-rounds discussion, I started to bridge both talks together, in the sense that Dr. Swain used his expertise in basic science to find a solution to a problem that was facing the Division of Gastroenterology in Calgary. Instead of remaining in the paradigm of extremely long wait times, Dr. Swain used objective measurements to understand why there are wait times, and then performed "experiments," in the form of SpecialistLINK and the Enhanced Primary Care Plans, to see if there was an objective and quantifiable improvement! This shows what an exceptional clinician-scientist Dr. Swain is, applying his basic science expertise (in a rather unconventional way and in a field where he did not have experience in), to devise a strategy to benefit patients. This is the spirit of Translational Medicine!
I was wondering whether there were other areas of patient care that clinician-scientists could apply their basic science expertise to. Perhaps we could move Dr. Swain's strategy of objective measurements of wait times into emergency room wait times? I would love to hear everyone's thoughts on this!

Name
Quentin Tsang

Hey Quentin,

Your question made me think of a news article that came out earlier this month. In Hamilton, they post real-time emergency room wait times online. The goal is to help people understand when is the best time to make the trip, depending on the severity of their visit! Here's the link:

https://globalnews.ca/news/6387106/hamilton-wait-times-online/

Name
Sophia Linton

Thank you, Quentin! I agree that this is a wonderful example of how not just research from the lab, but also the skills that basic science develops in scientists, can be used to address clinical challenges.

To your question - I believe this approach can be used to also indirectly address ER overload ! In the 2018-29 Specialist LINK report, they state that there was a 13% drop in the number of patients who ended up going to the ER after their primary care physician used the service. So, certainly, this has the potential to address issues surrounding ER visits and wait times. Currently, the service is available to primary care physicians only, but I wonder if it is feasible to open up a similar program that is open to patients, perhaps those that have symptoms that are most common in the ER.

Here's the link if you're interested: https://www.specialistlink.ca/about-us/by_the_numbers.cfm

Name
Daniel Rivera

Hi Quentin,

With an average wait time of 4 hours in the ER, this is definitely an area of research that could use some investigation! When comparing PCPs and ER physicians, there are notable differences between the two practices that may render Specialist LINK to be inapplicable for ER physicians (although still benefiting up to 13% as Daniel mentioned!).

Ineffective distribution of workload amongst ER staff is a major problem associated with prolonged wait times. Many patients come to the ER with non-emergency conditions in the evenings/weekends where their PCP clinics are closed. With consistently higher patient demands after-hours, a suggestion to reduce wait times is to have ER physicians complete initial patient evaluations rather than by nurses (as currently implemented). This method can significantly reduce redundancy and allow nurses to be involved directly with patient care immediately following ER physicians' diagnosis.

Name
Thalia Hua

Name
Marty VandenBroek

Mon, 01/20/2020 - 12:40

Thanks for the summary Daniel. Dr. Swain mentioned in his talk how the idea of having Clinical Care Pathways accessible to both doctors and patients is spreading, being incorporated by other specialities (for example cardiology), and has moved across the province of Alberta and even popped up in Ontario (Lakeridge in Oshawa for example is using them). I think they seem like a great idea to allow everyone to be on the same page when it comes to a patients plan for their care. I wondered what people's thought were on what might be preventing these pathways from being used on a much wider scale?

Name
Marty VandenBroek

Excellent point Marty! When I was reading up on ER wait times, a major reason as to why these policies are having difficulty being implemented is the resistance to change. With systems that have been running a certain way for decades, people are comfortable with how things are executed even though they may not be the most effective. With increasing stories of success and greater evidence of improved care, we will likely see an increase in receptivity for these new changed practices!

Name
Thalia Hua

Prolonged ER wait times have always been and are still a major challenge for the healthcare system not only across Canada but globally. Various interventions and strategies have been employed over the years to tackle this; however, the outcomes of these measures have not been as impressive as what Dr. Swain and his colleagues have been able to achieve with specialist referral wait times. As Dr. Swain mentioned during the post rounds discussion and as you have also mentioned, although resistance to change is of concern particularly in healthcare delivery, when presented with overwhelming evidence of improved care, the majority of people are likely to adopt the change. I believe any intervention targeted at reducing ER wait times will have to be multipronged, targeting all stakeholders at multiple points.
Regarding the issue of high ER patient volumes in the evenings/weekends due to the closure of walk-in and PCP clinics, I wonder if after-hours walk-in clinics my help this issue. This, of course, has its pros and cons but I would like to know what people's thoughts are on this.

Name
Edwin Ocran

Hey Marty,

That's a great question and I do think the goal is to implement the triage method and CCP on a wider scale. Do you think incorporating these CCPs into medical school curriculum is beneficial?

Name
Jay Kataria

Thats a good idea Jay, I think it would be a good idea to introduce these to new docs, and have them aware of the benefits of the CCPs as they start their careers!

Name
Marty VandenBroek

Name
Joseph Nashed

Tue, 01/21/2020 - 11:30

Great Summary Daniel! One of the things I enjoyed from our discussion was about how the media can have both a positive and negative impact on research. Dr. Swain discussed his basic science in the media with us. But, I found myself wondering after why hasn't the media picked up a story that has impacted so many people in Alberta? I mean Dr Swain's work has decreased wait times, improved collaboration between healthcare practitioners etc., I feel like something like this is the type of positive news we need in the world!

Name
Joseph Nashed

Name
Daniel Rivera

Wed, 01/22/2020 - 18:34

In reply to by Joe (not verified)

Thanks, Joseph. I wonder this too. Upon doing a quick search on google, I found a few news articles that mentioned the successes in Calgary, but not too many. Hopefully with the expansion of their framework elsewhere in Canada (which is ongoing) the successes will increase and news agencies that communicate these successes to the public will take greater notice. I would imagine that Dr. Swain's visiting Queen's and Kingston and his meetings with local partners might create some "hype" in Kingston about such a framework or similar strategies to reduce specialist referrals and wait times - hopefully this is communicated well with the public. You're right in how this is all positive news. I think it can also ease patients', who worry about wait times, minds and restore some faith in the healthcare system! And give credit to those who are tackling this complex problem!

Name
Daniel Rivera

Name
Spencer Finn

Tue, 01/21/2020 - 15:41

Hi Daniel,

Great summary of both his Grand Round and discussion, you did an excellent job! One thing I believe we briefly touched on during the discussion was implementing this phone line with specialists in other specialities. We spoke shortly maybe some specialities that this wouldn't work with. I definitely wonder which specialities this technique might not be especially beneficial in. There are definitely some specialities, like dermatology, that would benefit from being able to see the patient before giving a diagnosis or treatment. Do you agree and think that this technique might be weak in some specialities and if yes, does anyone have any ideas on any solutions? Maybe video calls?

Name
Spencer Finn

Thanks, Spencer! That's a good point - tele-advice may be applicable to most specialties in theory, but there are other practical barriers that must be overcome. I found a recent article written by patient navigator assistant at Sunnybrook that goes over some of these barriers, specifically to a online video chat service run in Ontario. http://health.sunnybrook.ca/navigator/online-health-care-why-cant-i-get…

But, to answer your question - yes! Mainly, I would imagine that specialties that, say, often require a physical exam as a part of their assessment, might have a tougher time realizing the full benefits of such e-health services.

Name
Daniel Rivera

Name
Reem Alzafiri

Tue, 01/21/2020 - 18:12

The system that Dr. Swain and colleagues have put in place for his department is not only brilliant but is something all physicians and medical practices should be equipped with. This would not only help doctors get to their patients needs in a timely manner but it will also make our health care better with physicians interacting together to give the patient the best possible care they can get. It brings to question whether these clinical care pathways will become the new standard of care in the future and if todays physicians are ready for this type of change to occur.

Name
Reem Alzafiri

Name
Jay Kataria

Wed, 01/22/2020 - 12:15

Hey Dan,

Thanks for the informative post! It's great to know Queen's grads are making a major impact in the healthcare field. A thought that came to mind during our discussion is how preventative care may help decrease wait times. Do you think we should invest more in educating the public and raising awareness on what these GI procedures are and when one should get one? For example, the fecal immunochemical test (FIT) screens for hidden blood in the stool and it is sent by mail to everyone once they hit a certain age.

Name
Jay Kataria

Hi Jay,
This is an interesting thought. I think to a certain degree, it might be beneficial in helping patients understand their healthcare journey. With that being said, this might only be effective for some of the common GI procedures or tests and I'm not sure how effectively the public can be educated in terms of understanding what their own symptoms necessitate, especially given variability of symptoms for some of the more common, less urgent diseases/disorders. Maybe better education regarding some of the more urgent or concerning symptoms, such as blood in stool, might be beneficial as they are considered "red flags".

Name
Daniel Rivera

Add new comment

Plain text

  • No HTML tags allowed.
  • Lines and paragraphs break automatically.
  • Web page addresses and email addresses turn into links automatically.