HealthPolicy118(2014)292–303
ContentslistsavailableatScienceDirect
Health
Policy
jo u r n al h om ep age :w w w . e l s e v i e r . c o m / l o c a t e / h e a l t h p o l
Measuring
and
comparing
health
care
waiting
times
in
OECD
countries
夽
Luigi
Siciliani
a,∗,
Valerie
Moran
b,1,
Michael
Borowitz
b,2 aDepartmentofEconomicsandRelatedStudies,UniversityofYork,YorkYO105DDUnitedKingdombDirectorateforEmployment,LabourandSocialAffairs,OECD,2,rueAndre’Pascal,75775,Paris,Cedex16,France
a
r
t
i
c
l
e
i
n
f
o
Articlehistory:Received9December2013
Receivedinrevisedform18August2014 Accepted22August2014 Keywords: Waitingtimes OECD Cross-countrycomparison Administrativedata
a
b
s
t
r
a
c
t
Waitingtimesforelectivetreatmentsareakeyhealth-policyconcerninseveralOECD countries.Thisstudydescribescommonmeasuresofwaitingtimesfromadministrative dataacrossOECDcountries.Itfocusesoncommonelectiveprocedures,suchashipandknee replacement,andcataractsurgery,wherewaitingtimesarenotoriouslylong.Itprovides comparativedataonwaitingtimesacross12OECDcountriesandpresentstrendsinwaiting timesoverthelastdecade.WaitingtimesappeartobelowintheNetherlandsandDenmark. InthelastdecadetheUnitedKingdom(inparticularEngland),FinlandandtheNetherlands havewitnessedlargereductionsinwaitingtimeswhichcanbeattributedtoarangeof policyinitiatives,includinghigherspending,waiting-timestargetschemesandincentive mechanisms,whichrewardhigherlevelsofactivity.Thenegativetrendinthesecountries has,however,haltedorreversedinrecentyears.Theanalysisalsoemphasizessystematic differencesacrossdifferentwaiting-timemeasures,inparticularbetweenthedistribution ofwaitingtimesofpatientstreatedversusthatofpatientsonthelist.Meanwaitingtimesare systematicallyhigherthanmedianwaitingtimesandthedifferencecanbequantitatively large.
©2014ElsevierIrelandLtd.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense
(http://creativecommons.org/licenses/by-nc-nd/3.0/).
1. Introduction
Waitingtimesforelectiveproceduresareamajorhealth policyconcerninmanyOECDcountries.Policymakersface considerablechallengesinreducingthem.Initiativesare
夽 OpenAccessforthisarticleismadepossiblebyacollaboration betweenHealthPolicyandTheEuropeanObservatoryonHealthSystems andPolicies.
∗ Correspondingauthor.Tel.:+4401904432300. E-mailaddresses:luigi.siciliani@york.ac.uk(L.Siciliani), valerie.moran@york.ac.uk(V.Moran),
Michael.Borowitz@theglobalfund.org(M.Borowitz).
1 CurrentAddressandAffiliation:CentreforHealthEconomics, UniversityofYork,YorkYO105DD,UnitedKingdom.
2 CurrentAddressandAffiliation:TheGlobalFund,Geneva, Switzerland.
regularlyintroducedtotackleexcessivewaitingtimeswith varyingsuccess[1].
This study aims toprovide comparative evidence of waitingtimesacrossOECDcountriesandexplorestrends and health policiesaimed atreducing waiting times in thelastdecade.OECDcountriestendtodifferintheway waitingtimesaremeasuredandutilisedfor benchmark-ingorregulatorypurposes.Weidentifythemostcommon measures and explain how these differ. We then com-parewaitingtimesacross12OECDcountries1forcommon
surgicalprocedures(suchashipreplacementandcataract). We comparemeanand medianwaiting timesandtheir
1Australia,Canada,Denmark,Ireland,Finland,theNetherlands,New Zealand,Portugal,Slovenia,Spain,SwedenandtheUnitedKingdom.None ofthedatacontainedinthisstudyareavailablein[1].
http://dx.doi.org/10.1016/j.healthpol.2014.08.011
distribution. We illustratetime trends and relate sharp reductionsinwaiting timestospecificpolicyinitiatives. Comparativeinformationcanfeedintopolicydiscussion and contribute to assessment of the waiting time phe-nomenon in each country. The analysison time trends servestoidentifycountriesthathavesuccessfullyand sig-nificantlyreducedwaitingtimes.
TheanalysisispartoftheSecondOECDWaitingTime Projectin2011–2012whoseobjectivesweretocompare policiesacrosscountries[1]andcollectcomparative wait-ingtimesfiguresforspecificprocedures,whichisthefocus ofthisstudy.2Theanalysisreliesonmeasuresofwaiting
timesfromlargeadministrativedatasetsforspecific surgi-calprocedures.
Existingevidenceoncomparativewaitingtimesisvery limited.SicilianiandHurst[2]providesimilardatafor2000. Thesearenowoutofdateandrefertoonlyoneofthethree measuresemployedin thisstudy (theinpatientwaiting timeofpatienttreated)foronepointintime.Ourstudy updatessuchdata,employsadditionalcommonmeasures (thewaitingtimeofpatientsonthelist,andthewaiting timefromreferraltotreatment),exploresthedistribution ofwaitingtimesandprovidestimetrendscoveringa 10-yearperiod.
Thereislimitedevidenceonwaitingtimesfromsurvey dataespeciallyfromCommonwealthcountries[4]. How-ever,theseareaggregatedforanyelectiveprocedureand basedonsmallsamples.Evidenceonwaitingtimes con-structedfromadministrativedataisbasedonlargesamples (oftenincludingthewholepopulationwhoreceived treat-ment),usesobjectivemeasuresofwaitingtimesandsuffer lessfromaggregationbias(sinceitfocusesonspecific pro-cedures).
Recent work by the Swedish Association of Local Authorities and Regions (SALAR) [5] compares Sweden withothercountries.Thesame datahavebeenusedby Viberg et al. in an international comparison of waiting timesinhealth care[6].Thelatterdescribeshow coun-triesmeasurewaitingtimesandassesseswhetherwaiting timescanbecomparedinternationally.Aninitialattempt tocomparewaitingtimesacrosscountriesisconductedfor hipreplacement,cataractsurgeryandelectivesurgeryin 2009.Theauthorssuggestthatitis“difficultand challeng-ingtomakemeaningfulcomparisonsofofficiallypublished waitingtimesinthe15countriesstudiesduetothemany methodologicaldifferencesinmeasuring...”.
Our study makesa first important stepin collecting comparablewaitingtimesdataacrossOECDcountries.Like Vibergetal.[6],weidentifiedthemostcommon defini-tionsofwaitingtimes.ThroughtheSecondOECDWaiting TimeProjectwecollectedcomparablewaiting timesfor ninesurgicalproceduresovera10-yearperiod(andupdate figuresreportedin[2]).Asaresultofoursuccessfulpilot, a selection of waiting timesvariables wereincluded in theOECDHealthDatabase(2013).Ourworkmakestwo contributionstocurrentknowledge.First,itcontributesto advancingthecomparabilityofwaitingtimesdataacross
2AsummaryoftheFirstOECDWaitingTimeProjectiscontainedin SicilianiandHurst[2],[3].
OECDcountries.Second,thedescribedtimetrendsgivean opportunitytodiscussmajorpolicyinitiativeswhich con-tributedtosignificantreductionsinwaitingtimes. 2. Materialandmethods
Themeasurementofwaitingtimesvariesacross coun-tries.Commonmeasuresfromadministrativedatasetsare the“inpatientwaitingtime”(fromspecialistadditiontothe listtotreatment)andthe“referral-to-treatmentwaiting time”(fromGP/familydoctorreferraltotreatment). Com-monfiguresincludethemeanwaitingtime, thewaiting timeat differentpercentiles ofthedistribution(e.g.the median,or90thpercentile),andthenumberofpatients waitingmorethanathreshold(e.g.sixmonths).
Waiting times are reported by procedure (e.g. hip andkneereplacement,cataractsurgery)orbyspeciality (e.g.ophthalmology,orthopaedics).Theyrefermainlyto twodistributions:(i)thedistributionofwaitingtimesof patientstreatedinagivenperiod(e.g.afinancialyear)and (ii)thedistributionofwaitingtimesofthepatientsonthe listatapointintime(acensusdate).
2.1. Methods
Thedatawere collectedaspartof theSecondOECD WaitingTimeProjectin2011–2012.Thedataquestionnaire wassent to OECD datacorrespondents based primarily in Ministries of Health and corresponding information centresandstatisticalinstitutes(Table1).Inmostcases the data are from patient-level hospital administrative databases.Insomeoccasionstheywerefirstreportedat hospitalorregionallevelandthenaggregatedtonational level.The definitionsemployed buildonthose reported by[2]undertheFirstOECDWaitingTimesproject(that collectedonlymeasure1belowforoneyearfollowingan expertgroupmeeting).Thedatacollectedunderthe Sec-ondOECDWaitingTimes projectwerepresented atthe OECDHealthDataCorrespondentsmeetingheldinParis inOctober2012.Asaresult,aselectionofwaitingtimes variables (measures 1 and 3 below) weresubsequently includedintheOECDHealthDataBase(2013)aspartof theregulardatacollection.Mostcountriesreportwaiting timesforthevastmajorityofpatients’populationandare thereforehighlyrepresentative.Mostdatacollectionsare availablefora numberofyears andusedforpolicyand monitoringpurposes.Theyaregenerallyconsidered reli-ableandcomparablewithineachcountry.Reliabilityhas improvedquicklywithtime(see[1]formoredetails). 2.2. Definitions
Waitingtimeswerecollectedforthefollowing com-mon elective (non-emergency) surgicalprocedures: hip replacement,kneereplacement,cataractsurgery,vaginal hysterectomy,prostatectomy, cholecystectomy, inguinal andfemoralhernia,percutaneoustransluminal coronary angioplasty(PTCA)andcoronarybypass.Toclassify surgi-calprocedures,weusedICD-9-CMcodesasareference(see onlineAppendix).Datawerecollectedfrom1999to2011.
294 L.Sicilianietal./HealthPolicy118(2014)292–303
Table1
Sourcesofdataanddatacoverage.
Country Institutionreporting data
Sourceofdata Datacoverage
Australia AustralianInstituteof
HealthandWelfare
(AIHW)
2012:AustralianHospitalStatistics2011–2012:elective
surgerywaitingtimes.HealthServicesSeriesn.46.cat.no.HSE
127.Canberra:AIHW(Table3.4p.18).2002–2011:Australian
InstituteofHealthandWelfare2012.AustralianHospital
Statistics2010–2011.HealthServicesseriesno.43.cat.no.HSE
117.Canberra:AIHW(Table10.21p.288).Referenceperiod:
1stJuly–30thJune.Publichospitalinformationsourcedfrom
theNationalElectiveSurgeryWaitingTimesDataCollection
(NESWTDC)andthelinkeddatasourcedfromNational
HospitalMorbidityDatabase(NHMD).
Includesall(publiclyand
privately-funded)patientsin
publichospitals.
Canada CanadianInstitutefor
HealthInformation
(CIHI)
Provincialwait-timeregistryrepresentativesfromeach
provincesubmitprovincialsummarylevelwaittimedataand
volumesofprocedurestoCIHIannually.Dataarefrom
provincialregistriesorchartaudits.Someprovincessuchas
PrinceEdwardIslandandNewfoundlandandLabradordonot
haveregistries.DataarepublishedinanannualCIHIwait
timesreport.Provincesbegansubmittingdataaccordingtoa
standarddefinitionin2008.
Referenceperiod:1stApril–30Septemberofeachyearor
nearestsixmonthproxy.
Includesmostprovincial
institutionsoroutpatient
clinicswhereproceduresare
performed.Waittimes
measuredfrom‘thebooking
dateofsurgerytodateof
procedure.’Thebookingdate
willbeafterassessedbya
specialistbutmayhaveatime
lapsebetweenthis
appointment(ordecisionto
treat)andthebookingdate.
Denmark MinistryofHealthand
NationalBoardof
Health
HospitalsreportdatatotheNationalPatientRegisterofthe
BoardofHealth.
Includesallpublicly-funded
patientsinpublichospitals,
privatehospitalsandclinics.
Finland NationalInstitutefor
HealthandWelfare
(THL)
CareRegister.From2005newlegislationstatesthemaximum
waitingtimesforhealthcareservices.Regions(central
hospitaldistricts)exceedingmaximumwaitingtimesare
monitoredbytheNationalSupervisoryAuthorityforWelfare
andHealth(VALVIRA).
Includesallpublicly-funded
patients.
Ireland NationalTreatment
PurchaseFund(NTPF)
PatientTreatmentRegister.Referenceyearismid-year(endof
June).
Publichospitalswithwaiting
lists.
Netherlands NationalHealth
Authority(NZa)
Hospitalsarerequiredtoreportdataonwaitingtimesontheir
websiteseachmonth(self-reportedprospectivewaitingtimes,
i.e.howlongapatientcanexpecttowait).Mediquestgathers
alldatafromthewebsitesofindividualhospitals.
Allhospitalsandprivateclinics
performingcarethatiscovered
bybasichealthinsurance
(publiclyfundedpatients).
NewZealand NationalHealthBoard,
MinistryofHealth
PublichospitalsarerequiredtoprovidedatatotheNational
BookingReportingSystem(NBRS),whichisusedbyDistrict
HealthBoardsandtheMinistryofHealthtomonitorwaiting
timeforelectiveservices.Dataforwaitingtimesofpatientson
thelistisasatDecemberineachgivenyear.
Publichospitals.
Portugal SIGLIC:thesupporting
informationsystemfor
SIGIC
IntegratedManagementSystemoftheWaitingListforSurgery
(SIGIC).Dataarefromthehospitaloperationalsystems
integratedinthecentraldatabaseofSIGLIC.TheSIGLICcollects
informationfromdifferentsourcesincludinghospitals,
regionalhealthadministrations,patientsandACSS
(AdministrativeCentralAgencyofPortugal’sNationalHealth
Service).
Allrelevantproviders–public
andprivate–inthefivehealth
regionsofcontinentalPortugal.
Spain MinistryofHealth,
SocialServicesand
Equity
NationalHealthSystemInformationSystemonWaitingLists. NationalHealthSystem
networkofhospitals(publicly
fundedpatients).
Sweden SwedishAssociationof
LocalAuthoritiesand
Regions(SALAR)
Nationalwaitingtimedatabase. Theexactwaitingtimesforany
patientisnotknown,hence
onlyanestimatednumberfor
themedianisprovided.
UK–England TheHealthandCare
InformationCentre
HospitalEpisodesStatistics(HES).NHSproviderssubmitdata
totheSecondaryUsesService(SUS)datawarehouse.HES
extractsaretakenfromSUSonamonthlybasis.HESincludes
alladmissionstoNHShospitals,allNHSoutpatient
appointmentsandA&Eattendances.
IncludesNHS-fundedpatients
treatedinNHStrustsand
independentproviders.
UK–Scotland NHSNationalServices
Scotland
InformationServicesDivision.General/Acute.
InpatientandDayCase—SMR01data.SMR01isan
episode-basedpatientrecordrelatingtoallinpatientsandday
casesdischargedfromnon-obstetricandnon-psychiatric
specialties.
Forasubsetofmeasuresdataareavailablealsofor2012 (aspartoftheOECDHealthDatacollection,2013).
Ourquestionnaireaskedcountriestoprovidewaiting timesaccordingtofourdifferentdefinitions:
1.Inpatientwaitingtimes(fromspecialistadditionto thelist)ofpatientstreatedinagivenyear(publiclyfunded patients).
Thisdefinitiondoesnotinclude‘thetimeelapsedfrom thedateofreferralofthegeneralpractitionertothedate ofspecialistassessment’(insomecountriesreferredtoas ‘outpatient waitingtime’).Inpatient waiting timeswere collectedfor all ‘publicly-fundedpatients’ that received treatmenteitherbypubliclyorprivately(non-profitand for-profit)ownedproviders.Wedonotfocuson privately-fundedpatientssincewaitingtimedataforthesepatients aregenerallynotcollectedonaroutinebasis.
2.Referral-to-treatmentwaitingtimes(fromfamily doc-torreferral) of patientstreated ina given year(publicly fundedpatients).
Referral-to-treatmentwaitingtimesreferto“thetime elapsedfromthefamilydoctor(Generalpractitioner) refer-ral to the date patients added to the non-emergency (elective)surgerywaitinglistwereadmittedtoaninpatient orday-casesurgicalunitfortheprocedure”.Therefore,it includesalsothetimeelapsedfromthefamilydoctor refer-raltothespecialistvisit.
3.Inpatientwaitingtimes(fromspecialistadditionto thelist)of patientsonthelist atacensusdate(publicly fundedpatients).
ThismeasureisanalogoustoMeasure1butrefersto thepatientsonthelistatagivencensusdate(asopposedto patientstreatedinagivenyear).Inpatientwaitingtimeson thelistincludes“thetimeelapsedforapatientonthe non-emergency (elective)surgery waiting listfrom thedate theywereaddedtothewaitinglistfortheprocedure (fol-lowingspecialistassessment)toadesignatedcensusdate”. 4.Referral-to-treatmentwaitingtime(fromfamily doc-torreferraltotreatment)ofpatientsonthelistatacensus date(publiclyfundedpatients).
ThismeasureisanalogoustoMeasure3butreferstothe totalwaitingtimeofpatients(startingfromGP/family doc-torreferral)onthelistatagivencensusdate(asopposed tothepatientstreatedinagivenyear).
The distribution of waiting time of patients treated measuresthefulldurationof thepatient’s waiting time experience(fromenteringtoexitingthelist).The distri-butionofthewaitingtimesofpatientsonthelistisinstead “incomplete”,sincethepatient’swaithasyettocometo anend.Thewaitingtimeofpatientstreatedhasthe advan-tageofcapturingthefulldurationofapatient’sjourney, butisretrospectiveinnature.Themainadvantageofthe waitingtimeofpatientsonthelististhatitcapturesthe experienceofthepatientswhoarestillwaitingatapointin time[7].
For each measure, we collected mean and median waitingtime,andtheproportionofpatientswaiting0–3 months,4–6months,7–9months,10–12monthsandover 12months.Thelatterfocusonpatientswhoaremost dis-advantaged,i.e.thosewiththelongestwait(althoughif prioritisation workswell,thesearelikely tobepatients withlowestseverity).
Eightcountriesprovidedinpatientwaitingtimesdata forpatientstreated;sixforinpatientonthelist.One coun-try(Denmark)provideddataonreferraltotreatmentfor patientstreated (measure2).No countrycould provide measure4.Notethatreferral-to-treatmentwaitingtimes arecollectedinEnglandbutnotbysurgicalprocedure(only byspecialityorforallspecialities;see[1],chapter2). 3. Results
3.1. Themeanwaitingtimecanbesubstantiallyhigher thanthemedian
Table2providesmeanand medianwaitingtimes,in days, in 2011 and 2012 according to our three defini-tions.Theresultsdescribedreferto2011(unlessexplicitly stated).
Themeanwaiting timeis systematicallyhigherthan themedianconfirmingtheskeweddistributionofwaiting times.Thedifferencecanbequantitativelylarge.InEngland andScotland,themeanwas8–34%higher.Among coun-triesthatreportbothmeanandmedianwaitingtimefor patientstreatedin2011(Finland,NewZealand,Portugal, EnglandandScotland)thecorrelationforagivenprocedure isveryhigh(above0.9forsevenoutofnineprocedures). 3.2. WaitingtimesarelowintheNetherlandsand Denmark
Amongcountriesreportinginpatientwaitingtimesof patientstreated(upperpartofTable2),theNetherlands exhibitsthelowest:meanwaiting timesare belowone month and a half. Denmarkalso exhibitsshort waiting times,despitetheirmeasureincludingtheadditionalwait fromGPreferraltospecialistappointment.
3.3. Waitingtimesofpatientstreateddiffer systematicallyfromthoseofpatientsonthelist
Three countries (New Zealand, Portugal and Spain) reportinpatient waiting timesboth forpatientstreated andonthelist.Thetwomeasuresgenerallyprovide dif-ferentresultsandarethereforenotcomparable.ForNew Zealand,themean/medianwaitingtimeofpatientstreated isgenerallyhigherthanforthoseonthelist(exceptfor coronarybypassin2011and2012andPTCAin2012).This isalsothecaseforSpain.ForPortugalthisholdsonlyfor oneprocedurein2011and2012:kneereplacement.The oppositeholdsforsevenproceduresin2011andfive pro-ceduresin2012withmeanandmedianwaitingtimebeing lowerforpatientstreatedthanonthelist.Thedistribution ofpatientsonthelistover-sampleslong-waitingpatients. SincePortugalhasalongertailofpatientswithlong wait-ingtimes,thismayexplain thedifferentresultsforthis country.
In Sweden waiting timesare provided for only four procedures.Theyappeargenerallylowcomparedtoother countries.Slovenia reports relativelylongwaiting times comparedtoanyothercountry,inparticularforhipand kneereplacement,andPTCA.
296 L. Siciliani et al. / Health Policy 118 (2014) 292–303 Table2
Median(mean)waitingtimesindaysforcommonsurgicalprocedures.
Hip replacement
Knee replacement
Cataract Hysterectomy Prostatectomy Cholecystectomy Hernia CABG PTCA Patientstreated–Inpatient(timefromspecialistadditiontolisttotreatment)
Australia 2011 108 173 90 49 47 54 57 17 2012 116 184 91 53 42 16 Canada 2011 89 107 49 7 2012 87 106 46 8 Finland 2011 113 (127) 136 (149) 111 (114) 81 (94) 49 (68) 69 (90) 76 (96) 43 (58) 23 (34) Netherlands 2011 (46) (44) (33) (35) (32) (35) (36) (27) (16) 2012 (42) (42) (35) (34) (31) (29) (16) NewZealand 2011 90 (104) 96 (112) 84 (94) 98 (109) 63 (86) 62 (86) 57 (82) 28 (37) 51 (66) 2012 99 (104) 111 (114) 88 (94) 90 (96) 66 (81) 27 (44) 38 (49) Portugal 2011 87 (128) 195 (206) 49 (66) 57 (86) 62 (101) 80 (134) 82 (120) 2 (24) 2012 105 (140) 210 (211) 59 (83) 57 (85) 63 (106) 2 (34) Spain 2011 (127) (89) (91) (89) (87) 2012 (161) (108) (97) UK-England 2011 82 (90) 87 (97) 59 (66) 62 (70) 31 (41) 70 (81) 60 (71) 53 (63) 35 (40) UK-Scotland 2011 75 (90) 80 (94) 62 (70) 48 (53) 51 (55) 61 (77) 63 (82) 35 (47) 29 (33) Patientstreated–Referraltotreatment(timefromfamilydoctorreferraltotreatment)
Denmark 2011 39 (51) 46 (59) 70 (99) 35 (49) 36 (56) 38 (46) 45 (56) 13 (19) Patientsonthelist–Inpatient
Ireland 2011 103 (130) 119 (153) 118 (144) 96 (131) 81 (127) 93 (132) 98 (128) 77 (102) 54 (78) 2012 83 (100) 100 (113) 133 (146) 118 (126) 90 (118) 107 (133) 64 (97) NewZealand 2011 60 (78) 65 (84) 51 (63) 65 (73) 51 (66) 58 (75) 54 (69) 46 (60) 38 (51) 2012 63 (72) 68 (74) 53 (62) 55 (69) 49 (63) 35 (45) 39 (46) Portugal 2011 137 (191) 164 (201) 67 (100) 67 (98) 110 (189) 117 (178) 95 (147) 88 (114) 2012 124 (178) 146 (192) 77 (108) 67 (101) 97 (192) 75 (145) Spain 2011 (93) (71) (74) (74) (71) 2012 112 (86) (85) Sweden 2011 43 45 40 25 Slovenia 2011 340 (354) 495 (512) 58 (63) 90 (122) 90 (132) 240 (275) 2012 341 (345) 380 (504) 92 (108) 64 (81)
3.4. Thereisevidenceofprioritizationacrosstreatments Thereisaclearevidenceofprioritizationacross differ-entprocedures.Waitingtimesformoreurgentprocedures, suchascoronarybypassandPTCA,aregenerallylowest. They are higherfor less urgentprocedures such aship replacement.Thisisunsurprising;doctorsaretrainedto prioritizepatientsonthewaitinglist.Thereisanincreasing policyfocusondevelopingguidelinestoimprove prioriti-zationofpatientsonthelistacrosstheOECDcountries, butinparticularNewZealand,Canada,Norwayandother Nordiccountries([1],chapter3).
3.5. Waitingtimesarenotalwayshighlycorrelated acrossprocedures
Wemaypondertheextenttowhichacountrywillhave longwaitingtimesformorethanoneparticularprocedure, as a resultfor example, ofa tighter capacity constraint acrossthewholesystem.
Insomeinstancessuchcorrelationsarehighbut sensi-tivetothemeasureandsampleofcountriesconsidered. We computed the correlation across eight procedures (excludingPTCA)forsixcountriesthatreportedmean wait-ing time for patientstreated (Finland, the Netherlands, New Zealand,Portugal, Scotland and England) in 2011. Excludingcoronarybypassandcataractsurgery,the corre-lationsamongtheremainingsixprocedureswererelatively high—above0.65.Cataractsurgeryhadacorrelationthat ranged between 0.44 (with cholecystectomy) and 0.82 (withhysterectomy).Coronarybypassgenerallyexhibits low correlation with the other procedures and a wide rangebetween0.36(withprostatectomy)and0.50(with cataractsurgery).ThisisduetoEnglandandScotland hav-ing relatively longer waiting times for coronary bypass comparedtotheothercountries,whileperformingwellon theotherprocedures.TheresultsweresimilarwhenSpain wasincludedin thesample(withonlyfiveprocedures). Whenusingthemedianwaitingtime ofpatientstreated correlationsweregenerallylower.Whenconsideringthe patientsonthelist,asimilarpicturegenerallyemerged. 3.6. Distributionofwaitingtimes
Wecangainsomeinsightsbylookingatthedistribution ofwaitingtimes,whichalsoallowsafocusonlong wait-ers.Weprovidehistogramsfortheproportionofpatients waiting3monthsorless,between4and6months,between 7and9months,between10and12months,andover12 months.Wefocusonhipreplacementandcataractsurgery. Fig. 1a shows the distribution of waiting times of patientstreatedfor hipreplacement.Thedistributionis skewed; most patients receive treatment quickly with morethan50%beingtreatedwithin3monthsintheUK, PortugalandNewZealand(butnotinFinland).Manyof theremainingpatientsaretreatedwithin6months(except forPortugal).Thereisatailofpatientswaitingmorethan 6months:around6–7%intheUK,15–18%inNewZealand andFinlandand28%inPortugal.
Thedistributioncandiffersignificantly.For example, PortugalandNewZealandbothhaveamedianwaitingtime
forhipreplacementofabout3months.However,the pro-portionwaitingover6monthsis15%inNewZealandand 28%inPortugalleadingtoalargermeanwaitingtimein Portugal(128days)thaninNewZealand(104days).This showshowsyntheticmeasurescanhidesignificant varia-tionsinthedistribution.
Wecanalsocomparethedistributionofpatientstreated (Fig. 1a) versus the distribution of patients on the list (Fig.1b).The comparisonofFig.1awithFig.1bfor hip replacementshowshowthesedistributionsdiffer.InNew Zealand,theproportionofpatientstreatedwaitingmore than6monthsisabout15%buttheproportionofpatients onthelist waiting morethan 6monthsisonly 6%.This isunsurprisingasthedistributionofpatientsonthelist suffers from ‘interruption’ bias (it measures an incom-pletewait), which biases themeasure downwards,and reflects‘oversampling’oflong-waitpatients,whichbiases themeasureupwards.Althoughthesebiasesgoin oppo-site directions, there isno reasonwhy theseshould be thesame.Insomecasesthefiguresbetweenthetwo dis-tributions may not be too dissimilar. For example, for Portugaltheproportionofpatientswaiting morethan6 (12)monthsisintherange27–28%(11–12%)underboth distributions.
Asanadditionalexample,considercataractsurgeryin Fig.2aandb.Theproportionofpatientstreatedwaiting morethan6monthsis8%inNewZealandanditishigher thantheproportionofpatientsonthelist,whichisaround 3%.InPortugaltheoppositeholds.
Such distributions showdifferent degrees of disper-sionsinwaitingtimesacrosscountries.Thesecanbethe resultofarangeoffactorsincludingprioritisationpolicies (whichreducewaitingtimesforhigh-severitypatientsand increasethemforlow-severitypatients)butalsovariations indemand(agecompositionswithinoracrosscountries) andinsupplywithinacountry(differencesacross hospi-tals).
3.7. Timetrends
TimetrendsinFig.3showthatwaitingtimeshavebeen relativelystableinmostcountriesandacrossprocedures. Thereare,however,severalcaseswherewaitingtimeshave reduced. In particular,theUnitedKingdom and Finland haveexperiencedlargereductionsinwaitingtimesfroma relativelyhighlevelinearly2000s.Therearealsodeclining trendsfortheNetherlands,DenmarkandPortugalalthough thistrendhasreversedinrecentyearsinPortugal.
In Finland waiting times are generally stable or increasing up to 2002 or 2003 and then character-izedbyasharpsubstantialreduction:about43–48%for hip and knee replacement, 30–51% for prostatectomy, hysterectomy, cholecystectomy and hernia, 55% for cataract and 24% for bypass. In the United Kingdom waiting timeshave been graduallyfalling starting from 2001/2002.In England waiting times morethan halved forseveralprocedures.InScotlandreductionsinwaiting timeswereof theorder25–40%.In 1999waiting times weregenerallylongerinEnglandthaninScotland.By2011 theywerecomparable.Waitingtimeshavethereforefallen morerapidlyinEnglandthaninScotland.TheUKhasalso
298 L.Sicilianietal./HealthPolicy118(2014)292–303 65 57 55 51 40 29 37 18 33 42 5 5 11 14 13 1 1 5 1 3 1 0 12 0 2 8 0 10 20 30 40 50 60 70 UK -Scotland UK -England Portugal New Zealand
Finland Australia
% % waiting 0-3 months % of patients waiting 4-6 months % of patients waiting 7-9 months % of patients waiting 10-12 months % of patients waiting over 12 months 84 65 62 47 47 14 28 26 26 28 6 13 17 1 3 6 2 0 10 0 2 11 3 0 10 20 30 40 50 60 70 80 90
Sweden New Zealand Spain Portugal Ireland
% % waiting 0-3 months % of patients waiting 4 -6 months % of patients waiting 7 -9 months % of patients waiting 10-12 months % of patients waiting 7 -12 months % of patients waiting over 12 months
(a)
(b)
Fig.1. (a)Hipreplacement;patientstreated(2011).(b)Hipreplacement;patientsonthelist(2011).
experiencedmoderateincreasesinrecentyearsexceptfor hysterectomy.
In New Zealand waiting times of patients treated havebeenfairlystableovertheperiod2003–2011. Hys-terectomy,cholecystectomyandherniaexperiencedsome increases,andcoronarybypasssomereductionsinrecent years.Thedynamicsofwaitingtimesforpatientsonthe listlooksratherdifferent.Overthesameperiod,the wait-ingtimeofthepatientsonthelisthasmorethanhalvedfor mostprocedures.Oneexplanationfordifferenttrendsis thatthelatteralsoincludespatientswhoultimatelydonot receivetreatment.Astimepasses,providersmaybecome moreactiveat‘validating’thewaitinglistand/orregularly checkingthatpatientsontheliststillrequiretreatment, i.e. quickly removing them when it becomes apparent thattreatmentisnolongernecessary(see[12]formore details).
IntheNetherlands,waitingtimeshavereducedover the period 2006–2011 for hip and knee replacement, cataractandtoalessextentforcoronarybypasswhilethey
werestablefortheremainingprocedures,andincreased slightlyforcholecystectomyandhernia.Waitingtimesare lowcompared toothercountriesandhavebeenlowfor atleastfiveyears.Comparedtofiguresfor2000provided by[3],waitingtimeshavesignificantlyreducedandmore thanhalvedforseveralprocedures.
InDenmark,weobservereductionsforhipandknee replacement(bymorethan30%),prostatectomy(20%)and modest reductionsfor cholecystectomy over the period 2005–2011,increasedforcataract(morethan50%),while waiting times arerelatively constant for theother pro-cedures. We observereductionsinwaiting timesacross mostprocedures forPortugalalthough thesestartedto reversein2011withtheexceptionofhysterectomy.The recentincreasesinwaitingtimesaremostpronouncedfor patientstreated.
Ireland has witnessed considerable reductions in waiting times of patients on the list–particularly over 2007–2008—forhipandkneereplacement,prostatectomy andcholecystectomy.SimilartoPortugalandNewZealand,
86 75 76 55 35 11 22 23 38 44 2 2 1 7 16 01 0 0 00 0 0 4 1 4 0 10 20 30 40 50 60 70 80 90 Portugal UK -Scotland UK -England New Zealand
Finland Australia
% % waiting 0-3 months % of patients waiting 4-6 months % of patients waiting 7-9 months % of patients waiting 10-12 months % of patients waiting over 12 months 88 78 72 71 41 10 19 21 18 26 3 14 19 0 4 10 2 0 0 6 1 2 3 0 10 20 30 40 50 60 70 80 90 Sweden New Zealand
Spain Portugal Ireland
%
% waiting 0-3 months
% of patients waiting 4-6 months %of patients waiting 7-9 months number of patients waiting 10-12 months % of patients waiting 7-12 months
(a)
(b)
Fig.2. (a)Cataractsurgery;patientstreated(2011).(b)Cataractsurgery;patientsonthelist(2011).
thesesharpdecreasescanin partbeattributedtosome validationofthewaitinglist[17].In contrast,therewas anincrease inwaiting timesforcataractsurgeryduring 2010–2012 and hysterectomyduring 2010–2011.There was a particularly sharp increase for coronary bypass surgeryfrom2009to2010butthissubsequentlydecreased in2011androseagainin2012.
Waiting times in Spain have been either stable or reducedtosomeextentinrecentyears(2003–2011)but have increased in 2012for cataract,prostatectomy and hipreplacement.InAustralia,medianwaiting timesfor patientstreatedhavegenerallygraduallyincreasedduring 2002–2012, sometimes significantly (knee replacement, hysterectomy,cholecystectomyby32–47%,prostatectomy andherniaby41–58%)buthavebeenstableforcataract and coronarybypass.InCanada,dataareavailableonly for 2008–2011for selected procedures. Medianwaiting timesforhipandkneereplacementhavebeenmoderately
increasing(bylessthan10%overfiveyears),andrelatively stableforcataract.InSweden,dataareavailableonlyfor 2010and2011.Thesesuggestreductionsinmedianwaiting timeofpatientsonthelistforhipandkneereplacement, andcataractsurgeryby11–14%.
4. Discussion
4.1. Reasonsforthereductioninwaitingtimes
OECDcountriespursuedarangeofpoliciesinorderto achieve reductionsin waitingtimes. Finlandintroduced a NationalHealth CareGuarantee into lawin 2005[8]. For elective treatmenttheguarantee wasthree months (withfewexceptions).Hospitalsthatfailedtocomplywere scrutinizedbytheSupervisoryAgency(Valvira)andwere subjecttoathreatoffines.Thereductionsinwaitingtimes
300 L.Sicilianietal./HealthPolicy118(2014)292–303 0 50 100 150 200 250 300 199 9 200 0 200 1 200 2 200 3 200 4 200 5 200 6 200 7 200 8 200 9 201 0 201 1 201 2 M ean wa it ing ti m e , d ay s Australia (median)
Canada (median)
Denmark (inpatient and outpatient)
Finland
Ireland (on the list)
Netherlands
New Zealand
Portugal
Spain
Sweden (median, on the
list) UK-England UK-Scotland 0 50 100 150 200 250 300 199 9 200 0 200 1 200 2 200 3 200 4 200 5 200 6 200 7 200 8 200 9 201 0 201 1 201 2 M ea n w a it ing ti m e , d a y s
Australia (median)
Canada (median)
Denmark (inpatient and outpatient)
Finland
Ireland (on the list)
Netherlands
New Zealand
Portugal
Spain
Sweden (median, on the list)
UK-England
UK-Scotland
(a) Hip replacement
(b) Cataract
Fig.3.(a)Hipreplacement;(b)cataract;(c)hysterectomy;(d)hernia;and(e)coronarybypass
wereassociatedwithanincreaseinhealthexpenditurefor municipalitiesinthefirstyearsoftheguarantee[8].
The considerable reduction in waiting times in the UnitedKingdomcanbeexplainedby(1)asustainedgrowth inhealthexpenditureinthelastdecade,and(2)theuseof waiting-timetargets.InEngland,heavysanctionsfor hospi-talsnotrespectingthetargetswereintroducedfrom2000, apolicyknownas“targetsandterror”[9,10]:seniorhealth administratorswereatriskoflosingtheirjobsiftargets werenotmet.Thismayexplainwhyreductionsinwaiting timesinEnglandwerelargerthanforScotland.Althoughin Scotlandhospitalswerenotsubjecttoeconomicpenalties, regionalhealthboardsfrom2003to2004weremonitored monthlyontheachievementofwaitingtimetargets. Indi-vidualbreacheshadtobereportedtotheScottishExecutive andwereinvestigated[11].
In the Netherlands, the reductions in waiting times between2000and2006wereachievedfollowingaradical changeinthehospitalfinancingsystemwhichswitched from fixed budgets to activity-based funding [13,14]. Additionalreductions in recent years can be attributed
to a reform of specialist payments leading toa change fromlump-sumpaymentstoactivity-basedpaymentsin 2008,andanexpansionofpricecompetition(aspartofa broadermanagedcompetitionreform)since2005[13].As aresultofthesereforms,waitingtimesarenota signifi-canthealthpolicyissueastheywereinthe1990s.Concerns havehowever,beenraisedabouttherapidgrowthinhealth expenditurethatactivity-basedfinancinghaspromoted.
AkeypolicyinDenmarkhasbeen“freechoice”of hos-pitalproviderforpatients.Theschemeimpliesthatifthe hospitalcanforeseethatthemaximumtimecannotbe ful-filled,thenthepatientcanchooseanotherpublicorprivate hospital,eitherwithinoroutsideDenmark[15].In2002 themaximum waiting time guaranteewastwo months (andreplaceda formerguaranteeofthree months).The guaranteewasfurtherreducedtofourweeksin2007 (inde-pendentofdiseasetypeandseverity).“Freechoice”was suspendedin2008–2009duetoahospitalpersonnelstrike [15].
InPortugal,reductionsinwaitingtimeswereobtained throughaseriesofpolicyinitiatives,whichincludedanew
0 50 100 150 200 250 199 9 200 0 200 1 200 2 200 3 200 4 200 5 200 6 200 7 200 8 200 9 201 0 201 1 201 2 M ea n w a it ing ti me, da y s
Australia (median)
Canada (median)
Denmark (inpatient and outpatient)
Finland
Ireland (on the list)
Netherlands
New Zealand
Portugal
Sweden (median, on the list) UK-England UK-Scotland 0 50 100 150 200 250 199 9 200 0 200 1 200 2 200 3 200 4 200 5 200 6 200 7 200 8 200 9 201 0 201 1 Me a n w a it ing ti me, da y s
Australia (median)
Denmark (inpatient and outpatient)
Finland
Ireland (on the list)
Netherlands
New Zealand
Portugal
Spain
UK-England
UK-Scotland
(d) Hernia
(e) Coronary bypass
0 20 40 60 80 100 120 140 160 180 199 9 200 0 200 1 200 2 200 3 200 4 200 5 200 6 200 7 200 8 200 9 201 0 201 1 201 2 M ea n w a it ing ti me, da y s
Australia (median)
Denmark (inpatient and outpatient)
Finland
Ireland (on the list)
Netherlands
New Zealand
Portugal
UK-England
UK-Scotland
(c) Hysterectomy
302 L.Sicilianietal./HealthPolicy118(2014)292–303 integratedinformationsystemcombinedwithavoucher
systemforpatientsreaching75%ofmaxwaitingtime guar-antee[16].Wealsonotedsharpreductionsforthepatients onthelistbetween2006and2007which,similartoNew Zealand,werepossiblyobtainedbymoreaccurate valida-tionofthelist(alsoexperiencedinEnglandinthe1980s, [2]).
AnumberofinitiativeshavebeenintroducedinSpain, mainly targeting the supply side, including extending workinghoursforhealthpersonnel,additionalresources andnewambulatorysurgerycentres[18].
4.2. Possiblesourcesoferrors
Likeanyinternationaldatacollectionusing administra-tivedata,theremaybesourcesoferrors.Wedefinewaiting times at surgical procedure level using ICD-9-CM. The approachisanalogoustootherinternationaldata collec-tionsmeasuringtotalinpatientsurgicalprocedures(OECD HealthStatistics).Althoughsomecountriesusealternative methods(suchasICD-10)theseareunlikelytocreate seri-ousbiases.Wedidnotattempttocollectdataatspeciality level(ophthalmology,orthopaedics,etc)sincedefinitions ofspecialitiesmaydiffersignificantly.
Forinpatientwaitingtimes,(small)differencescanarise withinandacrosscountriesregardingwhenthepatientis addedtothelistfollowingspecialistassessment(e.g.there maybeadelaybetweendecisiontotreatandformallybeing addedtothelist).Thisisnotthecaseforthetimethewait ends,whichismoreunambiguouslydefined.
Manycountrieshaveamixofbothpublicandprivate providers.Public hospitalstendtotreat publicly-funded patientsandtoaminorextentprivatepatients(ifdual prac-ticeis allowed).Privateprovidersdifferintheextentto whichtheytreatpublicly-fundedpatients.Ourfocusison publicly-fundedpatientsandthiscouldbeaccommodated inmostcountries.
Whendataarereportedathospital/regionallevel,care hastobeexertedwhen aggregating waiting times (e.g. weightingbyappropriatevolumes).
5. Conclusion
5.1. Waitingtimes:whatshouldpolicymakersmeasure? Policymakershaveattheirdisposalarangeofmeasures tocollectwaitingtimes.Weemphasizesystematic differ-encesbetweenthedistributionofwaitingtimesofpatients treatedversusthedistributionofpatientsonthelist.For example,themeanwaitingtimeofpatientsonthelistis generallyhigherthanofpatientstreatedalthough exam-plesoftheoppositeexist(andsimilarlyforothermeasures). Thesedifferencesnaturallyraisethequestionofwhat policymakers should measure and under what circum-stances. For regulatory and monitoring purposes, the waitingtimeofpatientsonthelistprovidesamore ‘up-to-date’figureofproviders’efforttokeepwaitingtimes withinstatedtargetsandispreferred(theothermeasure reflectinginsteadpastefforts).
Intermsofreportingtoprospectivepatients(aspart of patient’s choicepolicies) and thegeneralpublic, the
waitingtimeforpatientstreatedispreferredaspatients areinterestedinthefullexpecteddurationofthewait(the othermeasuresuffersfrominterruptionbias).Since exist-ingmeasuresarefromadministrativedata,thesamedata sourcescanbeemployedtogeneratebothdistributionsat lowadditionalcosts.
In terms of statistics employed, for regulatory pur-posesboththemedianandtheproportionoflong-waiting patientsshouldberecorded.Thelatterensuresthatno sig-nificantportionofpatientshaveunreasonablewaits.The medianismorerepresentativeandatthesametimereveals whetheralowproportionoflongwaitersisobtainedby let-tingpatientswithmiddleorhighseverity(whowaitless) waitforarelativelylongertime.Forpublicreporting,the proportion oflongwaitersandthemeanis moreeasily understoodbypatientsandthegeneralpublic.
Theanalysissuggeststhatmostcountriesmeasurethe ‘inpatient’ wait withfewcountriesmoving towardsthe waitfromGPreferraltotreatment.Intheshortrun, coun-triescanfocusoninpatientwaitingtimes,whichcapture thebulkofthewait.Measuringthereferral-to-treatment waitingtimesraisestechnicalissues.Forexample,when thepatientstartswaiting,followingaGPvisit,she(norher GP)maynotknowwhethershewillbeadmittedonlyfor aspecialistvisitorforaninpatienttreatment(following aspecialistvisit).Therefore,thewaitingtimeofpatients onthelistmayincludepatientsbelongingtobothgroups, whilethewaitofthepatientstreatedcanbedisaggregated in twogroups(asinEngland).Inthelongrun,itseems desirabletocapturethefullpatient’sjourney;short inpa-tientwaitingtimescouldbeobtainedatthecostoflong waitsforaspecialistvisit.
Intermsofinternationalreporting,theinpatient wait-ingtimeofpatientstreatedseemsthemostviableoption in thecurrent state ofaffairs. It is the mostcommonly availableandcapturesmostofpatient’swaitexperience. In thefuture, othercountriesmaybecomeinterestedin reportingwaiting times.Ultimately,waitingtimes mea-surethedifferencebetweentwoeventsandarecompatible withcurrentDRG-typeadministrativedatabases.Giventhe currenteconomicclimate,ageingpopulationand techno-logicalprogress,demandforhealthcaremayincreaseata fasterratethansupply,evenincountrieshistorically char-acterizedbylowwaitingtimes.
5.2. Successfulpoliciestoreducewaitingtimes
The analysis providesnew comparative evidenceon waiting times. Waiting times appear to be low in the NetherlandsandDenmark.TheUnitedKingdom,Finland and theNetherlands havewitnessedlargereductionsin waitingtimesinthelastdecade.
Acommonpolicyistheintroductionofmaximum wait-ingtimeguarantees,wherepatientsshouldnotwaitmore thanapre-determinedtime.Suchguaranteesare increas-inglylinkedtocleareconomicincentives andcombined withincreasedresources.However,economic incentives can differ significantly across countriesalong with the implementationofsuchguarantees.
One option is to usemaximum waiting-times guar-antees astargets(asin England andFinland). Providers
not respecting the targets were penalised with sanc-tions(eitherfinanciallyornon-financially).Combinedwith additional resources(necessarytoincreasesupply),this approachhasprovensuccessful.
A second possibility is to combine maximum wait-ingtimeswithpatients’ choiceand competitionpolicies (Denmark,theNetherlandsandPortugal).Patients wait-ingabovethetargetareentitledtotreatmentbyanother publicorprivateprovider.Theoriginatingprovidermaybe financiallyresponsibleforsomeexpensesincurred.These policiesalsoareaccompaniedwithadditionalresources, andhavebeensuccessfulinreducingwaitingtimes.
Akeyinsightisthatsupplypoliciesonlyareunlikelyto besuccessfulinreducingwaitingtimes.However,theycan workifdemandiskeptundercontrol.Thelattercan implic-itlybeobtainedwiththeintroductionofmaximumwaiting time guarantees.Thesewillensurethatthehigher sup-plyisnotoffsetbyequivalentincreasesindemandleaving waitingtimesunchanged.
TheDutchexperiencehowever,highlightsthat success-fulpoliciestoreducewaitingtimescanbeassociatedwith significantcosts.Healthexpenditurecanincreasesharply andpolicymakersneedtotradeoffthebenefitsfromlower waitingtimesandhigherpatients’carewithitscosts.
Wemaywonderwhattriggeredcountriestointroduce successfulpolicies.ForFinlandandtheUnitedKingdom, theanswerprobablyliesin theverylongwaiting times experienced in thelate 1990s (morethan double those in otherEuropeancountries). Healthexpenditureinthe UKhadhistoricallybeenbelowEuropeanaverage.Waiting times have now converged to the average. The imple-mentationoftargetsinvolvesatop-downapproach.Other countries(e.g.Denmark)mayprefera more consensual approach. Policies basedonpatients’ choiceappear less controversialandmaybepreferred.
The negative trend in waiting times seems to have haltedandevenreversedinrecentyears,mostlikelydue to the economic recession. These increases are evident forPortugalin2011and2012whiletheUKhas experi-encedsomeincreasesalbeittoalesserextent.Therewere alsoincreasesinSpainandFinland.Governmentsmaybe unabletoincreasesupplyinthenearfuture(ornotasmuch asinearly2000).
It is worth considering whether recent increases in waiting times were inevitable. With limited resources, enforcementofmaximumwaitingtimeguaranteesis dif-ficult. Without additionalresources, providerscan keep waiting timesdownonlybycontrollingdemandor fur-therincreasingproductivity.Bothstrategiesarecostlyfor providers. Although governments can ask providers to workmoreefficiently,thismaybecounter-productiveand comeatthecostoflowerquality,staffdissatisfactionand lowmorale.Settingrealisticmaximumwaitingtimes com-patiblewithavailablebudgetswillbecritical.
Withlimitedresources,policymakersmayneedtoshift focus fromreduced waiting times toimproved prioriti-zation,ensuringpatientswithhigherseverityaretreated morequickly,andlongwaitsareconcentratedamongthose whocanaffordthehealthcostsofwaiting.Countrieslike CanadaandNewZealandhaveexperimentedwith formal-izedprioritizationtools(basedonseverityscoringsystems)
although these are generally available only for specific treatments, and canbe expensiveto develop. Although doctors already prioritize patients, the development of guidelineswhichencourageprioritizationmaybe benefi-cial.
AppendixA. Supplementarydata
Supplementarydataassociatedwiththisarticlecanbe found,intheonlineversion,athttp://dx.doi.org/10.1016/ j.healthpol.2014.08.011.
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