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Findings

Accessibility is fundamental to the quality of health care. In Canada, waiting time has been identified as a key measure of access and the major barrier among those who experienced difficulties obtaining care.^1,2 In 2005, approximately 20% of Canadians reported adverse effects as a result of waiting for health care, including worry and stress and pain.²

Recently, numerous initiatives across Canada have endeavored to reduce waiting time for specialized health services,¹,^3-5 particularly for non-emergency procedures in five priority areas identified in the 2004 Health Accord.⁶ While waiting times for surgery and other procedures can be a significant barrier to care, they represent only one of the waiting periods experienced across the continuum of care.⁷ Interest is now shifting “upstream” toward waits that occur earlier in the delivery of health care, including waiting for specialist consultations, which can account for a significant component of overall waiting time. For example, in 2005, among Canadians who had had a joint replacement, waits for an initial orthopedic specialist consultation made up nearly 30% of total waiting time.⁵

Despite growing interest in access to specialists, little is known about patient- and provider-related factors associated with shorter versus longer waiting times for initial consultations. Access to specialists, like other types of health care services, may be associated with a range of factors.⁸ Patients’ socio-economic characteristics have been related to the use of specialist services,^9-13 but it is not known if these characteristics are also associated with waiting time for specialist consultations. Provider-related variables,^13,14 including physicians’ decision processes in assessing urgency,¹⁵ have also been related to who gets referred to specialists. But again, it is unclear if these factors are associated with how long patients wait.

Based on information from the 2007 Canadian Community Health Survey, this study examines associations between patient- and provider-related factors and the length of time patients wait to consult a specialist about a new illness or condition.

Methods

Data source

The data are from a subsample of respondents aged 15 or older in the 10 provinces, to whom the “Access to Care” and “Waiting Times” modules of the 2007 Canadian Community Health Survey were administered. These modules, formerly the Health Services Access Survey, were incorporated into the Canadian Community Health Survey in 2003.

The survey response rate was 75.7%. Residents of institutions, the three territories, Indian reserves, Crown lands and certain remote regions and full-time members of the Canadian Forces were excluded from the survey. Proxy responses were not permitted. Since respondents in this analysis are a subsample, the multiple sample frames of the parent survey apply. More information about the Canadian Community Health Survey is available in other reports^16,17 and on Statistics Canada’s website: /cgibin/imdb/p2SV.pl?Function=getSurvey&SDDS=3226&lang=en&db=imdb&adm=8&dis=2).

The study pertains to 5,515 respondents who reported that they had consulted a specialist about a new illness or health condition in the previous 12 months and who reported a waiting time.

Analytical techniques

Factors associated with waiting times for specialist consultations were determined with multivariate logistic regression analyses in total cohort and sex-specific models. The outcome of interest was waiting time for the initial specialist consultation, expressed as a dichotomous variable, indicating whether patients waited: 1) less than one month, or 2) longer. This cut-off was chosen based on the median waiting time (4.3 weeks). To account for the complex survey design, standard errors, coefficients of variation and 95% confidence intervals were estimated using the bootstrap technique.^18,19 Differences between estimates were tested for statistical significance, established at the level of p<0.05.

The patient-related factors hypothesized to be associated with waiting time for a specialist consultation were sex, age, education, household income, immigrant status and rural/urban residence.

Immigrants were defined as respondents who were born outside of Canada and were not Canadian citizens by birth. They were categorized according to their duration of residence in Canada: less than 10 years, or 10 or more years before the survey date.

Based on a national distribution of total household income (adjusted for household size), respondents were classified into household income quintiles.

Education is the highest level of personal educational attainment.

Waiting time for an initial specialist consultation has been shown to be related to the nature of the underlying health condition.⁵ Therefore, adjustment was made for the type of new condition reported and the presence of chronic conditions. The chronic conditions were asthma, arthritis, cancer, diabetes, chronic obstructive pulmonary disease, heart disease, and mood disorders (depression, bipolar disorder, mania and dysthymia).

People with chronic conditions, particularly those with multiple comorbidities, often experience poorer health. This may affect the severity of the condition for which they seek care, and in turn, waiting time. To partially adjust for this possibility, respondents were classified according to the number of selected chronic conditions they reported: none, one, or two or more. In addition, respondents were identified as having (or not having) high blood pressure.

Provider-related factors were represented by two variables: having a regular doctor and the source of the specialist referral (family doctor, another specialist, another health care provider, or did not require a referral).

The multivariate models initially included province of residence, but the results did not differ from those not adjusted for province. Therefore, because of the limited sample size, province was removed from the final models to preserve statistical power.

All independent variables in the models were tested for multicollinearity.

Results

Characteristics of patients consulting specialists

In 2007, an estimated 3 million patients aged 15 or older reported having consulted a specialist about a new condition in the previous year (Table1). Almost 60% of these patients were female. More than half of the patients were aged 45 or older. Men consulting specialists were slightly older than women, averaging 50 years versus 47 years (data not shown). The educational attainment and household income of patients tended to be slightly higher than those of the population overall (data not shown). Approximately 20% were immigrants, just under three-quarters of whom had been in Canada more than a decade.

Table 1
Characteristics of patients who consulted specialist about new condition, household population aged 15 or older, Canada excluding territories, 2007

The top three conditions about which specialists were consulted were gynecological conditions (12%), heart/stroke (9%), and cancer (7%), though of course, this varied by sex. Fully 21% of the women had consulted a specialist about a new gynecological condition (data not shown). Men were more likely than women to have consulted a specialist because of a new heart condition/stroke (13% versus 7%).

Slightly fewer than half the patients also had at least one chronic condition, and 17% reported multiple comorbidities.

Most of the patients (91%) who had seen a specialist had a regular doctor. Over two-thirds (68%) of the patients had been referred to the specialist by their family doctor, 11% by another specialist, 12% by another health care provider, and 9% reported that they had not needed a referral. The most common sources of referral varied by province, especially in Quebec, where almost 20% of patients reported that they had been referred by a health care provider who was not their family doctor or another specialist, and 17% had not required a referral (Table 2).

Table 2
Unadjusted percentage distribution of waiting times and of referral sources to consult specialist about new condition, by province, household population aged 15 or older, Canada excluding territories, 2007

Distribution of waiting times

Nearly half (46%) of the patients had waited less than a month for their initial specialist consultation (Table 2). Anadditional 40% waited one to three months, and 14% waited more than three months. The percentage who saw the specialist within a month varied from 37% in Newfoundland and Labrador and Manitoba to 51% in Quebec. Just under half (49%) of those who required a consultation for a new mental health condition waited less than a month.

The length of the wait depended on the nature of the new condition. Not surprisingly, patients with potentially life-threatening illnesses were the most likely to have seen a specialist within a month. Almost 60% of those with a heart condition/stroke or cancer waited less than a month for their initial consultation, compared with 29% of those with arthritis/rheumatism (Table 3). Just under half (49%) of those who required a consultation for a new mental health condition waited less than a month.

Table 3
Unadjusted percentage distribution of waiting times to consult specialist about new condition, by nature of new condition, household population aged 15 or older, Canada excluding territories, 2007

Overall, 51% of male patients with a new condition waited less than a month for their initial consultation. However, 63% of men with a new heart condition/stroke saw a specialist within a month, as did 56% of those with cancer, 55% with eye conditions, and 52% with mental disorders.

Compared with men, a lower percentage (42%) of female patients had their first specialist consultation within a month. Again, the likelihood of a short wait varied with the condition. More than half of those with cancer (57%) or a heart condition/stroke (55%) had their first consultation within a month. On the other hand, relatively small percentages with gynecological conditions (39%), skin conditions (39%) or arthritis/rheumatism (25%) waited less than a month.

Unadjusted bivariate results

Unadjusted analyses for the entire subsample suggest that, in addition to gender and the nature of the new condition, several other factors were associated with waiting time for specialist consultations (Table 4).

Table 4
Unadjusted prevalence and adjusted odds ratios for waiting time less than 1 month to consult specialist, by selected characteristics and sex, household population aged 15 or older, Canada excluding territories, 2007

People with high blood pressure were less likely than those not afflicted to be seen within a month. Comparatively high percentages of patients without a regular medical doctor and those who were referred by someone other than a family doctor or who did not need a referral waited less than a month.

Unadjusted sex-specific analyses show that among female patients, waiting less than a month was significantly associated with only two variables: the nature of the new condition and referral source. However, among male patients, in addition to the nature of the condition and referral source, not having high blood pressure or a regular family doctor and being an immigrant were associated with waiting less than a month.

Multivariate logistic regression results

Results from the full model indicate that even when the influence of the other variables was controlled, female patients were significantly less likely than male patients to see a specialist in less than a month. And as expected, for both sexes, the nature of the new condition was significantly associated with waiting time: compared with those who had a new heart condition/stroke, the odds of seeing a specialist within a month were significantly lower for men and women with skin and eye conditions and arthritis/rheumatism. As well, men with asthma or other breathing conditions and women with gynecological conditions had lower odds of consulting a specialist within a month.

The sex-specific multivariate results also confirm the importance of referral source in waiting times for both male and female patients. Compared with patients referred by their family doctor, those referred by another specialist or another health care provider had about twice the odds of seeing a specialist within a month. And among patients who indicated no referral was required, the odds of seeing a specialist within a month were five times higher for men and almost four times higher for women, compared with those referred by their family doctor.

For men, but not women, several other factors were significantly associated with waiting time to see a specialist. Among male patients, the odds of seeing a specialist within a month were twice as high for those who had immigrated more than 10 years earlier than for those who were Canadian-born. As well, male patients reporting high blood pressure had significantly low odds of seeing a specialist within a month, compared with those without high blood pressure. Household income was also significant for male patients. Compared with men in the top income quintile, those in the lowest were less likely to see a specialist within a month. Yet this was also true for men in the second-highest quintile.

Discussion

This national study identifies patient- and provider-related factors associated with waiting time for an initial specialist consultation about a new condition. Not surprisingly, waiting time varied with the nature of that condition, with generally shorter waits for those that were potentially life-threatening. But even when the influence of this variable was taken into account, the results highlight significant differences in waiting times by sex, source of referral, and for male patients, household income and immigration status.

Women were significantly less likely than men to see a specialist within a month. This could result from systemic gender biases in access to health care services, evidence of which has previously been demonstrated. For example, gender differences in access to primary care for heart disease have been reported , ^20-22 including physicians’ diagnostic and management practices.²² Differential access to specialized cardiovascular care based on non-clinical patient attributes, such as social status, has also been reported.²³

However, the disparity between male and female patients in waiting time may reflect differences in the severity of the condition that prompted the specialist consultation. Because information about the patients’ health status before the visit is limited, and no measure of the severity of the new condition is available, it was not possible to fully adjust for health status. It may be that men’s shorter waiting time for specialist consultations was attributable to more advanced conditions. Men are less likely than women to use physician services or to have a regular family doctor,^12,24 and consequently, may have less continuity of primary care. As a result, men may present at more advanced stages of disease and require expedited specialist consultations.

Differences in specialist waiting time by immigration status among male patients could also reflect greater severity of the emergent health condition. This is consistent with well-known associations between immigration status and changes to health over time, as well as differences in the use of and access to care among the immigrant population. Immigrants tend to have lower health literacy, ²⁵ which may contribute to less use of preventive care. For example, significantly lower rates of cancer screening have been found among visible minorities, a large proportion of whom are immigrants. ²⁶ And although recent immigrants tend to be in better health than the Canadian-born population, over time they are more likely to report health deterioration.²⁷ Therefore, the differences among men in waiting time for specialist consultations by immigrant status may be attributable to medical need.

Finally, the results of this study demonstrate the importance of the referral source in specialist waiting time. There may be several explanations. First, the referral source may indicate the point at which a patient is located in the pathway of diagnosis and treatment. The question on the Canadian Community Health Survey pertained to waiting time for a specialist consultation in the previous 12 months, but the specific visit about which the respondent answered might have resulted from prior visits to other specialists to confirm a diagnosis. This process may have yielded greater diagnostic certainty, and perhaps, influenced assessed urgency. General practitioners often use referrals to obtain assistance with diagnoses or advice about therapy. ²⁸ Therefore, diagnostic uncertainty may be involved when a family physician is the referral source, and may affect assessed urgency. As well, suboptimal communication between general practitioners and specialists has been cited as a difficulty in the referral process.²⁹ Recently, referral tools have been developed to improve and standardize communications between general practitioners and specialists.¹⁵

Respondents who reported not needing a referral had much higher odds of seeing the specialist within a month, compared with those referred by a family doctor. To some extent, this may be attributable to provincial variations in how services are organized, especially in Quebec. Relatively high percentages of Quebec residents reported referral sources other than family doctors or self-referrals. According to recent data,²⁴ Quebec residents are less likely than people in other provinces to have a regular family doctor, and so may rely on nurses³⁰ or other health care professionals working in primary health care teams in community health centres. This, in turn, may facilitate referral to specialists.

Limitations

The distribution of waiting times reported to the Canadian Community Health Survey was skewed. To attempt to preserve the continuous nature of the data, a logarithmically transformed, continuous dependent variable using linear regression was employed. But because respondents could report waiting times in days, weeks or months, and because they tended to round responses, especially for longer waits, these models were difficult to fit. Consequently, a dichotomous outcome was derived, and logistic regression analyses were used.

The study is based on self-reported data that were not clinically validated and may be subject to recall bias.

As well, if respondents interpreted the question, “In the past 12 months, did you require a visit to the specialist for a diagnosis or consultation for a new illness or condition?” to mean that both the occurrence of the new illness and the consultation arose within the past 12 months, some respondents with long waiting times may not have been captured.

Clinical need is a crucial indicator of waiting time for health care services, so it was expected that those in greater need would wait less time for a specialist consultation. However, it was not possible to fully adjust for the need for services because information about the severity of the new or existing conditions is not available from these data.

Conclusion

Waiting time for specialist services represents a key indicator of access to health care in Canada. Data from the Canadian Community Health Survey provide a unique opportunity to explore factors associated with how long patients wait for specialist care.

The results of this study suggest that, in addition to the nature of the new condition, gender and referral source are associated with obtaining a consultation within a month. And for males, household income and immigration status are also significant.

This is only a preliminary examination of factors related to waiting time for specialist consultations; more research is obviously required. In particular, given the apparent importance of the source of referral, future analyses might focus on decision-making and communication processes to determine how urgency is assessed and how patients are triaged for specialist consultations. The findings from this and subsequent research may be relevant to a better understanding of the role of different health care providers in accessing specialists and how these processes vary across patient groups.