Help spine surgery patients in Ontario

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If you can't read the entire letter to the Ministry of Health -

Aim of this petition: Help those who are suffering and either unable to get spine surgery in Canada, or forced into unacceptable spine surgery wait times

Background: Many people reading this petition are either personally affected, know someone personally affected, or care for one or more patients who have slipped through this crack in our healthcare system. Many of these patients have ongoing severe pain, progressive neurological decline and poor quality of life.

The facts: Recent published literature demonstrated significantly higher rates of spine surgery in New York state vs. Ontario (not surprising). Ontario also performs 20-30% less spine surgery per capita than other provinces in Canada. 

https://www.ncbi.nlm.nih.gov/pubmed/31261267 

Why? The study authors (primarily physicians from Ontario) comment that it is tempting to designate blame solely to our neighbours in the South by claiming they are indiscriminately operating; but, they also comment, it is important to consider that perhaps Ontario is 'under-operating'.  

Author Speculations: Canadian hospitals have incentives to minimize operating room time because of fixed budgets and financial constraints, which has likely led to reduced volumes of non-emergent spine surgery cases in Canada.

Our Speculations: The 'supply' of spine surgery in Ontario/Canada, is unable to meet the 'demand' (the medical need amongst the population), especially for patients who need spine surgery but are not yet in imminent life-threatening condition.

Our requests: We are calling on the Ministry of Health to re-evaluate its policies surrounding access to spine surgery in Ontario. Please implement a mandate that allows for a shuffling in resource allocation, so that operating room times can increase, and/or spine surgeons per capita can increase. Help end the needless suffering

 

LETTER 

Ms. Tara Wilson
Manager, Provincial Programs Branch
Ministry of Health and Long Term Care (MOHLTC)
Tara.L.Wilson@Ontario.ca

November 14, 2019

Dear Ms. Wilson,

Thank you for your most recent letter dated September 17, 2019. I appreciate the MOHLTC's attempt to address my concerns. While I disagree with much of what was outlined in your letter, for the sake of brevity, I will comment on just one of the Ministry's replies: 

“The ministry cannot intervene in medical treatment decisions of individual patients.”

I respectfully disagree.

Yes, the MOHLTC can, and yes the Ministry does intervene in medical treatment decisions, nearly every day in some capacity in virtually all patients in Ontario.

The Ministry of Health funds all the tools that physicians need to carry out their treatment. A physician may think (and know) as a result of evidence-based literature, that a specific treatment is medically necessary and ideal for his or her patient; however, when resources are rationed (or at the extreme end completely absent) they may render the physician incapable of offering what he or she believes to be the best treatment for his or her patient.

An article recently published by Ontario physicians / surgeons in a highly respected peer-reviewed journal ‘Spine’, provided evidence suggesting these dynamics are at play, specifically in regards to spine surgery. The study titled 'Utilization and outcomes for spine surgery in the United States and Canada' compared population data between jurisdictions, and found significant differences in rates of spine surgery:

https://www.ncbi.nlm.nih.gov/pubmed/31261267

“Utilization of spine surgery (decompression plus fusion) in Ontario was 6.6 procedures per 10,000 population per year, and in New York was 16.5 per 10,000 per year (P<0.001).”

Before the MOHLTC provides its automated response, I ask the Ministry to consider an alternative. The authors go on to say in their discussion:

“While it is tempting to assume that our findings represent excess utilization in New York, it is also important to consider potential underuse in Ontario…[and] important to consider the role of the health system financing and incentives.”

How does the health system influence utilization of spine surgery?

The authors continue:

“In Ontario…hospitals operate under global budgets determined largely by historical services and volumes. Any increases in spine surgery volume [will] increase hospital “costs.” As a result, Canadian hospitals have an incentive to minimize spine surgery volumes, typically done through restriction of operating room time for elective cases.”

The document attached looking at hospital budgets, demonstrates that these budgets are for the most part dictated by resources allocated from the Ministry of Health through our Local Health Integration Networks.

file:///Users/adenagutstein/Downloads/HospFundingON%20(1).pdf

The authors conclude the article with the following:

“We suspect that differences in ability to supply spine surgery is a major factor underlying cross-border differences in utilization rates per capita.”

In other words, spine surgery in Canada has become less about the ‘medical need’ of the patient, and more so about whether spine surgeons are physically capable of providing the service within the context of fixed resources in our healthcare system.

This rationed healthcare has had serious consequences for many patients. 

As a debilitated 35-year-old family physician, I was unable to find spine surgery in Canada, and had to pay for it out-of-country when OHIP rejected my funding application. My physicians in Ontario, and those from respected institutions out-of-country (eg, the Cleveland Clinic) supported my need for surgery. For years I struggled to find this care in Ontario. Through this time, my neurophysiology testing demonstrated a dramatic decline in spinal cord function. Upon hearing that OHIP refused to fund my spine surgery, one of my physicians in Canada commented: “what exactly did they want you to do, become paralyzed?”

Not all patients are able to afford $70,000 for major spine surgery out-of-country. It becomes evident then, that actions such as these, taken by the Ministry of Health are not only 'intervening in medical treatment decisions of individual patients' but also compromise human rights of many Ontario citizens.

While I do agree with authors that “these differences [in utilization rates in Ontario and New York] should inform broader spine surgery policy reforms in both jurisdictions, I for one, do not live in New York.

I live in Ontario, and I practice medicine here too. Furthermore, the MOHLTC also resides and operates in Ontario, with jurisdiction to change policy here.

For the sake of countless patients who are suffering, declining, and progressively losing motor, sensory and autonomic functioning, I implore the MOHLTC to address its policies regarding access to spine surgery in Ontario. Please implement a mandate that allows for more appropriate resource allocation, so that operating room times can increase. Help our surgeons help us!

Please provide a response within 4 weeks.

Sincerely,

Adena Gutstein 
MD, CCFP-EM