“Eliminating Wait Times”: Medical Grand Rounds featuring Dr. Annette Hay
Trinity Vey, MSc Candidate (Translational Medicine)
Last week’s Medical Grand Rounds were led by Dr. Annette Hay, a Hematologist and Senior Investigator with the Canadian Cancer Trials Group, on the topic of eliminating wait times. The existence of long wait times for specialized services in Canada has been well-documented, with wait times to see specialists significantly longer in all Canadian provinces than the international average (1). In 2020, the Canadian median wait time between referral and specialist consultation was 10.5 weeks, which has increased by 184% since 1993 (2). Such long waits can delay diagnosis and treatment, leading to chronic illness, disability, and other adverse outcomes (3,4). Patients have reported mental distress, stress on family and friends, pain, and loss of work associated with wait times (5).
To address wait times, primary care management pathways (PCPs) have been developed by Kingston Health Sciences Centre (KHSC) specialists in collaboration with family physicians. PCPs are online evidence-based tools designed to empower primary care physicians to manage non-urgent conditions while identifying high-risk patients necessitating referral (6). In Calgary, implementation of a gastrointestinal (GI) disorder PCP reduced routine wait list volume by 99% within 12 months (7).
Dr. Hay explained PCPs through the hematological lens of Monoclonal Gammopathy of Undetermined Significance (MGUS). MGUS is an asymptomatic condition in which low levels of monoclonal protein (MP), either whole immunoglobulins or light chain components, are detectable in the blood or urine (8). MGUS is common and prevalence increases with age. MGUS has a low risk of conversion to myeloma, which is plasma cell malignancy, at 1% per year (9).
The MGUS primary care management pathway supports family physicians in the screening and monitoring of MGUS. The PCP specifically outlines when MP presence should be tested for, such as when patients present with unexplained anemia, hypercalcemia, or renal failure (10). The document lists the tests that should be performed, including complete blood count and serum protein electrophoresis, and how frequently testing should be repeated based on results. The PCP also describes risk factors that put patients at higher risk of progression to myeloma, such as MP >15g/L, an abnormal free light chain ratio, and non-IgG type MP, who require closer monitoring (11).
Importantly, the MGUS PCP defines “red flag” symptoms that require urgent referral to a hematologist, including unexplained bone pain, hemoglobin levels <100g/L, or a deterioration in kidney function (10). PCP implementation has allowed KHSC’s hematology wait list to drop this month for the first time since 2018. Rounds also featured Dr. Al Jin in neurology and Dr. Melissa Kelley in GI, who discussed the development of PCPs for Parkinson’s Disease and Alcoholic Fatty Liver Disease, respectively. More information regarding KHSC PCPs can be found at: https://kingstonhsc.ca/refer/
Rounds highlighted that PCPs are driven and informed by the needs of family physicians, such as Dr. Matt Dumas. For Translational Medicine (TMED) students, the PCP model is an excellent example of how collaboration across and beyond healthcare providers can improve efficiency and coordination of patient care. By promoting ongoing management of certain conditions by primary care providers, specialist resources can be allocated to the most at-risk patients. While application of PCPs could reduce wait times across the country and various specialties, considerations and adjustments will certainly need to be made for local contexts and systems.
Along the theme of eliminating wait times, Rounds also featured data scientist Mr. Alex Hamilton, who discussed how natural language processing (NLP) technology could be integrated into the MGUS PCP. The NLP pipeline can extract information from referral forms and generate predictions, thereby holding potential for more rapid triage (12).
Following Rounds, the TMED Graduate students joined Dr. Hay for a fascinating discussion ranging from her career path to usage of artificial intelligence in cancer diagnosis and prognosis. Dr. Hay revealed how her medical training in the UK, where there is more equitable clinical trial drug access, has influenced her research interests as a Senior Investigator in Canada. She also provided insight into the medical community’s shift to becoming more thorough, and potentially “over-investigating”, explaining the continually rising referral numbers. A key takeaway from our discussion was the need for balance in medical testing. In addition to contributing to wait times, unnecessary tests can potentially harm patients due to exposure to radiation or inducing anxiety (13). Dr. Hay also emphasized the necessity of working in a supportive team and celebrating the small wins.
On behalf of the TMED class, I would like to thank Dr. Hay and other contributors for their time, insights, and substantial contributions to patient care.
- Canadian Institute for Health Information. (2017). How Canada Compares: Results from The Commonwealth Fund’s 2016 International Health Policy Survey of Adults in 11 Countries — Accessible Report. Ottawa, ON: CIHI.
- Barua, B. & Moir, M. (2020). Waiting your turn: Wait times for health care in Canada 2020 report. Studies in health care policy.
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- Barua, B., Rovere, M. C., & Skinner, B. J. (2010). Waiting your turn: Wait times for health care in Canada 2010 report. Studies in health care policy.
- Harrington, D. W., Wilson, K., & Rosenberg, M. W. (2014). Waiting for a specialist consultation for a new condition in Ontario: impacts on patients' lives. Healthcare policy, 9(4), 90–103.
- Arain, M., Rostami, M., Zaami, M., Kiss, V., & Ward, R. (2020). Specialist LINK and primary care network clinical pathways - a new approach to patient referral: a cross-sectional survey of awareness, utilization and usability among family physicians in Calgary. BMC family practice, 21(1), 86.
- Mazurek, M. S., Belletrutti, P. J., Heather, G. S., Swain, M., & Novak, K. L. (2019). A22 Routine Gastrointestinal referral wait list reduction via an enhanced primary care pathway. Journal of the Canadian Association of Gastroenterology, 2(Suppl 2), 42–43.
- Kyle, R. A., Therneau, T. M., Rajkumar, S. V., Larson, D. R., Plevak, M. F., Offord, J. R., Dispenzieri, A., Katzmann, J. A., & Melton, L. J., 3rd (2006). Prevalence of monoclonal gammopathy of undetermined significance. The New England journal of medicine, 354(13), 1362–1369.
- Kyle, R. A., Larson, D. R., Therneau, T. M., Dispenzieri, A., Kumar, S., Cerhan, J. R., & Rajkumar, S. V. (2018). Long-Term Follow-up of Monoclonal Gammopathy of Undetermined Significance. The New England journal of medicine, 378(3), 241–249.
- Rajkumar, S. V., Dimopoulos, M. A., Palumbo, A., Blade, J., Merlini, G., Mateos, M. V., Kumar, S., Hillengass, J., Kastritis, E., Richardson, P., Landgren, O., Paiva, B., Dispenzieri, A., Weiss, B., LeLeu, X., Zweegman, S., Lonial, S., Rosinol, L., Zamagni, E., Jagannath, S., … Miguel, J. F. (2014). International Myeloma Working Group updated criteria for the diagnosis of multiple myeloma. The Lancet. Oncology, 15(12), e538–e548.
- Rajkumar, S. V., Kyle, R. A., Therneau, T. M., Melton III, L. J., Bradwell, A. R., Clark, R. J., ... & Katzmann, J. A. (2005). Serum free light chain ratio is an independent risk factor for progression in monoclonal gammopathy of undetermined significance. Blood, 106(3), 812-817.
- Todd, J., Richards, B., Vanstone, B. J., & Gepp, A. (2018). Text Mining and Automation for Processing of Patient Referrals. Applied clinical informatics, 9(1), 232–237.
- Taylor, P. (2017). Why Unnecessary Medical Tests may do more harm than good. Your Health Matters Sunnybrook. Retrieved from: https://health.sunnybrook.ca/navigator/unnecessary-medical-tests-harmfu…