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									  Cardiac Surgery in Ontario:
Ensuring Continued Excellence
and Leadership in Patient Care


        A Cardiac Care Network of Ontario Discussion
                          Paper


          Prepared by a Panel of the Cardiac Care Network of Ontario
                               November 2006



                  Approved by the CCN Board of Directors on October 31, 2006




     This report was commissioned and funded by the 18 Member Hospitals of the Cardiac Care
                                       Network of Ontario.

                             Cardiac Care Network of Ontario
                                4211 Yonge Street, Suite 210
                                 Toronto, Ontario M2P 2A9
                        Telephone: (416) 512-7472 Fax: (416) 512-6425
                                       www.ccn.on.ca




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Mission

We are an advisory body to the Ontario Ministry of Health and Long-Term
Care that is dedicated to improving quality, efficiency, access and equity in
the delivery of the continuum of adult cardiac services in Ontario.

Using data- and consensus-driven methods, we offer planning advice for the
future of cardiac services and the provision of exemplary care, in
collaboration with the Ministry and others.




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                                                                                TABLE OF CONTENTS
1        EXECUTIVE SUMMARY ................................................................................................................................................................. 4
2        INTRODUCTION ............................................................................................................................................................................. 15
           2.1   BACKGROUND AND RATIONALE .............................................................................................................................................. 15
           2.2   PROJECT SCOPE & OBJECTIVES ................................................................................................................................................ 16
              2.2.1    Project Scope and Perspective.................................................................................................................................... 16
              2.2.2    Project Objectives ....................................................................................................................................................... 16
           2.3 FUNDAMENTAL ATTRIBUTES ................................................................................................................................................... 17
           2.4 RELATED ACTIVITIES AND PRIORITIES ..................................................................................................................................... 19
              2.4.1    CCN- HSFO Cardiovascular Visioning ..................................................................................................................... 19
              2.4.2    Toronto Academic Surgery Plan................................................................................................................................. 19
              2.4.3    Canadian Society of Cardiac Surgeons ...................................................................................................................... 20
           2.5 ORGANIZATION OF CARDIAC SURGERY IN ONTARIO .............................................................................................................. 20
3        METHODS......................................................................................................................................................................................... 21
           3.1       REPORT APPROVAL PROCESS ................................................................................................................................................... 21
           3.2       DECISION-MAKING FRAMEWORK ............................................................................................................................................ 21
           3.3       STAKEHOLDER CONSULTATION ............................................................................................................................................... 21
           3.4       DATA ........................................................................................................................................................................................ 21
           3.5       SYSTEMS MODELING ................................................................................................................................................................ 22
4        TRENDS IN CARDIAC SURGERY............................................................................................................................................... 23
           4.1       SUMMARY OF CARDIAC PROCEDURAL TRENDS ...................................................................................................................... 23
           4.2       CHANGES IN PATIENT CLINICAL CHARACTERISTICS ............................................................................................................... 27
5        THE CARDIAC SURGERY IN ONTARIO – UNDERSTANDING THE CURRENT ENVIRONMENT............................ 29
           5.1      KEY ISSUES IN CARDIAC SURGERY .......................................................................................................................................... 29
           5.2      KEY DRIVERS AND IMPACT OF CHANGE .................................................................................................................................. 30
                 5.2.1     Advances in technology............................................................................................................................................... 30
                 5.2.2     Convergence of specialties.......................................................................................................................................... 32
                 5.2.3     Practice patterns ......................................................................................................................................................... 32
                 5.2.4     Increased system capacity........................................................................................................................................... 32
                 5.2.5     Demographics ............................................................................................................................................................. 36
                 5.2.6     Human resource planning........................................................................................................................................... 37
                 5.2.7     Financial incentives .................................................................................................................................................... 38
                 5.2.8     Cardiac Surgery Systems Model................................................................................................................................. 39
6        PLANNING FOR THE FUTURE ................................................................................................................................................... 40
           6.1       A VISION FOR CARDIAC SURGERY IN ONTARIO ...................................................................................................................... 40
           6.2       A FUTURE MODEL FOR CARDIAC SURGERY IN ONTARIO ........................................................................................................ 40
           6.3       DISCUSSION POINTS AND RECOMMENDATIONS ....................................................................................................................... 41
ACKNOWLEDGEMENTS ......................................................................................................................................................................... 49
APPENDIX 1 – CABG CO-MORBIDITY TABLES................................................................................................................................ 51
APPENDIX 2 – CARDIAC SURGERY SYSTEMS MODEL ................................................................................................................. 52
                 Key assumptions ........................................................................................................................................................................... 56
                 Key change drivers ....................................................................................................................................................................... 57
                 Key timeframes ............................................................................................................................................................................. 57
APPENDIX 3 – CARDIAC SURGERY CONSENSUS PANEL TERMS OF REFERENCE ............................................................. 63
APPENDIX 4 – CARDIAC SURGERY CONSENSUS PANEL MEMBERSHIP ................................................................................ 68
APPENDIX 5 – CCN-MEMBER HOSPITALS RESPONDING TO CALL FOR SUBMISSIONS ................................................... 69
APPENDIX 6 – EXTERNAL INTERVIEWS ........................................................................................................................................... 70
APPENDIX 7 – CCN CLINICAL SERVICES COMMITTEE MEMBERSHIP.................................................................................. 70
APPENDIX 8 – CCN BOARD OF DIRECTORS ..................................................................................................................................... 72




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1 EXECUTIVE SUMMARY

The cardiac surgery enterprise in Ontario enjoys an international reputation for excellence.
Patient outcomes, already among the best in the world, continue to improve, while wait
times and wait list mortality are at historically low levels. Clinical and basic research
performed over several decades in Ontario has resulted in innovations that have been
adopted into surgical practice around the world. These accomplishments, however, are
occurring in a setting of increasingly rapid change –in patient demographics, in cardiac
technology and practice, and in the convergence of specialties – that raise questions about
the future of cardiac surgery.

The most pronounced consequence of change in the cardiac surgery environment has been
the decline in the volume of coronary bypass operations that began in the late 1990’s,
following almost three decades of significant growth. This is evident in most jurisdictions
worldwide, and has primarily been driven by the evolution of interventional cardiology and
catheter-based revascularization as a safe and effective alternative to coronary artery
bypass graft (CABG) surgery for many patients. In Ontario, the rate of CABG surgery,
which comprises approximately 75% of all adult cardiac surgery, has decreased by 5% over
the past five years, while the rate of percutaneous coronary intervention (PCI) increased by
more than 60% during this same period. Further driving this trend is a shift in cardiology
practice toward earlier intervention for many patients with acute forms of coronary disease,
resulting in more revascularization overall, but predominantly more PCI. Contemporary
patients who are referred for CABG, typically because they have extensive coronary
disease (or co-existing valve disease) that is beyond the scope of PCI, tend to be older and
have more co-morbidities than a decade ago, when the scope of PCI was more limited.
Thus the reduction in the overall number of CABG procedures has been accompanied by a
concurrent increase in complexity among the remaining cases.

Advances in technology have also led to increasing overlap between the traditionally
distinct specialities of interventional radiology, cardiology, cardiac surgery and vascular
surgery. This constitutes an additional driver of change for cardiac surgery that is
particularly relevant as new “hybrid” technologies move to the clinical arena.

Another development that is specific to Ontario relates to the opening of three community
cardiac surgery programs since 1998, and the associated shift in regional capacity and
access. Clearly this represents a positive change for patients (and their families) in that
many more can obtain the care they need closer to home. At the same time, the reduction
in volume at certain centres has been accentuated. Minimum volume standards for
hospitals and operators have (or may) become difficult to maintain in some centres. This
may compound some of the challenges already faced in maintaining clinical excellence and
fulfilling academic goals. Whether viewed from the perspective of improved access in one
region, or a reduced procedure volume in another region, the decentralization of cardiac
surgery over the past several years highlights the need for coordinated planning and
adaptability across the system.
Human resource capacity and capability has also been impacted in recent years. Currently,
there are more cardiac surgery residents graduating in Ontario and across Canada than
there are available positions. This is an inefficient use of training resources, and a potential
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waste of intellectual and technical skills honed over many years. New prospective trainees
are avoiding cardiac surgery because of the uncertainties for employment; this fact,
coupled with the age profile of the cohort of surgeons currently in practice and the long
lead time to train new surgeons raises the possibility of an undersupply of cardiac surgery
professionals seven to 10 years from now.

A theme that emerges from technology development and its application to a range of
cardiovascular conditions is the gradual convergence of techniques and clinical scope
across previously distinct specialities. Interventional cardiology, cardiac surgery, vascular
surgery, and interventional radiology exhibit an ever-increasing degree of overlap among
the type of patients and conditions treated, and the tools used in diagnosis and treatment.
While this has raised concern in some sectors of the medical profession regarding “turf
protection”, it is our view that collaboration should – and will - continue to increase, and
the boundaries across specialties will become further blurred. This will benefit patients by
optimizing the fit between the available technology, the human skill set, and each patient’s
particular circumstances. We also believe, however, that organizational structures – within
hospitals, medical specialty societies, and so on – will need to adapt to this new reality, as
will some of our existing concepts of professional training and credentialing.

A fundamental challenge, therefore, for health policy in Ontario is to devise strategies that
help sustain the tradition of clinical and academic excellence in an environment of rapid
change, and that best match system capacity and capability with changing needs and
opportunities. If this challenge can be successfully met, residents of Ontario will continue
to enjoy optimal access to the highest quality cardiovascular care, and patients everywhere
will benefit from innovation and expertise developed here in Ontario.

In order to help address this policy challenge, and to better understand the influence and
impact of the forces underlying changes in cardiac surgery in Ontario, we (the Cardiac
Care Network of Ontario – CCN) convened a consensus panel in early 2006 with a
mandate to produce a discussion paper on the future of cardiac surgery in Ontario. This
work was supported by the Network’s 18 member hospitals. We view this exercise as an
opportunity to engage diverse stakeholders in an important ongoing dialogue around
cardiac surgery in particular, and advanced cardiovascular services in general, areas in
which CCN has substantial experience and has contributed over a number of years to
clinically guided policy development.

The panel enumerated what we felt were the fundamental attributes of a successful patient-
focused system for cardiac surgery. The notion of an integrated “system” for cardiac
surgery is worth emphasizing, and is alluded to many times in this paper. It reflects the
reality – and desirability – of a large group of individuals and institutions providing a very
complex form of care under a set of common standards and practices that enhance quality
and efficiency of that care for patients. These fundamental attributes include:

   •   Excellence in patient-centred care
   •   Timely and equitable access to care
   •   Economically sustainable
   •   Optimizes existing resource investments
   •   Attracts, retains and grows expertise in Ontario
   •   Supports renewal and innovation
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   •   Aligns with government and LHIN strategic directions
   •   Collaboration and broad engagement


With these attributes in mind, a vision for cardiac surgery in Ontario was articulated that
we believe reflects the context of rapid and substantive change and could serve as a
foundation on which to base future planning decisions:

A cardiac surgery system that delivers internationally recognized excellence in quality
care, is innovative and adaptive to changing needs, optimizes the human resources needed
to support the system, and promotes academic excellence and inter-specialty collaboration
for the benefit of patients in Ontario and beyond.

In order to achieve this vision, we feel that cardiac surgery in Ontario needs to be viewed
and organized as not only a network of independent clinical programs, but also as a single
integrated “virtual” program, with a greater degree of province-wide planning and
management. This large “virtual program”, performing over 10,000 surgical cases per
year, would retain the mandate and ability to respond to local needs (as well as the benefits
of healthy competition between programs), but would allow the system as a whole to deal
more effectively with many of the current challenges. In particular, greater overall
capacity within this integrated model provides more flexibility to deal with rapid shifts in
the nature and volume of clinical activity.

Towards this end, we have highlighted a series of issues and policy options for further
discussion. In addition, where we felt there was a clear and immediate need for action, and
a consensus on policy direction, we provided actual recommendations and identified the
target audience(s) for these. The discussion points and recommendations have been
organized into four strategic areas : 1) strategies that strengthen the system’s ability to meet
patient needs by way of planning and monitoring within an integrated provincial
framework; 2) strategies that enhance short-term stability and responsiveness to patient
needs in the cardiac surgery; 3) strategies that will benefit care via alterations to the
cardiac surgery funding methodology; and 4) strategies to ensure long term sustained
accessibility and excellence in cardiac surgery.

The parties that should participate in further discussions (and ultimately must implement
new policies that arise) are diverse, and include patients and the public, clinical groups and
professional societies, hospitals, medical schools and universities, the Royal College of
Physicians and Surgeons of Canada, provincial licensing authorities, and provincial
governments. Because there is no specific unifying authority or umbrella organization that
encompasses all of these groups, there may be a facilitative role for CCN in bringing these
stakeholders together and moving these issues forward. To enhance collaboration in the
future planning and delivery of cardiovascular care, the consultative and decision making
processes should be fully transparent and should seek broad input from all relevant
stakeholders.

Many of the issues raised in relation to cardiac surgery are also relevant to coronary
angioplasty, diagnostic catheterization, and cardiac rhythm management. Therefore, while
this discussion paper is focused on cardiac surgery, we feel that is could serve as a template
for future discussions on other aspects of advanced cardiovascular care.
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DISCUSSION POINTS AND RECOMMENDATIONS


I. INTEGRATED PROVINCIAL PLANNING AND MONITORING

Excellent patient care, a key component of our vision for cardiac surgery, encompasses
access and clinical outcomes. Both require active and rigorous monitoring to ensure they
are delivered at the highest level. Timely and equitable access also requires matching of
capacity to demand – which in turn requires advance planning, especially given the long
lead times needed to adjust capacity up or down in something as complex as cardiac
surgery.


There are a number of initiatives, as detailed below, that are either proposed or already
under way and that contribute greatly to integrated system-wide planning and monitoring.
These initiatives should be implemented, or further supported, in a timely manner.

I(a) A Cardiac Surgery Planning Committee should be established to support integration
and alignment of cardiac surgery services in the province. This was previously
recommended in the MOHLTC Report: Advanced Cardiac Services – Outcome of the 2004
Cardiac Surgery Sessions, February 18, 2005.

I(b) The “Target Setting” process should continue on a regular basis – i.e. future cardiac
service needs should be identified through prospective evidence-based, regionally adjusted
planning of procedural targets and capacity for advanced cardiac services. (MOHLTC,
ICES, CCN)

I(c) The Systems Model created for this discussion paper should be further developed and
refined as it provides important insights into potential future constraints and may provide
quantitative input for future target setting. (U of T [Industrial Engineering], ICES, CCN)

I(d) Monitoring and reporting of major clinical outcomes such as in-hospital mortality
should continue as an important component of quality assurance and improvement.
Furthermore, as noted in the 2006 ICES-CCN Report on Surgical Outcomes, CCN should
work with member hospitals to collect key outcome data, including in-hospital mortality,
on a prospective real-time basis, to enable prompt recognition of any potential adverse
trends. (ICES, CCN, Cardiac Hospitals)

I(e) The relationship between volume and outcome should be monitored, and, if warranted
on the basis of contemporary evidence from Ontario and elsewhere, existing
operator/hospital volume standards should be re-evaluated. (ICES, CCN, Cardiac
Hospitals, MOHLTC)

I(f) A detailed and rigorous analysis of the variation in the PCI:CABG ratio in Ontario
needed to fully understand the factors that underlie marked differences in practice, and the
potential implications on outcomes, resource utilization, and surgical volumes.
(MOHLTC, ICES, CCN)
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II. ENHANCE SHORT TERM STABILITY IN THE SYSTEM

The general decline in CABG volume, coupled with new surgical capacity in certain
regions, has combined to cause significant shifts in overall surgical volume, referral
patterns, and in the human resource pool. Some surgical programs, particularly in smaller
communities like Sudbury and Kingston, along with a growing number of individual
surgeons (at both small and large centres), see their respective volumes approaching or
falling below previously recommended minimum benchmarks. Newly trained cardiac
surgeons have few if any job opportunities in Ontario or elsewhere at present. Many
cardiac hospitals face resource bottlenecks that limit the throughput of cardiac surgery
patients and further impact on volumes.

Our review of available data leads us to believe that the decline in CABG volume is
levelling off and that the demand for CABG will be relatively stable over the next three to
five years. Valve surgery will continue to grow modestly over this time frame but
contributes only a small component of total surgical volume.

Therefore, over a three to five year time frame, a number of imperatives are evident and are
itemized below. These should be viewed as discussion points and policy options.

II(a)                     Optimally utilize current capacity
                          Target audience         MOHLTC

Given the existing shortage of skilled personnel (anaesthesiologists, perfusionists, critical
care nurses, etc.), the timely (if not always “close to home”) availability of cardiac surgery
at present, and some degree of uncertainty as to future demand, the addition of significant
further capacity in the near term should be avoided. We believe that no new cardiac
surgery centres should be established over the next three years. In saying this we are
cognizant that some population centres are very remote from surgical services, and that
there may ultimately be a strong argument in support of further distributing such services.
Nonetheless, a three year hiatus seems reasonable in our view.

Because we also believe that demand will not fall appreciably further in the short term, the
overall capacity and capability that currently exists should be substantially maintained in
order to continue providing high quality accessible care. Ultimately, decisions on
distribution of capacity should be guided by the needs-based target setting process
referenced above, with appropriate attention to region-specific needs.

The distribution of cardiac surgery services at the three University of Toronto centres
(Sunnybrook, St. Michael’s, UHN) is being specifically addressed by a U of T working
group. An enhanced degree of clinical and academic integration among these centres is
being proposed.

II(b)                     Address resource bottlenecks
Target audience           MOHLTC, LHINs, Cardiac Hospitals


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Resource bottlenecks – whether they be human or physical infrastructure resources - should
not interfere with appropriate case selection and access for patients requiring cardiac
surgery. Therefore, MOHLTC, LHINs and cardiac hospitals should promptly and
collectively address any system and resource bottle necks such as insufficient ICU beds,
operating room capacity, or shortage of human resources that may negatively impact on
patient access. The ability to accommodate high-risk patients who are likely to benefit
from surgery but have a long anticipated ICU stay is particularly germane in this regard.
This initiative needs to be aligned with, and emphasized in, the current critical care
strategies.
.
II(c)                      Retain human resource investment
Target audience            MOHLTC, LHINs, Academic Health Science Centres,
                           Cardiac Hospitals

Investments already made in the training of new cardiac surgeons, and the “intellectual
capital” resulting from these investments, should be protected as much as possible. The
systems model suggests the possibility of a shortage of cardiac surgeons a decade from
now, which would be exacerbated if there is no entry of young surgeons into the workforce
for an extended period. Therefore, funding support for a human resource strategy should
be considered by the MOHLTC, LHINs and cardiac hospitals to retain expertise in Ontario.
The strategy could include short-term opportunities for employment or additional training
for at least some cardiac surgery residents who have completed training and are without a
staff position in cardiac surgery.

II(d)                     Coordinated volume planning
Target audience           Cardiac Surgery Planning Committee

There appears to be a new “steady state” for procedure volume, in which some centres and
some surgeons fall below traditional benchmarks. The balance between accessibility and
critical mass is a key (albeit delicate) consideration that needs to be addressed with
objective and innovative thinking. Many studies have identified some relationship between
higher volumes and better outcomes. However, there are also many published examples of
excellent outcomes associated with lower volumes. Rather than rigid adherence to volume
benchmarks, we believe the more cogent issue is to determine if, and how, lower volume
centres and/or surgeons can consistently achieve the best possible outcomes. If this is
indeed feasible, the cardiac surgery system in Ontario will be much better positioned to
meet the dual objective of high quality care that is regionally accessible.

Therefore, we foresee the need for an innovative and flexible approach to workload
distribution among surgeons that may involve, by way of example, one or more surgeons
from a low-volume centre performing some operations at another centre. This initiative
would be greatly facilitated by our view of the surgical hospitals as a single large virtual
program. In addition, its feasibility may be dependent on an acceptable funding
mechanism for institutions and providers (as addressed below).


III. REVISE THE FUNDING MODEL FOR CARDIAC SURGERY

III(a)                    Alternative funding methodology
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Target audience          MOHLTC, LHINs, Cardiac Hospitals

A high quality system that emphasizes collaboration and integration requires reducing the
dependence of income on procedure volumes. Indeed, many would see this as a critical
enabler for several of the human-resource related policy options that we have presented
herein. Therefore, strong consideration should be given to alternative funding
methodologies that separate procedural volumes from funding at both the physician and
hospital level. Patient acuity, training needs, and other special considerations need to be
factored into an alternate funding formula.

III(b)                   Expanded case-costing methodology
Target audience          MOHLTC, CIHI, Cardiac Hospitals

There is a need to identify legitimate variations in procedure costs and adjust funding
accordingly, so as to appropriately compensate hospitals for added complexity and/or use
of beneficial new technology. Toward this end, we believe that MOHLTC should support
the development of a more robust case-costing mechanism that would facilitate accurate
tracking of standardized indicators for clinical complexity, use of new technology and
other sources of cost variation for comparison across hospitals and LHINs. The case-
costing process needs to be expanded to include more hospitals and to include new and
evolving cardiac surgery procedures such as hybrid procedures, surgical treatment of
arrhythmias and congenital surgery. Processes for collecting this new/expanded
information need to be incorporated into developing information systems in the Province.




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IV. LONG-TERM PLANNING TO PROMOTE ADAPTABILITY

IV(a)                     Coordinated technology uptake
Target audience           MOHLTC, LHINs, Cardiac Hospitals

The uptake of selected new technology is important if patients are to receive state-of-the-art
care. While there is a formal process in Ontario for evaluating and establishing policy
around selected technologies (OHTAC - Ontario Health Technology Assessment Council),
some funding and implementation decisions are made at the hospital level, particularly
when a given technology is at an early or intermediate phase of its “evaluation life-cycle”
and there is not yet sufficient data to support widespread uptake. At this earlier phase there
may still be legitimate reasons for limited adoption – as a research or training tool, for
example. We believe there is an opportunity – and obligation – for greater collaboration
among cardiac surgery hospitals in the coordination of technology evaluation and uptake.
We would suggest that cardiac hospitals should collaborate to identify candidate new
technologies, and develop a reasonable plan for selective introduction and evaluation. We
would further suggest that the MOHLTC support this measured and collaborative
introduction of new technology, recognizing that if Ontario is to retain a leadership role
internationally in cardiac surgery, its surgical programs must be involved at all stages –
development, evaluation, and dissemination. There may be a valuable role for “field
evaluations” of specific technologies.

IV(b)                     Coordinated administrative structures
Target audience           Cardiac Hospitals, LHINs, Academic Health Science Centres

The convergence of treatments and technologies that is occurring in the clinical arena needs
to be reflected in the administrative structures that facilitate and govern clinical activities.
Within several hospitals this has already occurred to a degree under the concept of
“program management” – a cardiovascular program which encompasses cardiology,
cardiac surgery and vascular surgery may coexist in a hospital alongside the traditional
academic departments of surgery and medicine. We believe that some form of program
management organized around the patient with cardiovascular disease, rather than around
traditional disciplines, will better promote the shared responsibility and opportunity among
cardiac surgery, cardiology, vascular surgery, interventional radiology, and possibly other
disciplines (vascular medicine, neurology, endocrinology, etc.). This integrated
administrative structure needs to develop (or further develop) not only at the hospital level
but at the LHIN level and possibly at the University level as well.

IV(c)                     Coordinated human resource planning
Target audience           To be defined

It is clear to us that human resource issues represent the biggest potential barrier to
achieving our vision for cardiac surgery. The health care system as a whole faces
substantial HR challenges, and these are exacerbated in a highly specialized area like
cardiac surgery. A cardiac surgery team requires intensive care and operating room nurses,




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perfusionists, anaesthesiologists, and many others in addition to cardiac surgeons. The
challenge includes both meeting current HR needs and planning for future needs.

Strategies to enhance recruitment of specific categories of care-giver may have limited
short-term success, but often this represents a gain for one cardiac hospital at the expense
of another. A more effective strategy over the longer term would be to augment the overall
pool of highly trained personnel. However, the lead times are long, and our ability to
accurately predict future work-force needs is limited, raising the potential for oversupply as
well as undersupply in the future.

While cautious prediction of future needs certainly plays a role, we believe that ultimately
the best possible solution to the HR challenge in cardiac surgery lies in augmenting the
flexibility and adaptability of our current staffing structure. This might involve anaesthesia
assistants, nurse practitioners, hospitalists, and others. There are funding implications,
medico-legal implications, and other potential obstacles. Nonetheless, this is a critical
initiative that we believe must be explored. Clearly broad discussion needs to occur among
many stakeholders, including professional colleges and regulated health profession groups,
hospital risk management teams, health service researchers, and government. One goal of
such discussions should be the development of a standard – ideally a flexible standard that
is adaptable to local needs - with respect to the human resource mix that will optimize both
quality of care and accessibility of care across the province.

Given the diversity of stakeholders and the absence (to our knowledge) of an existing
forum to bring the relevant parties together, this is an area where CCN may be able to play
an important facilitative role.

IV(d)                     Coordinated human resource planning
Target audience           Academic Health Science Centres, Cardiac Hospitals

As noted above, the ability to accurately predict health care HR needs in specialized fields
that are rapidly changing is suspect. Nonetheless, there should be at least a partial attempt
to match the intake of trainees to an approximation of future demand. We heard from
several sources that the number of cardiac surgery resident training positions across the
country may be linked more to current workload requirements within the surgical programs
than to the future need for cardiac surgeons. That this is clearly not ideal is illustrated by
the present situation where few if any of the cardiac surgery residents in Canada now
finishing their training have been hired into a staff position (approximately 14 physicians
with an average of eight 8 years training after medical school).

To a degree the trainee/staff surgeon market will regulate itself as medical school graduates
shy away from cardiac surgery training given the lack of staff jobs. In the US this has
already occurred - many training programs have not filled their available positions. The
trend is more recent in Canada but likely to be similar. This can lead to a “boom-bust”
cycle and the legitimate concern of an actual shortage of cardiac surgeons seven to 10 years
hence. Our systems model suggests that under certain conditions this scenario could
indeed occur.


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Therefore, while precise matching between training positions and eventual demand is
impossible, we believe that collaborative planning among the Academic Health Science
Centres, Program Directors and the Chiefs of Surgery should take place with the goal to
ensure, to the extent possible, that the number of trainees in formal residency programs is
based on the anticipated need for cardiac surgeons, and not on local short-term clinical
workload. Modest resources will be required to support this planning process. If hospital
workforce needs are to be de-linked from the number of trainees, then alternate provision
of personnel outside of resident sources is necessary (e.g. nurse practitioners, extended care
RNs, hospitalists, etc.).


IV(e)                     Adaptability of the cardiac surgery workforce
Target audience           Royal College of Physicians and Surgeons, Academic Health
                          Science Centres, Cardiac Hospitals

The foregoing discussion points relate to the number of cardiac surgery personnel. We
believe that a flexible approach is also needed to achieve – and maintain – the appropriate
skill set among the personnel training for a career in cardiac surgery, or already working in
cardiac surgery.

The pace of change in practice and technology has become so rapid that the structure and
content of formal training likely need revision even within a given four to six year training
program. The Royal College of Physicians and Surgeons of Canada, with responsibility for
training standards, and the Academic Health Science Centres that provide such training,
should collaborate to ensure that the formal training requirements for cardiac surgery
residents have sufficient flexibility to address changes in the practice environment that
occur during residency. Today’s cardiac surgery residents may require (and desire)
training in imaging, catheter-based procedures, critical care, vascular surgery and
endovascular procedures. Here again the theme emerges that this involves innovative
collaboration and integration across cardiovascular disciplines. Providing this sort of
flexibility would help attract high calibre trainees who will be able to meet evolving patient
needs.

Surgeons and other caregivers already in practice have always faced the need to learn new
techniques and adapt their practice. Typically this has been done via informal on-the-job
training, or brief periods of more formal instruction. Today’s pace of change and the
potentially fundamental ways in which cardiovascular procedures may evolve suggest that
a more formal mechanism is needed to support professionals in the adaptation of their skill
set during their career, so that they may remain highly qualified providers of excellent care.
Cardiac hospitals should recognize the need for these mechanisms and develop plans to
support the retraining and/or cross-training of physicians and other cardiac surgery
professionals already in practice to enable them to acquire new skills, optimally utilize new
technology, align to system needs and develop collaborative practice. Cardiac hospitals
should work together to develop centres of excellence in specific areas of practice that
could serve as resources for retraining.



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Conclusions

Cardiac surgery in Ontario has provided excellent care for patients and has played a
leadership role internationally. It is clearly in the best interest of Ontario patients and
residents generally that this culture of excellence and innovation be maintained. Although
some aspects of cardiac surgery are undergoing profound change, and may have declined in
volume, the need for complex operative intervention on the heart remains essential for
many patients. Therefore, the existing capabilities within the specialty must be retained,
but must also be adapted to meet new requirements. An innovative approach must be
developed to balance critical mass and minimum volume with ready accessibility.
Rigorous monitoring and coordinated planning will help ensure that excellent care is
provided in a timely manner. Greater flexibility in the training and structure of the
workforce will ensure that future patients enjoy the same quality and accessibility of care
that today’s patients do.

This discussion paper is a starting point and we hope it will help engage many groups in
working together to move these issues forward. In doing so the goal of ensuring continued
excellence and leadership in cardiac surgery for Ontarians will be achieved.




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2 INTRODUCTION

2.1 Background and Rationale
Over the past two decades, the cardiac surgery enterprise in Ontario has earned an
international reputation for success. Patient outcomes, among the best in the world,
continue to improve, as evidenced in recent reports on peri-operative mortality across the
province.1,2 Furthermore, significant government investment in system capacity, coupled
with access monitoring and management by the Cardiac Care Network of Ontario (CCN)
and its member hospitals, have contributed to cardiac surgery wait times (and wait list
mortality) being at historically low levels.3 Consequently, coronary artery bypass graft
(CABG) surgery is among the first of the five clinical focus areas to achieve Federal-
Provincial wait time benchmarks this year.4 These encouraging results have occurred in
association with an increasing proportion of high-risk patients undergoing surgery.5

In addition to a strong record of clinical success, cardiac surgery in Ontario has a rich
history of transformative innovation and academic productivity – the result of many
outstanding clinicians and scientists working in various surgical programs across the
province.

While it is evident that cardiac surgery in Ontario in 2006 is clearly a successful enterprise,
it can also be characterized as one in a state of profound transition. Demographic changes,
rapidly evolving technology, improved survival from acute cardiac events and increasingly
sophisticated consumers have dramatically altered the landscape in which cardiac surgery
interacts with patients and with other components of the health care system.

Although developments have resulted in better quality, efficacy and access to patient care,
they have also resulted in significant uncertainty. The key question facing planners, policy
makers and providers is how to maintain excellence in the provision of cardiac surgery
services in meeting the needs of patients when and where required. Maintaining excellence
in cardiac surgery will be contingent on planning now to ensure that there are appropriate
human and physical resources in place to serve the needs of the population in the future and
to support a robust climate of innovation.

To help ensure that a plan exists for the provision of cardiovascular services in Ontario,
CCN, in partnership with the Heart and Stroke Foundation of Ontario, is engaged in
dialogue with the two Ontario Ministries of Health about the continuum of cardiovascular
health. This current project, however, specifically addresses cardiac surgery, and the

1
  Guru, V., et al. Cardiac Surgery in Ontario, Fiscal Years 2000 and 2001, ICES in collaboration with the
Steering Committee of CCN, April 2003.
2
  Guru, V. et al. Report on Coronary Artery Bypass Surgery in Ontario, Fiscal Years 2002 to 2004, ICES in
collaboration with the Informatics Committee of the Cardiac Care Network of Ontario, May 2006.
3
  CCN Annual Report 2004/05
4
  Ibid, CCN Annual Report 2004/05
5
  Ibid, Guru V et al 2006

    15
interaction between surgery and other elements of advanced cardiac care, such as catheter-
based procedures for revascularization, rhythm management and potentially valve repair or
replacement.

The Cardiac Surgery Panel (the Panel) is a CCN member-initiated undertaking aligned with
the Network’s three broad functions: i) a strategic commitment to promote timely,
equitable access to high quality advanced cardiac services; ii) an advisory role to the
Ministry of Health and Long-Term Care (MOHLTC); iii) support of the Provincial Wait
Time and Access to Care Strategy. Although member initiated and funded, officials
affiliated with the Provincial Wait Time Strategy did encourage CCN to address cardiac
surgery issues. We hope that the issues raised in this paper will not only inform local
hospital decision-making but will also prove helpful in the context of the anticipated
MOHLTC 10-year strategic plan (circa Spring 2007) and, by extension, LHIN∗ integrated
health service plans (IHSP).

2.2      Project Scope & Objectives
2.2.1      Project Scope and Perspective
This discussion paper is focused on adult cardiac surgery in Ontario. While it is recognized
that cardiovascular services are becoming increasingly integrated, other aspects of
cardiovascular care are discussed only within the context of understanding the factors and
environment impacting cardiac surgery.

In keeping with the CCN provincial mandate, the Panel maintained a provincial perspective
on the issues and recommendations. However, a balance between provincial, regional and
local perspectives was taken into consideration where applicable, such as academic and
geographic access issues.

This project was commissioned by the member hospitals of CCN, all of which provide
advanced cardiac services. Panel membership was primarily comprised of individuals
affiliated with advanced cardiac centres. It is the hope and intent of CCN that this paper
will generate discussion and elicit input from a broader group of stakeholders, including
health care providers outside CCN member institutions, health care analysts and planners,
leaders in medical education, and others.

2.2.2      Project Objectives
The Panel’s mandate was to gather information and engage key stakeholders in order to
better understand the factors driving change in the delivery of cardiac surgery in Ontario,
and to begin planning to guide policy development over the short- and longer-term.

Objectives:
1. To quantify temporal changes in volumes and rates of various cardiac surgical
   procedures.
2. To quantify the temporal changes in the characteristics of patients undergoing cardiac
   surgical procedures.

∗
    Local Health Integration Networks

      16
3. To catalogue and come to consensus on the key drivers affecting the quantity and
   nature of cardiac surgical care.
4. To review and evaluate models in other jurisdictions, including how other jurisdictions
   have responded to these industry changes.
5. To describe the implications of these changes and drivers as they relate to: a) human
   health resources and training; b) administrative and clinical practice standards (e.g.
   minimum institutional and surgeon volumes); c) structure and sustainability for
   research, teaching and the provision of highly specialized care; and d) the supporting
   infrastructure for the delivery of cardiac surgical care.
6. To develop a systems model that characterizes the drivers, interdependencies and
   outputs of the cardiac surgery system in order to provide a planning framework for
   policy makers and the CCN.
7. To guide the development of future policy aimed at ensuring that cardiac surgery in
   Ontario continues to provide excellence and leadership in patient care.

See Appendix 1 for the full Terms of Reference for this project.

2.3 Fundamental Attributes
At the outset, the Panel worked to develop and articulate a vision for cardiac surgery in
Ontario, on the premise that there needs to be agreement on such a vision before specific
recommendations on the future of cardiac surgery can be proposed. Several essential
underpinnings - fundamental attributes – of the envisioned system were identified.


Excellence in patient-centred care

The cardiac surgery enterprise in Ontario must continue to achieve excellence in patient
care and outcomes, with decision making guided by the needs of patients. This is best
accomplished in an environment that promotes research, innovation, and academic
development, and that actively supports knowledge transfer and the translation of
innovation into best practices.

High quality care is also contingent on achieving and maintaining a sufficient critical mass
of cases and of expertise among surgeons and other providers. The imperative to provide
this critical mass must be balanced against the goal of a system that is sufficiently
decentralized so as to be readily accessible to patients.

Timely and Equitable Access to Care

Not only must the quality of care be excellent, but the care must be readily available in a
time frame that is appropriate for patients’ clinical and social needs, and is as close as
reasonably feasible to home.




   17
Economically sustainable

A sustainable system is able to “buffer” the impact of external changes in the short-term,
and to adapt to these changes over the longer term, without compromising the commitment
to clinical excellence and innovation. This implies sustainability of the human resource
component of the surgical system. It also implies a funding mechanism that can buffer
individual providers and institutions against short term variation in the volume, intensity,
and distribution of surgical activity, and have the flexibility to respond over time to
changes in patient mix and in the nature of surgical practice. This is best achieved in a
large system, as the cardiac surgery enterprise in Ontario is when viewed in its entirety.


Optimizes existing resource investments while recognizing the potential need for
redistribution of services

Ontario has made a very substantial investment in cardiac surgery over the past two
decades – in the form of human, capital, and infrastructure resources. Future plans for
cardiac surgery should make optimal use of these existing resources, and avoid, to the
greatest extent possible, any liquidating or writing off of prior investments. At the same
time, this has to be balanced against the potential need for redistribution of services in
response to changes in population distribution and standards of practice.


Attracts, retains and grows expertise in Ontario

Human resources are Ontario’s greatest health care asset. Training high-calibre cardiac
surgeons and other surgical professionals is critical for the provision of high quality patient
care and requires significant resource investment and time. Therefore, retaining this
expertise in Ontario is a priority. It is equally important to provide an environment that
ensures that highly capable and motivated professionals will continue to choose a career in
cardiac surgery.


Supports renewal and innovation

In a setting of rapid technologic and demographic change, the uptake and knowledge
transfer associated with new technology and new practice needs to be dynamic but also
measured. This has to be recognized and supported at many levels throughout the surgical
system. For example, a flexible approach to the evaluation and funding of promising but
not yet fully established technology may be required. By the same token, providers may
need to coordinate their investigation and uptake of new technologies or techniques,
especially those that apply to only a limited number of patients. Training surgeons and
surgical teams in an era of increasing patient complexity requires innovative approaches
from numerous stakeholders.




18
Aligns with the government and LHIN strategic directions

Integration is a key driver of transformation in Ontario’s health care system, as the
government and LHINs are looking for opportunities for program integration as part of
their provincial and regional strategic plans. The size and nature of the provincial cardiac
surgery system provides unique opportunities for models of integration.

Reducing wait times is a current national and provincial priority. One measure of
successful long-term planning will be an appropriate match of capacity and skill set with
demand, as measured through the achievement of wait time benchmarks.

Collaborative and broadly engaged

The Panel’s work has been inclusive of all 17 specialized cardiac hospitals∗ in Ontario and
has provided opportunities for engagement through submissions and interviews. Going
forward, the implementation of the recommendations herein, and the continued
improvement of the cardiac surgery system in Ontario, should occur via collaboration
across medical specialities and across various administrative organizations in order to avoid
planning within isolated silos. Relevant stakeholders including government, regional
health bodies, specialty societies, patients, and the public should have an opportunity for
input and engagement in this process.

2.4 Related activities and priorities
During the deliberations of the CCN Cardiac Surgery Consensus Panel, other related and
important initiatives were occurring in parallel.

2.4.1    CCN- HSFO Cardiovascular Visioning
In early 2006, CCN, in partnership with the Heart and Stroke Foundation of Ontario
(HSFO), launched a Cardiovascular Visioning process. Following stakeholder consultation
and a “Summit” day in May, CCN and HSFO are continuing the process of building the
business case for creation of a comprehensive cardiovascular vision for Ontario. Further
engagement of the MOHLTC and the Ministry of Health Promotion will occur. A vision is
needed to integrate services within and across LHINs – from prevention to treatment to
rehabilitation; children to adults; and heart to brain to peripheral vasculature. Cardiac
surgery plays an important role in the treatment of heart disease, but is only one component
of the much broader spectrum of cardiovascular health. The Panel was cognizant of this
fact and worked to align its principles and recommendations within this context.

2.4.2    Toronto Academic Surgery Plan
The Toronto Central LHIN has three academic adult cardiac surgery hospitals affiliated
with the University of Toronto – Sunnybrook Health Sciences Centre, St. Michael’s


∗
  The 17 hospitals having a catheterization laboratory, 11 of which also perform cardiac surgery. As of April
1, 2006 CCN has 18 member hospitals with the addition of William Osler Health Centre. However, William
Osler Health Centre will not have an operational cath lab until 2007.

    19
Hospital, and University Health Network. Together, these three hospitals account for over
35% of all adult cardiac surgery procedures in the province.

In December 2005, the Chair of the Department of Surgery and the Chair of the Division of
Cardiac Surgery of the University of Toronto initiated discussions between the three
hospitals to explore opportunities to strengthen academic cardiac surgery in Toronto
through clinical and academic integration. These discussions have led to a proposal for a
substantially enhanced degree of clinical and academic integration among the three centres.

2.4.3    Canadian Society of Cardiac Surgeons
The Canadian Society of Cardiac Surgeons is developing a position paper to present to the
Royal College of Physicians and Surgeons of Canada later in 2006. This paper will outline
the current position of cardiac surgeons in Canada, and challenges faced such as matching
supply (numbers and skill set) to demand. Recommendations are anticipated to address
these issues.

2.5 Organization of Cardiac Surgery in Ontario
Advanced cardiac services in Ontario are centralized as a provincial resource. There are
eleven cardiac surgery centres in Ontario, all of which also provide percutaneous coronary
interventions (PCI). The following table provides the list of surgical centres by LHIN. Of
the 14 LHINs, only 9 have a cardiac surgery centre within their geographic boundaries.

Table 1 – Cardiac Surgery Centres in Ontario by Local Health Integration Network

LHIN                                                   HOSPITAL
Central                                                Southlake Regional Health Centre
Central East                                           N/A
Central West                                           N/A
Champlain                                              University of Ottawa Heart Institute
Erie St. Clair                                         N/A
Hamilton Niagara Haldimand Brant                       Hamilton Health Sciences Centre
Mississauga Halton                                     Trillium Health Centre
North East                                             Hopital Regional de Sudbury Regional Hosp.
North Simcoe Muskoka                                   N/A
North West                                             N/A
South East                                             Kingston General Hospital
South West                                             London Health Sciences Centre
Toronto Central                                        St. Michael’s Hospital
                                                       Sunnybrook Health Sciences Centre
                                                       University Health Network
Waterloo Wellington                                    St. Mary’s General Hospital

N/A = no cardiac surgery centre located in this LHIN




    20
3 METHODS

A multidisciplinary panel of cardiac surgery stakeholders was established to lead the
project, highlight important discussion points, and develop recommendations where
appropriate. (See Appendix 4 for a full list of committee members.). Four face-to-face
meetings were held between February and June, 2006. The discussion paper was drafted
over the summer of 2006.

3.1 Report Approval Process
The Panel was accountable to the CCN CEO and Board of Directors, with oversight and
input from the Clinical Services Committee (CSC). The draft discussion paper was
presented to the CSC and subsequently the CCN Board in September 2006. Following
revisions as suggested by the Board, the final version of the document was approved on
October 31, 2006 by the CCN Board of Directors. This will be provided to the Ministry of
Health and Long Term Care, followed 30 days later by broad distribution to many
stakeholders. (See Appendix 7 and Appendix 8 for a list of members on these committees.)

3.2 Decision-Making Framework
In advance of its deliberations, the Panel members agreed that the report conclusions and
recommendations should be consensus-based. Consensus would be derived from the
prevailing balance of perspectives and evidence presented.

3.3 Stakeholder Consultation
Input was sought from the 17 member hospitals in Ontario including all CCN Cardiac
Hospital Administrators, Cardiac Surgery Chiefs of Staff and Cardiac Surgery Program
Directors. In total, seven organizations responded to the submission process - six cardiac
surgical centres and one cath-only centre (see Appendix 5 for the list of responding
organizations).

Panel members identified content experts within and outside of Canada, several of whom
were contacted and interviewed by the Project Coordinator (see Appendix 6 for a list of the
interview participants and jurisdictions). Each submission was reviewed and the responses
were collated and distributed to the Panel for discussion at the launch meeting in February.

3.4 Data
Other sources of information included a data review (CCN data, Statistics Canada 2004
population projections), a survey of all CCN cardiac surgery hospitals on surgeon staffing
and demographics, and an extensive literature review related to technology development,
clinical outcomes, and utilization trends for cardiac surgery and for percutaneous
interventions.




   21
3.5 Systems Modeling
The Panel worked with the Department of Industrial Engineering at University of Toronto
to develop a systems model that would help illustrate the factors driving change in cardiac
surgery, their interdependencies and time latency of effect, and the impact on capacity and
demand in the cardiac surgery system. The intent of this exercise was to provide both a
qualitative model that described these inter-relationships and their timing dynamics, as well
as a quantifiable model that could be used for long-term planning by policy makers and
CCN. The model was developed with input from Panel members and through consultation
with external experts and staff at the University of Toronto.




22
4 TRENDS IN CARDIAC SURGERY

4.1 Summary of Cardiac Procedural Trends
The CABG rate in Ontario has increased overall since the early 1990’s, with most of this
increase occurring after 1994/95. This was the period following the first CCN Target
Setting report6, which resulted in increased government funding for these procedures to
meet the underlying demand. Since 1997/98, there has been a levelling of this growth as
shown in Figure 1. Since 2002/03 the actual CABG rate (99 per 100,000 adults) has been
less than the target rate for the province (110 per 100,000 adults).

Figure 1 – Actual and target (crude) CABG rates per 100,000 adult population*,
Ontario residents, 1993/94 to 2004/05



                                  120
        Rate per 100,000 adults




                                  100

                                  80

                                  60

                                  40

                                  20

                                   0
                                  19 4




                                  20 4
                                  19 5

                                  19 6

                                  19 7

                                  19 8

                                  19 9

                                  20 0

                                  20 1

                                  20 2

                                  20 3



                                         5
                                       /9

                                       /9

                                       /9

                                       /9

                                       /9

                                       /9

                                       /0

                                       /0

                                       /0

                                       /0

                                       /0

                                       /0
                                    93

                                    94

                                    95

                                    96

                                    97

                                    98

                                    99

                                    00

                                    01

                                    02

                                    03

                                    04
                                  19




                                               Fiscal Year

                                        Actual rate             Target rate

Source: CCN Cardiaccess Database
* CABG = isolated CABG plus CABG +/- valve procedure




6
    Target Setting Working Group, Final Report and Recommendations. CCN, October 2000.

      23
In contrast, the PCI rate has increased steadily since 1996/97 and has been above the target
rate since 2000/01 as shown in Figure 2. Consequently in 2004, CCN reviewed the
procedure target rates, which resulted in a substantial increase in the PCI target rate from
140 in 2003/04 to 220 per 100,000 by 2008/09.

Figure 2 – Actual and target (crude) PCI rates per 100,000 adult population, 1993/94
to 2004/05



                                250




                                200
      Rate per 100,000 adults




                                150




                                100




                                 50




                                  0




                                              Fiscal Year

                                      Actual rate           Target rate

Source: CCN Cardiaccess Database




24
While the rate of CABG surgery declined by 4.8% (00/01 to 04/05), PCI rates have
increased by 62.5% during this same time period. Similar trends are seen across Canada
and the U.S. The Canadian Institute for Health Information and Statistics Canada report a
2.8% decrease in CABG rates and a 66% increase in PCI across Canada between 1998-99
and 2002/03, while the American Heart Association report a 15% decrease in CABG
procedures and a 31% increase in PCI in the U.S. between 1997 and 2002.7 Figure 3
illustrates the CABG rates for each province from 1999 to 2004. With the exception of
Saskatchewan, CABG rates have flattened or decreased across all provinces during this
time period.

Figure 3 – Bypass Surgery Rates (crude) per 100,000 adults (≥ 20 yrs) by Province
and Canada, 1999 to 2004

                          180.0


                          160.0


                          140.0
       Rate per 100,000




                          120.0


                          100.0


                           80.0


                           60.0


                           40.0
                                  1999           2000         2001    2002           2003            2004

                                         New foundland and Labrador          Prince Edw ard Island
                                         Nova Scotia                         New Brunsw ick
                                         Quebec                              Ontario
                                         Manitoba                            Saskatchew an
                                         Alberta                             British Columbia
                                         Canada

Source: www.cihi.ca/hireports




7
    Sibbald, B. CMAJ, September 13, 2005;173(6)


25
As a result of these shifts, the ratio of PCI to CABG has tripled in Ontario since 1997/98
from 0.7 to 2.2 in 2004/05 as seen in Figure 4. Although the proportion of patients referred
on for revascularization has not changed substantially over the past decade (catheterization
to revascularization ratio of approximately 2.0), the choice of procedure has shifted from
CABG to PCI.

Figure 4 – Catheterization: Revascularization Ratios and PCI:CABG Ratios,
1995/96 to 2004/05


             2.5



             2.0



             1.5
     Ratio




             1.0



             0.5



             -
                   1995/96 1996/97 1997/98 1998/99 1999/00 2000/01 2001/02 2002/03 2003/04 2004/05


                                                   Fiscal Year

                                     Cath:revasc ratio             PCI:CABG ratio

Source: CCN Cardiaccess Database



The current crude CABG rate of 100 per 100,000 adult population is the sum of isolated
CABG procedures and CABG with a concomitant valve procedure. The majority of CABG
procedures are isolated CABG. However, since 2000/01, there has been a shift in the
distribution of cases to more combined CABG and valve procedures. Over the past five
years, the percentage of isolated CABG to total CABG has decreased from 91% to 86%.
The absolute numbers of isolated CABG performed has been on the decline (4% decrease
from 2000/01 to 2004/05), while combined CABG/valve and isolated valves have
increased during this same time period (48% and 15% increase respectively). As a
percentage of total surgery performed in Ontario, isolated CABG has decreased from 75 to
70%, combined CABG/valve has increased from 8 to 11% and isolated valve from 13 to
14% (2000/01 to 2004/05).8

Similar trends are reported in other jurisdictions. In Nova Scotia, isolated CABG as a
percentage of total surgery has decreased from 77% to 67% over the past 10 years9 and in
Quebec it has dropped from 73% to 69% from 1997 to 2003.10

8
    CCN Cardiaccess Database
9
    Dr. Greg Hirsch, personal interview, April 2006.


26
4.2 Changes in Patient Clinical Characteristics
While the number and rate of CABG procedures are levelling, there is a perception
amongst stakeholders that patients referred for this procedure are presenting with
increasingly complex health issues such as renal failure, peripheral vascular disease (PVD)
left ventricular dysfunction and failed PCI.11

Tables 2 and 3 show the incidence of selected co-morbid conditions in the surgical
population in Ontario between 1998/99 and 2005/06. (See Appendix 8 for the complete risk
factor tables.) The data supports the perception of a changing patient clinical profile,
particularly, that patients undergoing CABG and CABG + valve are generally older (6.6%
and 8.5% increase in patients > 75 years respectively), and have a higher prevalence of
diabetes (8.8% and 11.8% increase), CVD (2.3% and 3.6% increase), left main disease
(12.1% and 5%) and urgent/semi-urgent classification (6.2%). In general, this shift appears
to be more pronounced in the CABG + valve surgical population.


Table 2 - Prevalence of Selected Risk Factors for Isolated CABG and CABG + Valve,
1998/99 to 2005/06

                                     Isolated CABG         CABG + Valve
Risk Factor                        1998/99    2005/06    1998/99      2005/06
> 75 years                          12.5%      19.1%     29.4%         38.0%
Diabetes                            25.7%      34.5%     17.8%         29.6%
CVD                                  7.8%      10.2%     10.5%         14.1%
PVD                                 10.7%      12.6%     11.2%         12.0%
Dialysis                             1.0%       1.2%     1.1%           1.4%
Left main disease                   19.2%      31.2%     11.1%         16.1%
Semi-urgent/ urgent                 51.3%      57.5%      N/A            N/A
Source: CCN Cardiaccess Database




Table 3 – Number of Patients with Selected Risk Factors for Isolated CABG and
CABG + Valve, 1998/99 to 2005/06
                                     Isolated CABG         CABG + Valve
                                   1998/99    2005/06    1998/99      2005/06
Risk Factor                        N = 8021   N = 7894   N = 820      N = 1365
> 75 years                           999       1508       241           518
Diabetes                            2063       2725       146           404
CVD                                  629        802        86           192
PVD                                  857        995        92           163
Dialysis                              82        97         9            19
Left main disease                   1536       2461        91           220
Semi-urgent/ urgent                 4118       4542       N/A           N/A
Source: CCN Cardiaccess Database


10
   Le développement de l’hémodynamie au Québec. Rapport du Comité d’experts en Hémodynamie du
Réseau du Reseau Québécois de Cardiologie Tertiaire, June 2005.
11
   Response to the Cardiac Surgery Consensus Panel call for submissions to the CCN Cardiac Centres,
December 2005.

     27
When the actual numbers of patients within each risk factor are reviewed, the changes
appear more substantial. For example, in the CABG + valve population, the actual number
of patients over 75 has more than doubled (from 241 to 518), the numbers of patients
presenting with left main disease has increased 140% (91 to 220) and the number with
diabetes has increased by 175% (146 to 404).

On average, patients undergoing CABG procedures are 1.4 years older than the patients
who had this procedure done five years ago (63.7 to 65.1 years, See Figure 5).

Figure 5 - Mean Age of Patients Referred for Cardiac Surgery by Type of Procedure
2000/01 – 2005/06

      72


      70


      68


      66


      64


      62


      60


      58


      56
               2000          2001          2002           2003          2004           2005


                                    CABG           CABG +Val ve          Val ve


 Source: CCN Database




Compared to age demographics in the general population, the elderly population comprises
a higher percentage of the total population in the cardiac surgery population versus Ontario
as a whole. In 2005, the >75 year age group comprised only 6% of the total Ontario
population versus 19% and 38% for isolated CABG and CABG + valve patients
respectively. The rate of increase of the elderly cardiac patient is also growing
disproportionately to the general population. Over the 5 year period 2000/01 to 2004/05 the
+75 year age group increased by 22% in the CABG population versus 14% in the general
population.12



12
 Source: CCN Cardiaccess database and Statistics Canada estimates (2005) projections by the Ontario
Ministry of Finance

     28
5 THE CARDIAC SURGERY IN ONTARIO – UNDERSTANDING
  THE CURRENT ENVIRONMENT

5.1 Key Issues in Cardiac Surgery
The key challenge facing the cardiac surgery enterprise in Ontario is to maintain a tradition
of clinical and academic excellence despite the rapid changes occurring in the general
health care environment, and the cardiac environment in particular. These rapid changes
challenge our ability to “right size” the delivery of cardiac surgery, and to match system
capacity and capability with system demand in order to maintain optimal access to high
quality care.

A mismatch in the system can manifest on multiple levels, such as the ability to match: 1)
human resource needs and available supply; 2) regional distribution of capacity and patient
need; and 3) human resource skills sets to emerging technology.

Over the past two decades, cardiac surgery has been managed at the Ministry level as a
priority service, and has received targeted funding for expansion to meet the increasing
demand for this procedure. This planned expansion occurred at the cusp of an unanticipated
shift in this growth trend with the evolution and growth of interventional cardiology.
Subsequently, cardiac surgery in Ontario, and in many other jurisdictions in Canada and
internationally, relatively recently finds itself in an “oversupply” situation with under-used
capacity in some regions, some hospitals not achieving their targets for government
funding, some operators nearing minimum volume thresholds, and a lack of positions for
graduating cardiac surgery residents.13

However, many predict this pendulum may shift over the longer-term, including the
Canadian Society of Cardiovascular Surgeons14 and the Royal College of Physicians and
Surgeons of Canada. 15 Perceived disincentives to enter a flattening cardiac surgery field
today, together with the long latency period to train surgeons and emerging technology,
could result in an “undersupply” of high-calibre graduating surgeons tomorrow to meet
patient need.

There is also a concern that there is a current lack of attention to upgrading surgeon and
allied health professional skills in parallel with changing technology and patient clinical
complexity. Subsequently, a mismatch between human resource capacity, capability and
distribution in the system could lead to a recurrence of increasing wait lists, as seen in the
early 1990’s, and impact the quality of patient care without the appropriate long-term
planning today.




13
   Canadian Cardiovascular Society Workforce Project Team. Profile of the cardiovascular specialist
physician workforce in Ontario, 2004. Can J Cardiol. 21(13); pg 1157-1162, Nov 2005.
14
   Interview, Dr. Christopher Feindel, President Canadian Society for Cardiovascular Surgeons
15
   CMAJ, 17(6), pg 583-584, September 13, 2005

     29
5.2     Key Drivers and Impact of Change
5.2.1      Advances in technology

5.2.1.1 Recent trends
New and expanding technologies have had an important impact on practice patterns in
cardiovascular care and on the demand for cardiac surgery. For the past few decades,
coronary artery bypass graft surgery (CABG) has been the revascularization procedure of
choice for patients with ischemic heart disease and myocardial infarction. Despite good
long-term outcomes, the procedure involves significant surgical trauma and time for full
recovery. Percutaneous transluminal coronary angioplasty (PTCA) in the 1970s and
coronary stenting in the 1980s were developed as minimally invasive alternatives to CABG
surgery. The prominent advances in percutanous interventions (PCI), such as the
refinement of coronary stents and the more recent advent of drug-eluting stents (DES),
have resulted in the rapid growth of these less-invasive procedures as a safe and effective
alternative to traditional open-heart surgery for many patients. Consequently, PCI rates in
Ontario have increased 62.5% while CABG rates have decreased 4.8% over the past five
years. In addition to the growth in angioplasty, other new and/or experimental interventions
such as percutaneous valve replacement and catheter-based treatment options for rhythm
disturbances, are on the horizon and may impact on surgical procedures for these
conditions in the future.16

With advances in operative techniques, CABG surgery has also become safer and more
durable even for patients with multiple co-morbidities.17 Improvement in myocardial
protection has reduced peri-operative and post-operative complications. Multiple arterial
grafting has been advocated for its improvement in long-term outcomes over saphenous
vein graft bypass in selected coronary targets.18 19 However, aside from a few institutions
who are proponents of this approach, multiple arterial grafting has not gained immense
popularity among most cardiac surgeons, possibly due to increased operative time and costs
and limited experience in arterial conduit harvest.20

Several novel approaches have been developed to address the limitations of on-pump
CABG surgery. Off-pump coronary artery bypass (OPCAB) avoids the systemic effects of
cardiopulmonary bypass, and has been shown to decrease blood product use and hospital
length of stay, and may avoid the negative neurological effects associated with the use of



16
   Latter DA. Evolution of percutaneous endovascular interventional cardiovascular specialists: Convergence
of cardiac surgery and interventional cardiology. Can J Cardiol; 21(14):1296-1297, Dec 2005.
17
   Ferguson TB, Jr., et al., A decade of change – risk profiles and outcomes for isolated coronary artery
bypass grafting procedures, 1990-1999: a report from the STS National Database Committee and the Duke
Clinical Research Institute. Society of Thoracic Surgeons. Ann Thorac Surg. 2002;73:480-489.
18
   Desai ND, Cohen EA, Naylor CD, Fremes SE. A randomized comparison of radial-artery and saphenous-
vein coronary artery bypass grafts. N Engl J Med. 2004;351:2302-2309.
19
   Lytle BW, Sabik JF. Use of multiple arterial grafts and its effect on long-term outcome. Curr Opin Cardiol.
2002;32:489-501.
20
   STS database

      30
the cardiopulmonary bypass machine. 21 However, OPCAB is used infrequently in Ontario
with only 15% of patients receiving this type of bypass surgery (fiscal years 2002 to 2004)
with the majority of these procedures (59%) done at one centre.22

Minimally invasive direct coronary artery bypass (MIDCAB), total endoscopic coronary
artery bypass (TECAB) as well as robot-assisted coronary artery bypass address the issue
of surgical trauma from large incisions. However, there is a significant learning curve and
costs associated with these procedures and cardiac surgeons have not widely adopted these
novel techniques. (One centre in Ontario is using robotic technology.)

Therefore, the majority of CABG surgeries performed today still employ the “maximally
invasive” approach: open sternotomy and cardiopulmonary bypass on an arrested heart.
In general, advances in cardiac surgery have had less profound impact and the uptake has
been less widespread than for PCI, primarily due to costs, technical limitations and longer
learning curves.

5.2.1.2 Emerging Trends
It is anticipated that imaging will play a prominent role in the transformation of
cardiovascular services in the next 5 to 10 years. The enhanced imaging capability of
magnetic resonance imaging (MRI), computed tomography (CT) and positron emission
tomography (PET) demonstrated in ongoing trials may lead to earlier and more accurate
diagnosis and interventions, and better targeted therapies, thereby potentially expanding the
eligible cardiac surgery and PCI pool and resulting in improved outcomes. These
technologies are currently going through iterative improvements and as they evolve, may
generate opportunities for either conflict or collaboration between technologies and
departments and for resources.

Drug-eluting stents account for approximately 58% of all PCI procedures in Ontario. It is
anticipated that this treatment will move to carotid arteries, renal arteries and peripheral
arteries over the next 2 to 5 years. With the exception of an additional shift of 5 to 10% of
CABGs to PCI due to the introduction of biodegradable stents, experts feel that overall, the
PCI:CABG ratio has stabilized.

Patient demand for the least disruptive procedure is pushing the development of minimally
invasive techniques. Advances in this field include endovascular surgery for repair of
abdominal aortic aneurysms, ablative treatment of cardiac arrhythmias, atrial and
ventricular septal defects, vein harvesting and valve repairs. These advances will be closely
linked with advances in imaging capabilities and surgical tools. Current limitations in their
advancement include the high costs for research, development, and capital costs.

These emerging technologies have implications for physical space requirements, capital
costs and human resource skill sets. Increased use of endovascular procedures will increase
the need for more interventional space and for rooms that can convert to either hybrid or

21
   Raja SG. Pump or no pump for coronary artery bypass: current best available evidence. Tex Heart Inst J
2005;6:187-193.
22
   Guru, V., 2005

    31
open procedure rooms. It was the consensus of the Panel that surgery in the future will be
more expensive; driven partially by an increasingly more complex patient population and
changing technology and physical infrastructure. Government planning now for these
future cost pressures and capital investments would be prudent.

5.2.2     Convergence of specialties
With the advancements in technology, the scope of practice between various specialties is
starting to overlap. The new technologies transcend the traditional barriers between
radiology, cardiology, cardiac surgery and vascular surgery, but organizational structures,
professional credentialing and funding methodologies do not. For example, percutaneous
valve replacement requires the integration and convergence of skills sets from both
interventional cardiologists and cardiac surgeons – skill with percutaneous catheters and a
working knowledge of the intra-cardiac anatomy. Currently, neither specialty alone is fully
competent to do these procedures. 23 However, there is little overlap in the training
programs. The Royal College of Physicians and Surgeons of Canada’s 6 year training
program for cardiac surgeons has only a one month rotation in the interventional catheter
laboratory.24

There is concern that maintaining the current status quo will result in competition between
radiologists, cardiac surgeons, cardiologists and other specialists for control of these new
modalities and eligibility to perform the procedures. These new fields present new
opportunities for surgeons, but are still evolving and the impact is relatively unknown.
However, the managed introduction of these practices, supported by adequate training
programs and realignment of functional programs to support integration and collaboration
will be critical. Currently, with the exception of pacemaker implants, no cardiac surgeons
in Ontario are performing interventional or vascular procedures.25

5.2.3     Practice patterns
Changing practice patterns over the past 5 years have also had an impact on the increasing
PCI:CABG ratio. Improved outcomes in acute coronary syndrome patients (ACS) treated
within 90 minutes by PCI versus traditional fibrinolysis has resulted in some ACS patients,
previously treated by CABG, being diverted to the catheterization laboratory for early PCI.
Similarly, the increasing use of same-sitting PCI is an efficient use of resources, but its
impact on case selection decisions for PCI versus CABG is uncertain. There is significant
variation in the same-sitting rate and PCI:CABG ratio across the province, and reason and
impact of this variability is unknown.

5.2.4     Increased system capacity
Provincially, access to cardiac services has been greatly enhanced over the past several
years due to large investments in additional procedure volumes, expanded existing facilities
and the opening of new centres. Since the beginning of the MOHLTC six-year cardiac
expansion plan in 1998/99, 2 cath-only centres and 1 stand-alone PCI centre have opened
23
   Latter DA. Evolution of percutaneous endovascular interventional cardiovascular specialists: Convergence
of cardiac surgery and interventional cardiology. Can J Cardiol; 21(14):1296-1297, Dec 2005.
24
   Ibid, Latter DA. 2005.
25
   CCN Hospital Survey, May 2006.

     32
and a total of 17 new cath labs have become operational. Surgical physical capacity has
increased with the addition of the 3 community full-service centres at St. Mary’s General
Hospital, Southlake Regional Health Centre, and Trillium Health Centre and the additional
surgical suite at Hamilton Health Sciences. In total, 7 surgical suites have opened during
this time. (See Tables 4 and 5). This expansion has enabled care to be brought closer to
home for the patient and has resulted in median wait times for cardiac surgery to decrease
from 43 days (1997/98) to 14 days (2005).

Table 4- Summary of Ontario Surgical Capital Expansions pre- and post-6 year
Cardiac Expansion Plan (1998/99)
                                                                   No. of Suites as   No. of New Suites
                                                   LHIN
                HOSPITAL                                             of 1998/99        Since 1998/99

 Southlake Regional Health Centre                 Central                                    2
 Hamilton Health Sciences                         HNHB                    3                  1
 St. Mary’s Hospital                        Waterloo Wellington                              2
 Trillium Health Centre                     Mississauga Oakville                             2

 Kingston General Hospital                      South East                2

 University of Ottawa Heart Institute           Champlain                 4

 Sudbury Regional Hospital                      North East                2

 London Health Sciences Centre                  South West                4

 Sunnybrook Health Sciences Centre            Toronto Central             3

 University Health Network                    Toronto Central             5

 St. Michael’s Hospital                       Toronto Central             3

 Total suites (prior to 1998/99)                                         26

 Total new suites (1998/99 to April 2006)                                                    7




    33
Table 5 - Summary of Ontario Cath Lab Capital Expansions pre- and post-6 year
Cardiac Expansion Plan (1998/99)
                                                                        No. of Labs    No. New Labs
                      HOSPITAL                                         as of 1998/99   Since 1998/99
                                                       LHIN

     Peterborough Regional Health Centre            Central East                            126

     Rouge Valley Health System                     Central East            1               1
     Southlake Regional Health Centre                 Central                               2
     Hamilton Health Sciences                         HNHB                  3               1
     Trillium Health Centre                     Mississauga Oakville                        3
     St. Mary’s Hospital                        Waterloo Wellington                         2
     University of Ottawa Heart Institute           Champlain               3               1

     Kingston General Hospital                      South East              1               1

     Sudbury Regional Hospital                      North East              1               1

     Sault Area Hospital                            North East              1

     Thunder Bay Regional HSC                       North West              1

     London Health Sciences Centre                  South West              3               1
                                 27
     Hôtel-Dieu Grace, Windsor                     Erie St. Clair           1

     Sunnybrook Health Sciences Centre            Toronto Central           2               1

     Toronto East General Hospital                Toronto Central                           1

     St. Michael’s Hospital                       Toronto Central           3

     University Health Network                    Toronto Central           6

     Total labs (prior to 1998/99)                                          26
     Total new labs (1998/99 to April 2006)                                                 16




Although viewed as a important success for the cardiac system, this expansion has also had
ripple effects in other areas such as changes in case volumes, referral patterns, case mix,
and human resources in cardiac hospitals across the province. In some cases, this has
shifted the balance between local capacity and local need, with the potential for surplus
capacity in some hospitals or region(s). With the current flattening of cardiac surgery
volumes provincially, the increased surgical capacity has resulted in a redistribution of the
same number of surgical cases and fewer cases per surgical suite.




26
   Peterborough has a “swing lab” - two procedure tables separated by folding doors with a common X-ray
stand that “swings” between the tables. Such a suite has a capacity intermediate between one and two rooms.
27
   The cath lab in Windsor was relocated from Grace Hospital to Hôtel-Dieu Grace Hospital.

       34
Table 6 – Total Planned and Actual Surgery Volumes by Hospital and LHIN, 2001/02
to 2005/06
          Hospital                    LIHN                2001/02            2002/03              2003/04              2004/05              2005/06
                                                      Planned Actual   Planned     Actual   Planned     Actual   Planned     Actual   Planned     Actual
Southlake Regional HC                 Central          N/A     N/A       N/A        N/A       140        132       914        731       914        880
Hamilton HSC                          HNHB             1400    1383     1400       1439      1400       1404      1400       1357      1478       1389
St. Mary's General Hospital    Waterloo/Wellington     N/A     N/A      N/A        N/A        338       370       550         494       700        708
Trillium Health Centre         Mississauga Oakville    1100     975      950        958      1104       1128      1100       1102      1100       1108
Kingston General Hospital           South East          567     567      530        570       567        588       610        565       590        570
University of Ottawa HI             Champlain          1368    1180     1296       1139      1170       1129      1170       1069      1130       1255
Sudbury Regional HC                 North East          705     628      675        601       622        530       575        499       535        455
London Health SC                   South West          1999    1675     1730       1654      1686       1514      1525       1325      1480       1365
Sunnybrook HSC                   Toronto Central       1364    1146     1250       1178      1226       1062      1250        939      1100        926
University Health Network        Toronto Central       2459    2145     2500       2010      2112       1877      2000       1898      1950       1871
St. Michael's Hospital           Toronto Central       1278    1201     1276       1267      1200       1110      1276       1218      1276       1082
                              Toronto Central Total    5101    4492     5026       4455      4538       4049      4526       4055      4326       3879
Total                                 Total           12240   10900     11607      10816     11565      10844     12370      11197     12253      11609

Source: CCN Cardiaccess Database
Note: shaded rows represents new cardiac surgery centres

Table 4 illustrates the changes in total surgery volumes by surgical centre. With the
exception of the new centres (shaded areas) that have increased volumes as part of a
planned expansion, the majority of centres have seen levelling or decreasing surgical
volumes, and are having difficulty achieving planned funded volumes. The greatest
reductions in actual volumes (2001/02 to 2005/06) are seen in hospitals in the North (28%),
the South West (18.5%) and Toronto Central (13.6%). As of the end of 2005/06, one centre
is below the CCN-recommended minimum standard28 for hospitals (500 surgery
cases/year).

Similarly, several surgeons are also operating below the CCN-recommended minimum
standard for operator volumes of 150 cases per year29 as seen in Table 5. Although there is
a wide range in the number of surgery cases completed per year by operator, the majority
complete between 200 and 250 cases per year.

Table 7 – The number of cardiac surgeons completing a range of surgery cases per
year, 2001/02 to 2005/06
                      2001/02    2002/03                                   2003/04          2004/05            2005/06
   <150 cases/yr         11        10                                         6                5                  8
  150-200 cases/yr       10         9                                        17               16                 17
  200-250 cases/yr       20        20                                        18               16                 13
  250-300 cases/yr        9        11                                         8               10                 10
   >300 cases/yr          6         5                                         3                6                  6
     # Surgeons          56        55                                        52               53                 54
Source: CCN Cardiaccess Database



Despite increased surgical procedural capacity, bottlenecks in accessing the surgical system
can exist, such as sufficient ICU capacity and capability. With the increasing patient
complexity at some centres, ICU lengths of stay are increasing and creating bottlenecks in

28
   Consensus Panel on Cardiac Surgical Services in Ontario. Final Report and Recommendations. CCN, April
1998.
29
   Ibid, CCN 1998.

        35
throughput. As well, new and increasing skill sets to meet the clinical needs of these more
complex ICU patients and their new procedures/equipment will be required.

5.2.5                Demographics
Important demographic drivers of change in cardiovascular care include the increasing
lifespan of our population, the development of prolonging technologies and the effect of
increasing risk factors (obesity) on cardiovascular health.

The largest increasing age cohorts in the Ontario population are the 60-69 and 70-79 age
groups as seen in Figure 6.30 The increase in lifespan is marked with a rising prevalence of
chronic disease. As described earlier, the prevalence of the > 75 year age group in the
cardiac surgical population is larger and increasing at a faster rate than in the general
Ontario population. This could be partially driven by the success of current medical
interventions resulting in the delay of patients presenting for cardiac surgery. Nevertheless,
this has most likely contributed to the increasing complexity and co-morbidity in the
cardiac surgery patient pool. As the lifespan of the broader population increases, the size
and complexity of the patient pool presenting for cardiac interventions will also likely
increase.

Figure 6 - Ontario Population Projections by Age Category, 2005 to 2025
                   2,400,000
                   2,200,000
                   2,000,000
                   1,800,000
      Population




                   1,600,000
                   1,400,000
                   1,200,000
                   1,000,000
                    800,000
                    600,000
                    400,000
                           05


                                  07


                                         09


                                                 11


                                                        13


                                                               15


                                                                      17


                                                                             19


                                                                                    21


                                                                                            23


                                                                                                   25
                         20


                                20


                                       20


                                               20


                                                      20


                                                             20


                                                                    20


                                                                           20


                                                                                  20


                                                                                          20


                                                                                                 20




                                                               Year

                           40-49              50-59            60-69              70-79                 80+

Source: Statistics Canada



Obesity has a major impact on the burden of disease in Canada. Over the past two decades,
rates of overweight and obesity have more than doubled for Canadian adults and nearly
tripled among Canadian children.31 Research has shown that obesity has a major health
impact on children’s health such as increased occurrence of hypertension, high cholesterol
and Type 2 diabetes. Therefore, obesity increases the risk of cardiovascular disease and

30
     Statistics Canada estimates (2005); projections by the Ontario Ministry of Finance
31
     Improving the Health of Canadians. Canadian Population Health Initiative, CIHI, 2004.

         36
decreases the age of its onset. Although the latency period is generally several decades, it is
anticipated that obesity will increase the incidence and burden of cardiovascular disease in
Canadians over the long term.

5.2.6       Human resource planning
The Royal College of Physicians and Surgeons of Canada is responsible for the content and
quality of physician training programs. However, there is no recognized authority to limit
or manage cardiac surgery training programs, nor is there inter-site communication to
properly predict and communicate the needs across Ontario. The numbers of residents
accepted each year are, for the most part, determined by the individual Academic Centres.

As seen in Tables 8 and 9, there are currently 54 cardiac surgeons performing adult cardiac
surgery in Ontario. Only 7 (13%) will reach the age of retirement in the next 5 years.
However, there are a total of 26 cardiac surgery residents currently being trained at a rate of
approximately 4 graduates per year. Over the next five years, there is a potential for 22 new
cardiac surgeons (41% of the total number of cardiac surgeons) entering the market that
currently has only one vacancy in addition to the 7 upcoming retirement vacancies. Across
Canada, there are 14 cardiac surgeons due to be certified in 2006 and 13 in 2007.32 Due to
the lengthy training requirements for cardiac surgery, many of these residents made the
decision to enter this specialty during its period of expansion and are now graduating at a
time when the field is saturated.

Table 8 – The number of cardiac surgery residents in Ontario and estimated date of
residency completion

Year of completion           2006       2007          2008        2009       2010     >2010     Total
No. cardiac residents            4         4             5         4           5            4    26
Source: CCN Hospital Survey, May 2006

Table 9 – The number of cardiac surgeons in Ontario by age category

Age category (yrs)         <40       40-49         50-59     60-65       >65        total
No. surgeons               10         25            12        5          2           54
Source: CCN Hospital Survey, May 2006

Although there is currently an oversupply of cardiac surgery residents in Ontario and
Canada, there is concern that this pendulum could shift within the next 7 to 10 years. Dr.
David Ross of the Royal College of Physicians and Surgeons of Canada’s Cardiac Surgery
Speciality Committee has cautioned against responding to the current flat market by
restricting the number of surgery trainees, as other factors that could influence the long-
term need for surgery are difficult to predict.33 For example, other types of surgical work
are increasing such as surgically implanted devices, and the long-term efficacy and impact
of stenting is still unknown. Despite this caution, some Academic Health Science Centres


32
     CMAJ, 17(6), pg 583-584, September 13, 2005
33
     Ibid, CMAJ, 2005.

       37
in Ontario have already implemented plans to reduce their cardiac surgery residency
enrolment over the next few years.

As well, in 2002 and 2003 only half of the expected number of surgeons retired in Canada,
and numbers are anticipated to increase. With a large cohort of cardiac surgeons over the
age of 55 in the U.S. anticipated to also retire in the next 5 to 10 years, market forces may
draw high calibre talent south of the border.

There are many other members of the health care team that are critical to our ability to
deliver timely and quality patient care. Currently, there is an undersupply of many other
specialists such as anesthetists, nurse practitioners and critical care nurses. For example, the
report and recommendations of the Operative Anesthesia Committee (2006) describes an
8% shortfall of anesthesiologists in Canada (114 in Ontario which is predicted to increase
to 459 in 2016).34

Many feel this is a result of the recommendations from the 1991 Barer-Stoddart report. The
report made approximately 30 recommendations, including increasing the number of nurse
practitioners, implementing interdisciplinary teams and reducing the number of physicians
in Canada. Only the last was implemented, and resulted in approximately a 10% reduction
in enrolment in medical schools.35 Associations are now looking to implement some of the
other recommendations such as making use of more collaborative teams and alternative
providers such as nurse practitioners. The Operative Anesthesia Committee (April 2006)
recently recommended the formal introduction of Anesthesia Care Teams (ACTs).

Implementing collaborative teams and making greater use of alternative providers for
cardiac surgery patients would also help de-link hospital manpower needs from the number
of cardiac surgery residents required each year. Many hospitals currently use their cardiac
surgery residents to help manage non-surgical short-term clinical work load, such as 24/7
coverage in the CCU or CVICU or provide research assistance. Many of these services
could be provided more appropriately by hospitalists, intensivists, and nurse practitioners.
A better alignment of human resource skill sets to patient and hospital needs would help
better define cardiac surgery resident and other health care provider resource needs and
help focus training on new/evolving procedures and technology as well as on the evolving
clinical care needs of the patient.

5.2.7     Financial incentives
Advanced cardiac procedures are funded through volume-based funding for both
physicians and hospitals. Volume-based remuneration can create a competitive versus a
collaborative environment. It limits the flexibility of hospitals to implement new
technologies and innovative techniques as well as the sustainability of academic
envirnoments. The funding methodology does not recognize variation in case complexity
or technology – more complex, resource or technology intensive cases are remunerated at


34
   Transforming the Delivery of Operative Anesthesia Services in Ontario. Report and Recommendations of
the Operative Anesthesia Committee, MOHLTC, April 2006.
35
   Cyboran J. Specialists’ thinning ranks. National Review of Medicine. 3(5), March 15, 2006

     38
the same level as simple cases. Recent adjustments to historical cardiac surgery funding
rates have helped, but have adjusted more for demographics than clinical acuity.

5.2.8   Cardiac Surgery Systems Model
The Panel worked with the University of Toronto Department of Industrial Engineering to
develop a systems model that would help illustrate these change drivers, their impact on
cardiac surgery system capacity and demand, and their complex time latency periods of
effect. A preliminary model was developed which helped illustrate for the Panel how the
many factors influence the balance between demand and capacity in the system. Although
additional work is required to further refine the model and its underlying assumptions, a
draft quantitative analysis provided a useful illustration of the timing dynamics of the need
and supply for cardiac surgeons in the province. This type of modeling may prove useful to
inform future long-range planning and would be an important addition to the CCN-ICES
procedural target setting analysis.

A complete description of the preliminary model and its underlying assumptions and data
sources can be found in Appendix 8. The full report on the systems model is available as a
supplementary document to this report.




   39
6 PLANNING FOR THE FUTURE

6.1    A Vision for Cardiac Surgery in Ontario

A cardiac surgery system that delivers internationally recognized excellence in quality care, is
innovative and adaptive to changing needs, optimizes the human resources needed to support the
system, and promotes academic excellence and inter-specialty collaboration for the benefit of
patients in Ontario and beyond

We believe that this vision serves as a foundation on which to base future planning decisions: it
reflects the context of rapid and substantive change while encompassing the fundamental attributes
of an ideal cardiac surgery system: patient-centred excellence that is readily accessible,
economically sustainable, innovative, attractive as a work environment, accountable for
existing and future investment, collaborative and broadly engaged, and aligned with
political and social priorities.

6.2 A Future Model for Cardiac Surgery in Ontario
To help achieve this vision, we believe there is merit in viewing cardiac surgery in Ontario
as a single integrated “virtual” program with cross-provincial planning and management. A
large integrated program performing over 10,000 cases per year is highly viable and
influential, and provides a very robust capability for “buffering” against, and adapting to,
changes in the external environment. Small, or relatively small, individual programs with
fluctuating case volumes do not have the same buffering and adaptive capability.

We are not suggesting complete integration of all programs at all levels, but rather a
selective use of this model to address a number of issues. For example, one key challenge
is the balancing of critical mass against geographic accessibility. The general decline in
coronary bypass case volume has accentuated this challenge. When viewed as a large
integrated pan-provincial program, a number of innovative options – which might
otherwise not be available - open up for achieving this balance. To further the example,
this might encompass a plan to maintain both regional access and minimum operator
volumes in a smaller community by providing local surgeons the opportunity to perform
some cases at another larger centre. Such a plan would be contingent on strong
collaborative relationships at the institutional and individual provider level, a shared
commitment to patient-centred excellence, and an acceptable remuneration mechanism that
rewards rather than penalizes collaborative system-oriented behaviour.

One particular model of integration has recently been proposed by the University of
Toronto Cardiac Surgery Hospitals (St. Michael’s, Sunnybrook, and UHN). Ultimately,
the extent of integration between various cardiac surgery centres in the province will likely
vary based on the size and scope of individual programs and on geographic and other
factors. Regardless of the extent, it seems evident to us that increased collaboration and
integration will be essential to achieve the vision as outlined.


      40
6.3 Discussion Points and Recommendations
The discussion points and recommendations have been organized into four strategic areas :
1) strategies that strengthen the system’s ability to meet patient needs by way of planning
and monitoring within an integrated provincial framework; 2) strategies that enhance
short-term stability and responsiveness to patient needs in the cardiac surgery; 3)
strategies that will benefit care via alterations to the cardiac surgery funding methodology;
and 4) strategies to ensure long term sustained accessibility and excellence in cardiac
surgery.

The parties that should participate in further discussions (and ultimately must implement
new policies that arise) are diverse, and include patients and the public, clinical groups and
professional societies, hospitals, medical schools and universities, the Royal College of
Physicians and Surgeons of Canada, provincial licensing authorities, and provincial
governments. In Ontario, the recently created Local Health Integration Networks will also
play a key role in influencing and adapting strategies to the regional level. Because there is
no specific unifying authority or umbrella organization that encompasses all of these
groups, there may be a facilitative role for CCN in bringing these stakeholders together and
moving these issues forward. To enhance collaboration in the future planning and delivery
of cardiovascular care, the consultative and decision making processes should be fully
transparent and should seek broad input from all relevant stakeholders.

Many of the issues raised in relation to cardiac surgery are also relevant to coronary
angioplasty, diagnostic catheterization, and cardiac rhythm management. Therefore, while
this discussion paper is focused on cardiac surgery, we feel that is could serve as a template
for future discussions on other aspects of advanced cardiovascular care.


I. INTEGRATED PROVINCIAL PLANNING AND MONITORING

Excellent patient care, a key component of our vision for cardiac surgery, encompasses
access and clinical outcomes. Both require active and rigorous monitoring to ensure they
are delivered at the highest level. Timely and equitable access also requires matching of
capacity to demand – which in turn requires advance planning, especially given the long
lead times needed to adjust capacity up or down in something as complex as cardiac
surgery.


There are a number of initiatives, as detailed below, that are either proposed or already
under way and that contribute greatly to integrated system-wide planning and monitoring.
These initiatives should be implemented, or further supported, in a timely manner.

I(a) A Cardiac Surgery Planning Committee should be established to support integration
and alignment of cardiac surgery services in the province. This was previously
recommended in the MOHLTC Report: Advanced Cardiac Services – Outcome of the 2004
Cardiac Surgery Sessions, February 18, 2005.


   41
I(b) The “Target Setting” process should continue on a regular basis – i.e. future cardiac
service needs should be identified through prospective evidence-based, regionally adjusted
planning of procedural targets and capacity for advanced cardiac services. (MOHLTC,
ICES, CCN)

I(c) The Systems Model created for this discussion paper should be further developed and
refined as it provides important insights into potential future constraints and may provide
quantitative input for future target setting. (U of T [Industrial Engineering], ICES, CCN)

I(d) Monitoring and reporting of major clinical outcomes such as in-hospital mortality
should continue as an important component of quality assurance and improvement.
Furthermore, as noted in the 2006 ICES-CCN Report on Surgical Outcomes, CCN should
work with member hospitals to collect key outcome data, including in-hospital mortality,
on a prospective real-time basis, to enable prompt recognition of any potential adverse
trends. (ICES, CCN, Cardiac Hospitals)

I(e) The relationship between volume and outcome should be monitored, and, if warranted
on the basis of contemporary evidence from Ontario and elsewhere, existing
operator/hospital volume standards should be re-evaluated. (ICES, CCN, Cardiac
Hospitals, MOHLTC)

I(f) A detailed and rigorous analysis of the variation in the PCI:CABG ratio in Ontario
needed to fully understand the factors that underlie marked differences in practice, and the
potential implications on outcomes, resource utilization, and surgical volumes.
(MOHLTC, ICES, CCN)


II. ENHANCE SHORT TERM STABILITY IN THE SYSTEM

The general decline in CABG volume, coupled with new surgical capacity in certain
regions, has combined to cause significant shifts in overall surgical volume, referral
patterns, and in the human resource pool. Some surgical programs, particularly in smaller
communities like Sudbury and Kingston, along with a growing number of individual
surgeons (at both small and large centres), see their respective volumes approaching or
falling below previously recommended minimum benchmarks. Newly trained cardiac
surgeons have few if any job opportunities in Ontario or elsewhere at present. Many
cardiac hospitals face resource bottlenecks that limit the throughput of cardiac surgery
patients and further impact on volumes.

Our review of available data leads us to believe that the decline in CABG volume is
levelling off and that the demand for CABG will be relatively stable over the next three to
five years. Valve surgery will continue to grow modestly over this time frame but
contributes only a small component of total surgical volume.

Therefore, over a three to five year time frame, a number of imperatives are evident and are
itemized below. These should be viewed as discussion points and policy options.


   42
II(a)                     Optimally utilize current capacity
                          Target audience         MOHLTC

Given the existing shortage of skilled personnel (anaesthesiologists, perfusionists, critical
care nurses, etc.), the timely (if not always “close to home”) availability of cardiac surgery
at present, and some degree of uncertainty as to future demand, the addition of significant
further capacity in the near term should be avoided. We believe that no new cardiac
surgery centres should be established over the next three years. In saying this we are
cognizant that some population centres are very remote from surgical services, and that
there may ultimately be a strong argument in support of further distributing such services.
Nonetheless, a three year hiatus seems reasonable in our view.

Because we also believe that demand will not fall appreciably further in the short term, the
overall capacity and capability that currently exists should be substantially maintained in
order to continue providing high quality accessible care. Ultimately, decisions on
distribution of capacity should be guided by the needs-based target setting process
referenced above, with appropriate attention to region-specific needs.

The distribution of cardiac surgery services at the three University of Toronto centres
(Sunnybrook, St. Michael’s, UHN) is being specifically addressed by a U of T working
group. An enhanced degree of clinical and academic integration among these centres is
being proposed.

II(b)                     Address resource bottlenecks
Target audience           MOHLTC, LHINs, Cardiac Hospitals

Resource bottlenecks – whether they be human or physical infrastructure resources - should
not interfere with appropriate case selection and access for patients requiring cardiac
surgery. Therefore, MOHLTC, LHINs and cardiac hospitals should promptly and
collectively address any system and resource bottle necks such as insufficient ICU beds,
operating room capacity, or shortage of human resources that may negatively impact on
patient access. The ability to accommodate high-risk patients who are likely to benefit
from surgery but have a long anticipated ICU stay is particularly germane in this regard.
This initiative needs to be aligned with, and emphasized in, the current critical care
strategies.
.
II(c)                      Retain human resource investment
Target audience            MOHLTC, LHINs, Academic Health Science Centres,
                           Cardiac Hospitals

Investments already made in the training of new cardiac surgeons, and the “intellectual
capital” resulting from these investments, should be protected as much as possible. The
systems model suggests the possibility of a shortage of cardiac surgeons a decade from
now, which would be exacerbated if there is no entry of young surgeons into the workforce
for an extended period. Therefore, funding support for a human resource strategy should
be considered by the MOHLTC, LHINs and cardiac hospitals to retain expertise in Ontario.


   43
The strategy could include short-term opportunities for employment or additional training
for at least some cardiac surgery residents who have completed training and are without a
staff position in cardiac surgery.

II(d)                     Coordinated volume planning
Target audience           Cardiac Surgery Planning Committee

There appears to be a new “steady state” for procedure volume, in which some centres and
some surgeons fall below traditional benchmarks. The balance between accessibility and
critical mass is a key (albeit delicate) consideration that needs to be addressed with
objective and innovative thinking. Many studies have identified some relationship between
higher volumes and better outcomes. However, there are also many published examples of
excellent outcomes associated with lower volumes. Rather than rigid adherence to volume
benchmarks, we believe the more cogent issue is to determine if, and how, lower volume
centres and/or surgeons can consistently achieve the best possible outcomes. If this is
indeed feasible, the cardiac surgery system in Ontario will be much better positioned to
meet the dual objective of high quality care that is regionally accessible.

Therefore, we foresee the need for an innovative and flexible approach to workload
distribution among surgeons that may involve, by way of example, one or more surgeons
from a low-volume centre performing some operations at another centre. This initiative
would be greatly facilitated by our view of the surgical hospitals as a single large virtual
program. In addition, its feasibility may be dependent on an acceptable funding
mechanism for institutions and providers (as addressed below).


III. REVISE THE FUNDING MODEL FOR CARDIAC SURGERY

III(a)                    Alternative funding methodology
Target audience           MOHLTC, LHINs, Cardiac Hospitals

A high quality system that emphasizes collaboration and integration requires reducing the
dependence of income on procedure volumes. Indeed, many would see this as a critical
enabler for several of the human-resource related policy options that we have presented
herein. Therefore, strong consideration should be given to alternative funding
methodologies that separate procedural volumes from funding at both the physician and
hospital level. Patient acuity, training needs, and other special considerations need to be
factored into an alternate funding formula.




   44
III(b)                    Expanded case-costing methodology
Target audience           MOHLTC, CIHI, Cardiac Hospitals

There is a need to identify legitimate variations in procedure costs and adjust funding
accordingly, so as to appropriately compensate hospitals for added complexity and/or use of
beneficial new technology. Toward this end, we believe that MOHLTC should support the
development of a more robust case-costing mechanism that would facilitate accurate tracking
of standardized indicators for clinical complexity, use of new technology and other sources
of cost variation for comparison across hospitals and LHINs. The case-costing process needs
to be expanded to include more hospitals and to include new and evolving cardiac surgery
procedures such as hybrid procedures, surgical treatment of arrhythmias and congenital
surgery. Processes for collecting this new/expanded information need to be incorporated into
developing information systems in the Province.


IV. LONG-TERM PLANNING TO PROMOTE ADAPTABILITY

IV(a)                     Coordinated technology uptake
Target audience           MOHLTC, LHINs, Cardiac Hospitals

The uptake of selected new technology is important if patients are to receive state-of-the-art
care. While there is a formal process in Ontario for evaluating and establishing policy
around selected technologies (OHTAC - Ontario Health Technology Assessment Council),
some funding and implementation decisions are made at the hospital level, particularly when
a given technology is at an early or intermediate phase of its “evaluation life-cycle” and there
is not yet sufficient data to support widespread uptake. At this earlier phase there may still
be legitimate reasons for limited adoption – as a research or training tool, for example. We
believe there is an opportunity – and obligation – for greater collaboration among cardiac
surgery hospitals in the coordination of technology evaluation and uptake. We would
suggest that cardiac hospitals should collaborate to identify candidate new technologies, and
develop a reasonable plan for selective introduction and evaluation. We would further
suggest that the MOHLTC support this measured and collaborative introduction of new
technology, recognizing that if Ontario is to retain a leadership role internationally in cardiac
surgery, its surgical programs must be involved at all stages – development, evaluation, and
dissemination. There may be a valuable role for “field evaluations” of specific technologies.

IV(b)                     Coordinated administrative structures
Target audience           Cardiac Hospitals, LHINs, Academic Health Science Centres

The convergence of treatments and technologies that is occurring in the clinical arena needs
to be reflected in the administrative structures that facilitate and govern clinical activities.
Within several hospitals this has already occurred to a degree under the concept of “program
management” – a cardiovascular program which encompasses cardiology, cardiac surgery
and vascular surgery may coexist in a hospital alongside the traditional academic
departments of surgery and medicine. We believe that some form of program management
organized around the patient with cardiovascular disease, rather than around traditional



45
disciplines, will better promote the shared responsibility and opportunity among cardiac
surgery, cardiology, vascular surgery, interventional radiology, and possibly other disciplines
(vascular medicine, neurology, endocrinology, etc.). This integrated administrative structure
needs to develop (or further develop) not only at the hospital level but at the LHIN level and
possibly at the University level as well.

IV(c)                     Coordinated human resource planning
Target audience           To be defined

It is clear to us that human resource issues represent the biggest potential barrier to achieving
our vision for cardiac surgery. The health care system as a whole faces substantial HR
challenges, and these are exacerbated in a highly specialized area like cardiac surgery. A
cardiac surgery team requires intensive care and operating room nurses, perfusionists,
anaesthesiologists, and many others in addition to cardiac surgeons. The challenge includes
both meeting current HR needs and planning for future needs.

Strategies to enhance recruitment of specific categories of care-giver may have limited short-
term success, but often this represents a gain for one cardiac hospital at the expense of
another. A more effective strategy over the longer term would be to augment the overall pool
of highly trained personnel. However, the lead times are long, and our ability to accurately
predict future work-force needs is limited, raising the potential for oversupply as well as
undersupply in the future.

While cautious prediction of future needs certainly plays a role, we believe that ultimately the
best possible solution to the HR challenge in cardiac surgery lies in augmenting the
flexibility and adaptability of our current staffing structure. This might involve anaesthesia
assistants, nurse practitioners, hospitalists, and others. There are funding implications,
medico-legal implications, and other potential obstacles. Nonetheless, this is a critical
initiative that we believe must be explored. Clearly broad discussion needs to occur among
many stakeholders, including professional colleges and regulated health profession groups,
hospital risk management teams, health service researchers, and government. One goal of
such discussions should be the development of a standard – ideally a flexible standard that is
adaptable to local needs - with respect to the human resource mix that will optimize both
quality of care and accessibility of care across the province.

Given the diversity of stakeholders and the absence (to our knowledge) of an existing forum
to bring the relevant parties together, this is an area where CCN may be able to play an
important facilitative role.

IV(d)                     Coordinated human resource planning
Target audience           Academic Health Science Centres, Cardiac Hospitals

As noted above, the ability to accurately predict health care HR needs in specialized fields
that are rapidly changing is suspect. Nonetheless, there should be at least a partial attempt to
match the intake of trainees to an approximation of future demand. We heard from several
sources that the number of cardiac surgery resident training positions across the country may


   46
be linked more to current workload requirements within the surgical programs than to the
future need for cardiac surgeons. That this is clearly not ideal is illustrated by the present
situation where few if any of the cardiac surgery residents in Canada now finishing their
training have been hired into a staff position (approximately 14 physicians with an average of
eight 8 years training after medical school).

To a degree the trainee/staff surgeon market will regulate itself as medical school graduates
shy away from cardiac surgery training given the lack of staff jobs. In the US this has
already occurred - many training programs have not filled their available positions. The
trend is more recent in Canada but likely to be similar. This can lead to a “boom-bust” cycle
and the legitimate concern of an actual shortage of cardiac surgeons seven to 10 years hence.
Our systems model suggests that under certain conditions this scenario could indeed occur.

Therefore, while precise matching between training positions and eventual demand is
impossible, we believe that collaborative planning among the Academic Health Science
Centres, Program Directors and the Chiefs of Surgery should take place with the goal to
ensure, to the extent possible, that the number of trainees in formal residency programs is
based on the anticipated need for cardiac surgeons, and not on local short-term clinical
workload. Modest resources will be required to support this planning process. If hospital
workforce needs are to be de-linked from the number of trainees, then alternate provision of
personnel outside of resident sources is necessary (e.g. nurse practitioners, extended care
RNs, hospitalists, etc.).


IV(e)                     Adaptability of the cardiac surgery workforce
Target audience           Royal College of Physicians and Surgeons, Academic Health
                          Science Centres, Cardiac Hospitals

The foregoing discussion points relate to the number of cardiac surgery personnel. We
believe that a flexible approach is also needed to achieve – and maintain – the appropriate
skill set among the personnel training for a career in cardiac surgery, or already working in
cardiac surgery.

The pace of change in practice and technology have become so rapid that the structure and
content of formal training likely need revision even within a given four to six year training
program. The Royal College of Physicians and Surgeons of Canada, with responsibility for
training standards, and the Academic Health Science Centres that provide such training,           Comment [EC1]: Transpose this new
                                                                                                  wording to chapter 6.
should collaborate to ensure that the formal training requirements for cardiac surgery
residents have sufficient flexibility to address changes in the practice environment that occur
during residency. Today’s cardiac surgery residents may require (and desire) training in
imaging, catheter-based procedures, critical care, vascular surgery and endovascular
procedures. Here again the theme emerges that this involves innovative collaboration and
integration across cardiovascular disciplines. Providing this sort of flexibility would help
attract high calibre trainees who will be able to meet evolving patient needs.




   47
Surgeons and other caregivers already in practice have always faced the need to learn new
techniques and adapt their practice. Typically this has been done via informal on-the-job
training, or brief periods of more formal instruction. Today’s pace of change and the
potentially fundamental ways in which cardiovascular procedures may evolve suggest that a
more formal mechanism is needed to support professionals in the adaptation of their skill set
during their career, so that they may remain highly qualified providers of excellent care.
Cardiac hospitals should recognize the need for these mechanisms and develop plans to
support the retraining and/or cross-training of physicians and other cardiac surgery
professionals already in practice to enable them to acquire new skills, optimally utilize new
technology, align to system needs and develop collaborative practice. Cardiac hospitals
should work together to develop centres of excellence in specific areas of practice that could
serve as resources for retraining.


Conclusions

Cardiac surgery in Ontario has provided excellent care for patients and has played a
leadership role internationally. It is clearly in the best interest of Ontario patients and
residents generally that this culture of excellence and innovation be maintained. Although
some aspects of cardiac surgery are undergoing profound change, and may have declined in
volume, the need for complex operative intervention on the heart remains essential for many
patients. Therefore, the existing capabilities within the specialty must be retained, but must
also be adapted to meet new requirements. An innovative approach must be developed to
balance critical mass and minimum volume with ready accessibility. Rigorous monitoring
and coordinated planning will help ensure that excellent care is provided in a timely manner.
Greater flexibility in the training and structure of the workforce will ensure that future
patients enjoy the same quality and accessibility of care that today’s patients do.

This discussion paper is a starting point, and we hope it will help engage many groups in
working together to move these issues forward. In doing so, the goal of ensuring continued
excellence and leadership in cardiac surgery for Ontarians will be achieved.




   48
                                           Acknowledgements
CCN would like to acknowledge and thank the following contributors to this report:

Gopal Bhatnagar, MD, Cardiac Surgeon, Trillium Health Centre
Christopher Feindel, MD, Medical Director, Heart & Circulation Program, University Health Network
Lyall Higginson, MD, Cardiologist, University of Ottawa Heart Institute
Greg Hirsch, MD, Cardiac Surgeon, Dalhousie University
Nancy Jutte, Director, Cardiac Care Program, London Health Sciences Centre
Bernadette MacDonald, VP, Surgery Clinical Business Unit, London Health Sciences Centre
David Mazer, MD, Professor of Anesthesia, University of Toronto, St. Michael’s Hospital
Neil McEvoy (Chair), President and CEO, Hotel Dieu-Grace Hospital
Hemwanti Parasram, Policy Analyst, Ontario’s Wait Time Strategy, Ministry of Health and Long-Term Care
Donna Riley, Regional Cardiac Care Coordinator, St. Michael’s Hospital
Fraser Rubens, MD, Cardiac Surgeon, University of Ottawa Heart Institute
Gilbert Tang, MD, Resident, Cardiac Surgery, University of Toronto
Rosalind Tarrant, Program Consultant, Ministry of Health and Long-Term Care, Operational Support Branch
James Velianou, MD, Cardiologist, Hamilton Health Sciences Centre, McMaster University
Nancy Walton, PhD, Associate Professor, School of Nursing, Ryerson University
Richard Weisel, MD, Chair, Division of Cardiac Surgery, University of Toronto, UHN
Richard Whitlock, MD, Cardiac Surgery Resident, Hamilton Health Sciences Centre, McMaster University
Tim Zmijowskyj, MD, Division Head, Clinical Sciences, Northern Ontario School of Medicine, Laurentian University

Michael Carter, Mechanical and Industrial Engineering, University of Toronto – systems model development
Rink Kraakman, Intern, University of Toronto – systems model development
Lucy Li, Decision Support Analyst, CCN – data analysis
Neil McEvoy, President and CEO, Hotel Dieu Grace Hospital – Chair, Cardiac Surgery Consensus Panel
Jennifer Mokry, Project Manager, CCN
Peter Papadakos, System Support Specialist, CCN – data analysis
Caroline Rafferty, Director of Clinical Practice, CCN
Terri Swabey, Director, Projects and Liaison, CCN – Project Lead
Gilbert Tang, MD, Resident, Cardiac Surgery, University of Toronto – literature review

CCN Member Hospitals
Hamilton Health Sciences Centre
Hôpital Régional de Sudbury Regional Hospital
Hôtel-Dieu Grace Hospital, Windsor
Kingston General Hospital
London Health Sciences Centre
Peterborough Regional Health Centre
Rouge Valley Health System, Toronto
St. Mary’s General Hospital, Kitchener
St. Michael’s Hospital, Toronto
Sault Area Hospital, Sault St. Marie
Southlake Regional Health Centre, Newmarket
Sunnybrook Health Sciences Centre, Toronto
Thunder Bay Regional Health Sciences Centre
Toronto East General Hospital
Trillium Health Centre, Mississauga
University Health Network, Toronto
University of Ottawa Heart Institute
William Osler Health Centre, Brampton



    49
50
Appendix 1 – CABG Co-morbidity Tables

Table 10 – Prevalence of risk factors (percentage of total isolated CABG), 1998/99 to
2005/06
                                                                                                              Change
                                                                                                             1998/99 to
Risk Factor             1998/99     1999/00    2000/01    2001/02   2002/03   2003/04   2004/05   2005/06     2005/06
age<65                  50.7%       49.2%      49.7%      48.2%     47.6%     48.1%      45.5%     46.8%       -4.0%
age65-74                36.8%       36.0%      35.4%      35.7%     35.7%     34.9%      35.5%     34.1%       -2.7%
age75+                  12.5%       14.7%      14.9%      16.1%     16.6%     17.0%      19.0%     19.1%        6.6%
Female                  22.6%       22.9%      21.9%      21.0%     21.7%     20.9%      20.8%     21.7%       -0.9%
Emergency                2.2%        1.9%       2.6%       2.1%      2.3%      2.3%       2.4%     2.8%         0.6%
Urgent/Semi-urgent      51.3%       52.2%      55.2%      57.0%     58.9%     59.2%      60.2%     57.5%        6.2%
Elective                48.3%       47.4%      44.6%      42.6%     40.7%     40.1%      38.8%     40.6%       -7.7%
Re-Operation             4.0%        3.2%       3.6%       3.5%      2.6%      2.2%       2.4%     2.2%        -1.7%
Grade 1 LVF             41.4%       41.5%      44.3%      46.2%     47.5%     48.6%      49.5%     49.3%        7.9%
Grade 2 LVF             35.3%       34.5%      33.4%      32.7%     31.1%     30.8%      29.3%     28.0%       -7.2%
Grade 3 LVF             17.0%       17.5%      15.2%      14.9%     16.0%     15.6%      14.7%     14.3%       -2.7%
Grade 4 LVF              3.5%        3.8%       3.6%       3.2%      2.6%      3.0%       2.9%     2.5%        -0.9%
Left Main Disease       19.1%       20.0%      22.4%      25.0%     27.1%     27.5%      29.6%     31.2%       12.0%
CCS Class 4A            18.0%       19.0%      23.6%      25.1%     27.7%     27.1%      28.4%     30.1%       12.1%
CCS Class 4B            19.4%       19.7%      17.3%      12.4%     12.5%     11.1%      12.1%     11.2%       -8.3%
CCS Class 4C             8.8%        7.8%       7.9%       6.5%      6.3%      6.9%       6.8%      6.0%       -2.7%
PVD                     10.7%       12.1%      11.1%      12.5%     12.8%     12.4%      13.3%     12.6%        1.9%
CVD                      7.8%        8.6%       8.6%       9.3%      9.1%      9.9%      10.9%     10.2%        2.3%
COPD                     7.1%        6.8%       6.3%       7.1%      7.1%      7.5%       7.8%     7.1%         0.0%
Diabetes                25.7%       28.1%      28.4%      31.1%     31.8%     32.0%      34.4%     34.5%        8.8%
Dialysis                 1.0%        1.7%       0.9%       0.9%      1.1%      1.1%       1.2%     1.2%         0.2%
CHF                     11.1%       14.2%      12.8%      13.6%     10.1%     10.4%      10.8%     10.4%       -0.7%
Source: CCN Cardiaccess database

Table 11 – Prevalence of risk factors (percentage of total CABG + valve), 1998/99 to
2005/06
                                                                                                             1998/99 to
Risk Factor          1998/99       1999/00    2000/01    2001/02    2002/03   2003/04   2004/05    2005/06    2005/06
age<65               27.6%         21.2%      23.4%      23.9%      25.4%     25.6%     24.2%       24.2%       -3.3%
age65-74             43.0%         46.1%      39.3%      43.9%      39.5%     40.8%     38.2%       37.8%       -5.2%
age75+               29.4%         32.7%      37.2%      32.3%      35.1%     33.6%     37.7%       37.9%        8.6%
Female               29.9%         33.3%      32.4%      30.7%      30.6%     32.8%     29.5%       28.6%       -1.3%
Emergency             1.5%          1.9%       2.9%       1.6%       1.9%      1.6%      1.5%        1.6%        0.1%
Re-Operation          6.0%          3.7%       4.1%       5.2%       5.3%      4.8%      5.8%        5.3%       -0.6%
Grade 1 LVF          43.9%         44.8%      47.6%      51.7%      52.7%     57.5%     55.1%       54.2%       10.3%
Grade 2 LVF          29.9%         29.7%      27.4%      25.6%      21.7%     20.4%     21.7%       17.9%      -12.0%
Grade 3 LVF          15.5%         15.7%      15.8%      14.7%      15.2%     16.3%     15.7%       15.3%       -0.2%
Grade 4 LVF           5.0%          3.7%       4.6%       3.1%       5.2%      4.3%      3.9%       5.7%        0.7%
Left Main Disease    11.1%         10.5%      12.5%      13.4%      13.8%     12.7%     12.8%       16.1%        5.0%
CCS Class 4A         13.8%         12.2%      14.0%      14.9%      15.8%     17.5%     17.1%       17.7%        3.9%
CCS Class 4B          7.4%          8.3%       8.2%       6.5%       4.3%      5.9%      6.6%        7.9%        0.5%
CCS Class 4C          3.5%          4.8%       3.8%       2.0%       2.7%      2.4%      2.6%        2.8%       -0.8%
PVD                  11.2%          9.0%      10.7%      11.5%      11.9%     13.3%     14.0%       11.9%        0.7%
CVD                  10.5%         12.5%      12.5%      12.3%      12.8%     14.2%     15.6%       14.1%        3.6%
COPD                 10.7%         11.3%       8.2%      10.0%       9.2%      9.4%     10.6%        9.7%       -1.1%
Diabetes             17.8%         17.9%      23.1%      23.4%      25.7%     26.4%     29.7%       29.6%       11.8%
Dialysis              1.1%          2.9%       1.7%       1.5%       1.4%      1.6%      1.7%        1.4%        0.3%
CHF                  37.4%         40.7%      43.1%      40.9%      36.0%     37.7%     38.3%       35.4%       -2.1%
Source: CCN Cardiaccess database




     51
Appendix 2 – Cardiac Surgery Systems Model

INTRODUCTION
The inter-relationships and impacts of the factors that effect capacity and demand of the
cardiac surgical system are very complex. The Panel worked with the University of Toronto,
Department of Industrial Engineering36 to develop a systems model that would help
characterize these factors, their interdependencies and impact on capacity and demand. The
intent of this exercise was to provide both a qualitative model that described these inter-
relationships and their complexity, but also provided a quantifiable model that could be used
for long-term planning by policy makers and CCN.

The model was developed with the input of the Cardiac Surgery Consensus Panel members
as well as through consultation with external experts and staff at the University of Toronto.

This section provides a summary of the systems model and explains the key assumptions
used in its development. Strategic focus areas for planning are identified and are defined as
those factors that will have a dominant impact on capacity and demand in the future or that
have long-latency periods and would require attention now in order to have a positive impact
over the longer-term. A complete description of the model, all its components, underlying
assumptions and data sources can be found in Appendix 8. The full report on the systems
model is available as a supplementary document to this report.

THE VISUAL MODEL
Figure 7 illustrates the full complexity of the systems model. As the majority of cardiac
surgery is CABG for patients with coronary artery disease (CAD), the focus of this model is
on the eligible pool of CAD patients and the factors influencing capacity and demand for its
treatment (CABG, PCI and alternative treatment). There is considerable overlap and
similarity between the left arm of the model (CABG) and the right arm (PCI), as the factors
driving change are, for the most part, similar. Therefore, for the purposes of this report, the
description of the model will focus on the CABG arm.

The three red circles indicate the key strategic areas of focus of the model; 1) the factors
effecting the demand for CABG; 2) the factors effecting referral rates to CABG; and 3) the
factors effecting the capacity of the cardiac surgery system. These areas are enlarged in the
subsequent figures with a brief explanation of the relations between the indicators in these
areas.




36
 Professor Michael Carter, University of Toronto, Rink Kraakman, graduate student from the University of
Twente, The Netherlands.

     52
Figure 7: Systems model of strategic demand and capacity issues for CABG and PCI


                                                                                                                                                             immigration




                                                                                                                                                         +
                                                                                                             population                                                    +
                                                                                                                                      aging population
                                                                                                               health                                                      population
                                                                                    prevention                                                                                size
                                                  Alternative
                                                                                    measures
                                                                                                                                      1
                                                  technology
                                                 development                                                                                                                       Family doctor
                                                                                                                                                                                  practice patterns


                                                                            + Alternative                                                                                           diagnostic         PCI technology
                                                                                                                                     + +                                                                development
                                                                          treatment demand+                                   - +            +
                                                                                                                                                                                   technology
                                                                                                                            -
                                                                                                                          pool of identified                                      development
                                                                                                                           CAD patients
                                                                                                                             +                                                                      Cardiologist
                                          CABG technology
                                                                                                                                                 +                                                practice patterns
                                            development                       non-benefit pool           +                        +
                                                                                                                             diagnosed
                        - -                                                                                                     pool
                                                                                                                                                                                                                                                -
                                 +                                                            +                                        +                                         +                                                       +
                    CABG relative                                               CABG                                                                                                   PCI        +                          -           PCI relative
                       value                                              +    demand
                                                                                              +
                                                                                                2                                                                                +
                                                                                                                                                                                     demand                                                value
                           -                                                                                                                                                                                                                      -



                                 +                                              +                                                                                                                                                +
                                                                                                                                                                                    +
                    CABG unmet                                          # CABG procedures                                              +                                      # PCI procedures                                           PCI unmet
                      demand                                               done in time                                                                                         done in time                                              demand
                                     -                                                                                      diagnostic
                                                                                    +                                        capacity                                                  +
                                                                                                                                                                                                                                     -
                                                                                                                               +    +


                                                                                                                                                              PCI other HR                                      +
                                                      +
                                                                                                                                                                                                               PCI doctor
                                         CABG doctor                                                                                                                                                           utilizatoin
                                          utilization                           CABG          +          CABG other                                                               +
                                                                                                                                                                                   PCI capacity                 -
                                                    -                          capacity                     HR                             diagnostic physical
                +                                                                                                                                                                          +
                                                                                          +                                                    resources
                                                                                                                                                                                     +                                                                    +
          CABG desired                                                          +
            skill set                                                                                                                                                                                                                             desired PCI
                                                                                                                                                                                                                                                    skill set
                                                          # skilled CABG                          CABG physical                                          PCI physical                        # skilled PCI
                                                              doctors                               resources                                             resources                             doctors
                                                  -                    +
                                                             +                                                                                                                                           +
  US job                                                                                                                                                                                       +
                                             +
opportunities
                                         CABG skill set
                                                            +
                                                                    3                                                            # Cath
                                                                                                                                 doctors
                                                                                                                                                                                                                      +
                                                                                                                                                                                                               PCI skill set
                                                                                                                                             +                                # PCI
                                                                                     # CABG                                                                                                                +
                                                                                                                                                                             doctors
                                                                                     doctors
                                                                                                    +
                                                                                                                                                                             +
                        + -                                                                                                                                                                                                                   -       +
                     CABG skill set                        CABG HR training
                                                              programs                                                                                                                     PCI HR training                                PCI skill set
                       shortfall                                                                                                                     # trainees in
                                                                                                         # trainees in                                                                       programs                                      shortfall
                                                                                                                                                      Cardiology +
                                                                +                                       Cardiac Surgery
                                                                                                                    +                                        +                                         +
                                                                                                          +
                                                                                                                                                                                            +              +
                                                                    +            +
                                                                        attractiveness of the cardiac                                                                             attractiveness of the
                                                                             surgeon profession                             # students in                                        cardiologist profession
                                                                                                                            Med school




                            A                                       +      B        C                                 -       D
                                                                                                                                                     E                                        F                                  1
 Legend                         If A increases, then B                               If C increases, then D                                      Latency between a change                                      A specific area of the
                               increases above what it                              decreases below what it                                        in E and the resulting                                      model, the areas are
                                    would have been                                      would have been                                                change in F                                             explained later on




       53
Figure 8 is an enlargement of section 1 from Figure 7 and illustrates all the factors that
influence the pool of identified CAD patients and have an input into the demand side of the
system. Changes in prevention measures, population health, the aging population
(demographics), immigration and population size lead to an increase or decrease in the total
pool of identified CAD patients. Changes in family doctor practice patterns, diagnostics
technology and diagnostic capacity influence the proportion of patients that will be identified
as potential CAD patients through a diagnostic procedure. Diagnostic technology and
diagnostic capacity will subsequently determine the size of the pool of identified CAD
patients that gets a diagnostic Cath (the diagnosed pool).

Figure 8: factors effecting demand (enlargement of section 1 from figure7)

                                                        immigration
                                                                                                Legend

                       population            aging +             +
                                           population            population
                                                                                           A                + B
                         health
 prevention                                                         size                    If A increases, then B
 measures                                                                                  increases above what it
                                                                                                would have been
                                                                       Family doctor
                                                                      practice patterns    C                    D
                                                                                                            -
                                                                                            If C increases, then D
                                                                        diagnostic         decreases below what it
                                            + +                                                 would have been
                                     - +            +
                                                                       technology
                                   -
                                 pool of identified                   development
                                  CAD patients
                             +                                                             E                    F
                                       +         +                                        Latency between a change
              diagnostic             diagnosed
                                                                                             in E and the resulting
               capacity          +      pool                                                      change in F




   54
Figure 9 is an enlargement of section 2 from Figure 7 and illustrates the factors driving
referral to CABG as a second key component of the demand side of the system.
Developments in diagnostic and interventional technology, cardiologist practice patterns and
unmet demand all influence the referral rates for patients in the diagnosed pool and the
demand for both CABG and PCI. This figure also shows the intersection of CABG demand
and capacity at the final outcome of the system – the number of CABG procedures completed
within recommended maximum wait times.


Figure 9: factors effecting referral rates (enlargement of section 2 from figure 7)

                            Alternative
 PCI technology             technology
  development              development
                                                                                                                            diagnostic
                                                     +                                                                     technology
                                                             Alternative                                  +
                                                                                     pool of identified                   development
                                                         treatment demand+
                                                                                      CAD patients
                               CABG technology
                                 development                                            +
                                                                                            +        +
                                             non-benefit pool         +                                                         Cardiologist
                                                                                        diagnosed                             practice patterns
              -                                                                            pool
         -          +                                        +                                   +                        +
        CABG relative                           CABG                                                                            PCI
           value                           +   demand                                                                         demand
                                                             +                                                            +
                  -
                                                                                                 +
                                                                                        diagnostic
                                                                                         capacity
                       +                         +
        CABG unmet                        # CABG procedures
          demand                             done in time
                           -
                                                     +

                                                                                                              PCI unmet
                                                                                                               demand
                                                CABG
                                               capacity




                                                         C                                   E                      F
                  A                        + B                               -   D
 Legend                If A increases, then B             If C increases, then D            Latency between a change
                      increases above what it            decreases below what it               in E and the resulting
                           would have been                    would have been                       change in F




   55
Figure 10 is an enlargement of section 3 from Figure 7 and illustrates the factors influencing
the capacity side of the model. Capacity is primarily driven by physical resources and
infrastructure as well as human resource capacity and skill mix. The key component of this
section is the availability of the number of skilled cardiac surgeons due to the long latency
period to anticipate need and train surgeons. Figure 4 also incorporates the continuous
learning cycle for cardiac surgeons, which gets triggered by their utilization (the number of
procedures they do) and the new skills required due to uptake of new technology.

Figure 10: factors effecting capacity (enlargement of section 3 from figure 7)


                                                              # CABG procedures
                                                                 done in time
                                                                         +
           CABG technology
             development

                                              +
                                  CABG doctor
                                   utilization                       CABG          +         CABG other                   Legend
                                             -                      capacity                    HR
                 +
                                                                               +
           CABG desired                                              +                                               A                + B
             skill set                                                                                                If A increases, then B
                                                                                                                     increases above what it
                                                  # skilled CABG                       CABG physical
                                                                                                                          would have been
                                                      doctors                            resources
                                          -                   +
    US job
                                                     +                                                               C                - D
                                      +
 opportunities                                                                                                        If C increases, then D
                                                    +                                                                decreases below what it
                                  CABG skill set
                                                                     # CABG                                               would have been
                                                                     doctors
                                                                               +
                                                                                                                     E                    F
                    + -
                 CABG skill set                    CABG HR training                                                 Latency between a change
                                                                                        # trainees in
                   shortfall                          programs                                                         in E and the resulting
                                                                                       Cardiac Surgery
                                                                                                   +                        change in F
                                                        +                                 +
                                                    +
                                                                  +
                                                        attractiveness of the cardiac               # students in
                                                             surgeon profession                      Med school



KEY ASSUMPTIONS, CHANGE DRIVERS AND TIMEFRAMES
In order to identify key strategic areas of focus for planning and recommendations, the panel
members agreed on the key drivers in the model, the key assumptions regarding the
relationship of these drivers to capacity and demand in the system, as well as important time
latencies that influence our ability to plan and match system capacity and demand. The key
drivers were defined as those factors anticipated to have the largest impact on either capacity
or demand over the next 10 years.

Key assumptions
1. The impact of obesity and the aging population will have the greatest impact on the pool
   of identified CAD patients. The impact of these factors will be far greater than the impact

    56
   of prevention measures, other population health issues, immigration and the population
   size.
2. With the exception of a small change related to the development of biodegradable stents,
   we assume that the relative referral rates for CABG, PCI and alternative treatments have
   equilibrated. We do not anticipate any technology over the next 10 years that will
   markedly change the market distribution for CAD patients.
3. We assume changes in family doctors’ or cardiologists’ practice patterns will not have a
   big impact on the pool of identified CAD patients or the referral rates.

Key change drivers
1. Increasing obesity rates and the aging population will have the biggest impact on the pool
   of identified CAD patients and will increase the overall pool.
2. Cardiac CT diagnosis might have a big impact on both the pool of identified CAD
   patients and the referral rates. However because a lot depends of technology
   development, these impacts are difficult to predict.
3. It will be crucial to keep the profession of cardiac surgeon attractive to attract new high-
   caliber residents into the field. The panel anticipates this to be an issue in the upcoming
   years and may decrease the enrolment into cardiac surgery.
4. It is anticipated that upcoming high retirement rates among US cardiac surgeons and
   decreasing enrolment into cardiac surgery residency will create a shortage of cardiac
   surgeons in the US. Recruitment in the US will attract some Ontario residents and further
   decrease the pool of cardiac surgeons in Ontario over the long term.

Key timeframes
1. The two big issues on the demand side, obesity and the aging population, both have
   latency times of several decades.
2. It will take three to ten years before Cardiac CT diagnosis might have an impact.
3. On the capacity side, cardiac surgeon training has a latency time of nine years. This is
   much longer than other HR or physical resources.
4. It will take five to eight years before US job opportunities might have an impact on
   cardiac surgeon retention in Ontario.

DRAFT QUANTITATIVE ANALYSIS
A preliminary quantitative model has also been developed. For the time being, the
quantitative model is for illustration purpose only, because the assumptions need further
verification.

Although very preliminary, the quantitative model gives a sense of the relative impact of the
various scenarios and the timing of the changes. Figure 11 shows one example, the need for
additional cardiac surgeons over the next ten years.




   57
Figure 11: number of additional surgeons needed according to preliminary quantitative
analysis


                                      Additional cardiac surgeons needed
                        11
                        10
                         9
     cardiac surgeons




                         8
                         7
                         6
                         5
                         4
                         3
                         2
                         1
                         0
                         06


                                  07


                                             08


                                                   09


                                                           10


                                                                    11


                                                                             12


                                                                                       13


                                                                                             14


                                                                                                       15
                        20


                                20


                                        20


                                                  20


                                                         20


                                                                   20


                                                                           20


                                                                                   20


                                                                                            20


                                                                                                   20
                                                            year
                             Base scenario        Obesity high           Obesity low         CT high
                             CT low               US jobs high           US jobs low


This model could be continued to be refined to support future cardiac surgery planning.
However, even with the limitations of the current model, in Figure 11, we can see there is a
need to improve the planning. Based on the current practice, in Ontario, approximately four
cardiac surgery residents will graduate per year and enter the job market. The annual need for
additional surgeons will intersect with the supply at 2013 under our base scenario. At this
inflection point, our current oversupply situation will change to an undersupply situation.
This inflection point could shift based on the impact of the various scenarios tested as seen in
Figure 11.

GLOSSARY TO THE SYSTEMS MODEL

# CABG doctors: the number of cardiac surgeons that completed their education to perform
CABG and other procedures. They do on average 200 cases a year37. This number also
includes the cardiac surgeons that have lost some of their skills, for example by not
completing the minimum number of procedures per year or by not keeping up with the
technology.

# CABG procedures done in time: the number of CABG procedures that are done within a
timeframe that is acceptable for the specific patient.

37
 According to the Panel the optimal number of cases for a cardiac surgeon is 200. Currently the number of
procedures surgeons do, ranges from 160 to 400.

                 58
# Cath doctors: the number of cardiologists that do Cath diagnosis at an average of 230 cases
a year.

# PCI doctors: the number of interventional cardiologists that completed their education to
perform PCI and do on average 225 cases a year. This number also includes the cardiologists
that have lost some of their skills, for example by not completing the minimum number of
procedures or by not keeping up with the technology.

# PCI procedures done in time: the number of PCI procedures that are done within a
timeframe that is acceptable for the specific patient.

# Skilled CABG doctors: the number of cardiac surgeons with up to date skills. Up to date is
determined by the number of procedures they do and the training they had in new
technologies.

# Skilled PCI doctors: the number of PCI doctors with up to date skills. Up to date is
determined by the number of procedures they do and the training they had in new
technologies.

# Students in Med School: the number of students that are currently enrolled in Medical
School.

# Trainees in Cardiac Surgery: the number of trainees or residents in Cardiac Surgery that are
currently trained to become a cardiac surgeon.

# Trainees in Cardiology: the number of trainees or residents in Cardiology that are currently
trained to become either a Cath doctor or an interventional cardiologist.

Aging population: this indicator concerns the age distribution of the population of Ontario.
The main issue for this indicator is the baby boom generation, a relative big part of the
population that is reaching the age at which they will need cardiac care.

Alternative technology development: technology development in non-revascularization
procedures that could be used for CAD patients. This technology concerns mainly medical
treatment and includes not only the actual discovery/invention itself, but also clinical
demonstration of utility/benefit and the uptake of the technology.

Alternative treatment demand: in this model alternative treatment demand means the number
of CAD patients referred for other treatment than CABG or PCI. This treatment concerns
mainly medical treatment.

Note that this does not address the appropriateness of the referral, nor the likelihood that
any particular patient would benefit from the procedure. It also does not address the degree
of benefit.




   59
Attractiveness of the cardiac surgeon profession: the attractiveness of the cardiac surgeon
profession in the eyes of medical school students when they choose their field to specialize
in.

Attractiveness of the cardiologist profession: the attractiveness of the cardiologist profession
in the eyes of medical school students when they choose their field to specialize in.

CABG capacity: the capacity to perform CABG procedures.

CABG demand: in this model CABG demand means the number of patients referred for
CABG, i.e. the “demand” in the system to provide CABG.

Note that this does not address the appropriateness of the referral, nor the likelihood that
any particular patient would benefit from the procedure. It also does not address the degree
of benefit.

CABG desired skill set: the total skill set a cardiac surgeon should have to perform CABG,
working with the newest technologies.

CABG doctor utilization: the total number of procedures all CABG doctors together could do
divided by the actual number they do.

CABG HR training programs: the programs that CABG doctors follow to retain and upgrade
their skills. These programs concern the continuous education of the doctors.

CABG physical resources: the total number of OR’s available in the province to perform
CABG.

CABG relative value: the value of CABG compared to PCI.

CABG skill set: the current skill set of the average CABG doctor.

CABG skill set shortfall: the current skill set compared to the desired skill set.

CABG technology development: technology development in CABG. This includes not only
the actual discovery/invention itself, but also clinical demonstration of utility/benefit and the
uptake of the technology.

CABG unmet demand: this includes referrals that are never done or may be done (eventually)
but not in a timely manner.

Cardiologist practice patterns: these are the patterns that influence the cardiologists’ referrals
to the different procedures.




   60
Diagnosed pool: these are the patients who have been diagnosed (either CAD or no CAD)
and will either be referred for an intervention or will benefit from an intervention. Currently
all diagnosis takes place by Cath, but this might change in the future.

Diagnostic capacity: currently this concern the provincial wide capacity to perform diagnosis
by Cath.

Diagnostic physical resources: the total number of labs available in the province to perform
diagnosis by Cath.

Diagnostic technology development: technology development diagnosis of CAD patients.
This includes not only the actual discovery/invention itself, but also clinical demonstration of
utility/benefit and the uptake of the technology.

Family doctor practice patterns: this indicator concerns the practice patterns of family doctors
in recognizing and referring CAD patients.

Immigration: this indicator is about the number of immigrants that arrives in Ontario every
year. In important issue are the immigrants from South Asia, who tend to suffer more from
CAD and get it at a younger age as well.

Non-benefit pool: the pool of patients that does not benefit from revascularization procedures
or alternative treatment.

Other HR: this is not defined yet, but might include nurses, anesthesiologists and
perfusionists.

PCI capacity: the capacity to perform PCI procedures.

PCI demand: in this model PCI demand means the number of patients referred for PCI, i.e.
the “demand” in the system to provide PCI.

Note that this does not address the appropriateness of the referral, nor the likelihood that
any particular patient would benefit from the procedure. It also does not address the degree
of benefit.

PCI desired skill set: the total skill set an interventional cardiologist should have to perform
PCI, working with the newest technologies.

PCI doctor utilization: the total number of procedures all PCI doctors together could do
divided by the actual number they do.

PCI HR training programs: the programs that PCI doctors follow to retain and upgrade their
skills. These programs concern the continuous education of the doctors.

PCI physical resources: the total number of labs in the province available to perform PCI.


   61
PCI relative value: the value of PCI compared to CABG.

PCI skill set: the current skill set of the average PCI doctor.

PCI skill set shortfall: the current skill set compared to the desired skill set.

PCI technology development: technology development in PCI. This includes not only the
actual discovery/invention itself, but also clinical demonstration of utility/benefit and the
uptake of the technology.

PCI unmet demand: this includes referrals that are never done or may be done (eventually)
but not in a timely manner.

Pool of identified CAD patients: the pool of potential CAD patients who are identified by a
family doctor and who are referred for diagnosis by Cath.

Note that, for simplicity, we did not include the total potential pool of CAD patients
(identified and unidentified) in the model.

Population health: issues in this field that influence the pool of identified CAD patients are
amongst others:
       o Smoking
       o Obesity
       o Hypertension

Population size: this is the number of people that live in Ontario.

Prevention measures: these are the measures taken by the government or other groups in
society to deal with issues in population health.

US job opportunities: job opportunities for Canadian cardiac surgeons in the US, where they
potentially can earn more money than they do in Canada. US employers will specifically look
for the best Canadian surgeons.




    62
Appendix 3 – Cardiac Surgery Consensus Panel Terms of Reference


Project Name – Cardiac Surgery – An Industry in Transition

Initiated By – CCN Board, CCN Member Hospitals

Prepared By – Terri Swabey, Director, Projects and Liaison;
              Dr. Eric Cohen, CCN, Medical Officer

Approvals – CCN CEO – November 2005
            Clinical Services – November 9, 2005
            CCN Board – November 29, 2005
________________________________________________________________________

Preamble
Cardiac care is an industry in transition. Demographic changes, rapidly evolving technology,
and improved survival from acute cardiac events are dramatically altering the landscape. In
order to ensure that a rational plan exists for the provision of optimal cardiovascular services
in Ontario, CCN is undertaking a broad planning exercise across many aspects of the
continuum of cardiovascular care. This first “chapter” of the plan addresses cardiac surgery,
and the interaction between surgery and other elements of advanced cardiac care, especially
catheter-based procedures for revascularization, rhythm management, and, potentially, valve
repair or replacement.

The impact of recent changes has been particularly evident in cardiac surgery. After
sustained and rapid growth in procedure volume over two decades, coronary artery bypass
graft (CABG) surgery has seen little growth, and in many jurisdictions has experienced a
decline in procedure numbers in recent years. This has largely been due to the development
of new technology and hence expanded use of percutaneous coronary intervention (PCI).38 At
the same time, patients currently undergoing CABG surgery tend to be older and with greater
comorbidity than in the past. While this underlying shift in the overall specialty of cardiac
surgery is evident around the world, additional superimposed changes in the delivery of
cardiac surgery in Ontario have resulted in an even more profound impact. Specifically, the
recent addition of new community hospital cardiac surgical centres has impacted on
procedure volume, referral patterns, case mix, and human resources in cardiac hospitals
across the province. In some situations, this has shifted the balance between local capacity
and local need, with the potential for surplus capacity in some hospitals or region(s).


38
  The rate of CABG surgery, which comprises approximately 85% of all adult cardiac
surgery in Ontario, has declined by 4.8% (00/01 to 04/05) while PCI rates have increased by
62.5% during this same time period. Similar trends are seen across Canada and the US. The
Canadian Institute for Health Information and Statistics Canada report a 2.8% decrease in
CABG rates and a 66% increase in the number of PCIs performed across Canada between
1998-99 and 2002-03.

     63
Where substantial variations in the uptake in new technology and in patterns of care exist
across regions, concerns are raised as to the appropriateness and quality of care. This is an
issue for consideration across the entire spectrum of cardiovascular care. Specifically in
relation to cardiac surgery, wide variation in the ratio of PCI to CABG exists across Ontario
centres. Evaluation of the drivers and the impact of such variations are warranted.

The changes occurring in cardiac surgery have profound implications for human resource and
infrastructure planning. Therefore, long-range planning is urgently needed in order to retain
and make optimal use of existing expertise and resources while also providing the most
appropriate cost-effective care to patients.

Purpose
The purpose of the Cardiac Surgery Consensus Panel project is to gather information and to
engage stakeholders in discussions in order to understand and come to consensus on the
factors driving change in the delivery of cardiac surgery in Ontario and to provide a plan that
will help policy makers move forward to ensure the sustainability of the cardiac surgery
enterprise in Ontario.

Project Objectives
1. To quantify temporal changes in volumes and rates of various cardiac surgical
   procedures.
2. To quantify the temporal changes in the characteristics of patients undergoing cardiac
   surgical procedures.
3. To catalogue and come to consensus on the key drivers (e.g. primary prevention,
   technology, demographics, referral patterns, practice pattern variation, availability of
   resources) affecting the quantity and nature of cardiac surgical care.
4. To review and evaluate models in other jurisdictions, including how other jurisdictions
   have responded to these industry changes.
5. To describe the implications of these changes and drivers as they relate to: a) human
   health resources and training; b) administrative and clinical practice standards (e.g.
   minimum institutional and surgeon volumes); c) structure and sustainability for research,
   teaching and the provision of highly specialized care; and d) the supporting infrastructure
   (e.g. CCU) for the delivery of cardiac surgical care.
6. To develop a systems model that characterizes the drivers, interdependencies and outputs
   of the cardiac surgical system in order to provide a planning framework for policy makers
   and the CCN.
7. To develop a plan and recommendations that will focus on how policy makers and the
   CCN should move forward to ensure the sustainability of the cardiac surgery enterprise in
   Ontario.

Project Submission and Secondary Review
Following approval of the project Charter, the Charter will be circulated to the following
stakeholders inviting a submission of interest to the project according to a pre-specified
template that addresses project objectives only.
    • Cardiac administrator leads at each advanced cardiac hospital
    • Chiefs of Staff at each cardiac surgical hospital

   64
    •    Surgical Academic Program Directors at each cardiac surgical hospital

In addition, the Panel may choose to solicit expert opinion from specific individuals within or
outside of Ontario on any particular issue. A preliminary draft may be circulated to selected
Secondary Reviewers and their feedback will be considered before finalization of the report.
Expected Benefits
• Data and expert opinion to support appropriate planning for cardiac services in Ontario;
• High quality and appropriate patient care by the best qualified personnel;
• Improved health care delivery and operational efficiencies
• Retention of health care expertise in Ontario

Assumptions
• The CCN will provide in-kind secretarial and administrative support to this project;
• A Steering Committee of experts, drawn from the CCN-member community and other
   jurisdictions, will provide overall direction to this project, will conduct the expert review
   and will formulate the final recommendations.

Constraints/Risks
This project charter has been initiated at the request of the CCN member hospitals and CCN
Board. At the time of the initiation of the project charter, Ministry funds were not available.
Therefore, the financial costs of this project will be supported through CCN membership
fees.

Constraints/Risks                              Mitigating Factors
• CCN membership fees may be                   • Limit initial scope
   insufficient to cover a comprehensive       • Investigate opportunities for Ministry
   review at this time,                           funding support
                                               • Investigate interdependencies with
                                                  other projects and partner on initiative
                                               • In-kind CCN resources
                                               • In-kind member hospital resources
                                               • Additional member fees to support
                                                  project
•   Availability of CCN volunteer              • Use stakeholders in an effective and
    resources                                     efficient manner;
                                               • Personalized initial contact by CCN
                                                  CEO or medical officer


Principles for Decision Making
Report recommendations and conclusions will be consensus-based. Consensus will be
derived from the prevailing balance of perspectives and evidence.

Deliverables


    65
•   Final report to the Clinical Services Committee and the CCN Board, and following report
    approval, dissemination to CCN stakeholders, including member hospitals, the Ministry
    of Health and Long-Term Care and the LHINs.
•   Documentation of Steering Committee minutes
•   Regular status reports to CSC and the CCN Board

Executive Sponsor
Kevin Glasgow (CEO) on behalf of the CCN Board

Project Accountability
The Steering Committee will report to the CCN Clinical Services Committee which will
report to the Board.

Project Leader
Terri Swabey, Director Projects and Liaison

Project Team
Eric Cohen                    Medical Officer                Expert Clinical Advice;
                                                             CSC oversight role
Terri Swabey                  Director of Projects/Liaison   Project Leader
Dave Ilkka                    Director of I/IT               Data/IT oversight
Caroline Rafferty             Director Clinical Practice     Hospital Operations,
                                                             Clinical Practice
Ben Vozzolo                   Director, Operations and       CSC Staff Lead
                              Business Affairs
Linda Gill                    Secretary                      Administrative Support
Lucy Li                       Decision Support Analyst       Data and analysis support
TBD                           Project Manager                Project management

Steering Committee Membership
Membership developed to represent a broad range of perspectives, geography, analytic
expertise and jurisdictions (e.g. other provinces). One person may fill multiple roles.
• Chair
• Patient representative – input into secondary review process
• Cardiac surgeon(s) – academic hospital, community hospital
• Cardiologist(s) – interventional, community – non-interventionalist
• Hospital Cardiac Administrator
• Regional Cardiac Care Coordinator
• Chair or representative, Clinical Services Committee
• Systems planner/modeling expertise – special resource to the project
• Cardiac surgery residency/training representative
• Representative from the Canadian Society of Cardiac Surgeons
• Representative from Canadian Cardiovascular Society Human Resources Task Force
• Bioethicist
Ex-officio:

    66
•   Ministry/Health Results Team representation
•   CCN project manager (contract)
•   CCN project leader (Director, Projects and Liaison)
•   CCN CEO
•   CCN Medical Officer
•   CCN Director Clinical Practice
•   CCN Director Operations and Liaison

Stakeholders
Patients/public
CCN staff
MOHLTC/Health Results Team
CCN member hospitals
Cardiac surgeons
Cardiologists
Other cardiac allied health professionals
LHINs

Implementation/Workplan
• Confirm Chair and committee membership December
• Secure project manager, early December (to be tendered)
• First meeting of Steering Committee end of January
• 3 meetings
• Final report end of June 2006

Interdependencies
• Investigate interdependencies with other projects for possible partnerships and sharing of
   resources (Long-Term Planning Scenarios, MOHLTC)

Communication Strategy
• Identify stakeholders and appropriate modes of communication

Approvals:

_________________________________________
K. Glasgow, Executive Sponsor on behalf of the CCN Board



_________________________
Date




    67
Appendix 4 – Cardiac Surgery Consensus Panel Membership


Gopal Bhatnagar, MD, Cardiac Surgeon, Trillium Health Centre
Christopher Feindel, MD, Medical Director, Heart & Circulation Program, University Health
Network
Lyall Higginson, MD, Cardiologist, University of Ottawa Heart Institute
Greg Hirsch, MD, Cardiac Surgeon, Dalhousie University
Nancy Jutte, Director, Cardiac Care Program, London Health Sciences Centre
Bernadette MacDonald, VP, Surgery Clinical Business Unit, London Health Sciences Centre
David Mazer, MD, Professor of Anesthesia, University of Toronto, St. Michael’s Hospital
Neil McEvoy (Chair), President and CEO, Hotel Dieu-Grace Hospital
Hemwanti Parasram, Policy Analyst, Ontario’s Wait Time Strategy, Ministry of Health and Long-
Term Care
Donna Riley, Regional Cardiac Care Coordinator, St. Michael’s Hospital
Fraser Rubens, MD, Cardiac Surgeon, University of Ottawa Heart Institute
Gilbert Tang, MD, Resident, Cardiac Surgery, University of Toronto
Rosalind Tarrant, Program Consultant, Ministry of Health and Long-Term Care, Operational
Support Branch
James Velianou, MD, Cardiologist, Hamilton Health Sciences Centre, McMaster University
Nancy Walton, PhD, Associate Professor, School of Nursing, Ryerson University
Richard Weisel, MD, Chair, Division of Cardiac Surgery, University of Toronto, UHN
Richard Whitlock, MD, Cardiac Surgery Resident, Hamilton Health Sciences Centre, McMaster
University
Tim Zmijowskyj, MD, Division Head, Clinical Sciences, Northern Ontario School of Medicine,
Laurentian University

Ex-Officio:
Eric Cohen, MD, Medical Officer, Cardiac Care Network of Ontario
Cris Gresser, Interim Project Manager
Kevin Glasgow, MD, Chief Executive Officer, Cardiac Care Network of Ontario
Peter Papadakos, System Support Specialist, Cardiac Care Network of Ontario
Terri Swabey, Director of Projects and Liaison, Cardiac Care Network of Ontario




   68
Appendix 5 – CCN-Member Hospitals Responding to Call for Submissions

  •    London Health Sciences Centre
  •    St. Mary’s General Hospital, Kitchener
  •    Southlake Regional Health Centre, Newmarket
  •    Thunder Bay Regional Health Sciences Centre
  •    Trillium Health Centre, Mississauga
  •    University Health Network, Toronto




  69
Appendix 6 – External Interviews

   •    Royal College of Physicians and Surgeons of Canada (Dr. Roy Masters)
   •    Canadian Society of Cardiovascular Surgeons (Dr. Christopher Feindel, President)
   •    Quebec (Dr. Benoit de Varennes, Chief, Royal Victoria Hospital, Montreal)
   •    Nova Scotia (Dr. Greg Hirsch, Cardiac Surgeon, Dalhousie University)
   •    British Columbia (Rob Halpenny, Provincial Executive Director, Cardiac Services,
        Provincial Health Services Authority, British Columbia)
   •    New York (Dr. Gene Grossi, New York University)




   70
        Appendix 7 – CCN Clinical Services Committee Membership


Lorna Bickerton, Regional Cardiac Care Coordinator, University of Ottawa Heart Institute
Eric Cohen, MD, (Chair), Director, Cath Lab, Sunnybrook Health Sciences Centre
Vladimir Dzavik, MD, Director, Interventional Cardiology, University Health Network
Jean Drumm, Operations Director, Medical Program, The Royal Victoria Hospital of Barrie
Michael Freeman, MD, Director, Heart Program, St. Michael’s Hospital
Wendy Fucile, VP, Chief Nursing Officer, Peterborough Regional Health Centre
Anup Gupta, MD, Director, Cardiac Catheterization, Toronto East General Hospital
Sanjay Jindal, MD, Internist, Huntsville District Memorial Hospital
Christopher Lai, MD, Director of Cardiology, Thunder Bay Regional Health Sciences Centre
Neil McEvoy, President and Chief Executive Officer, Hotel-Dieu Grace Hospital
Jean-Francois Marquis, MD, Interventional Cardiologist, University of Ottawa Heart Institute
Thierry Mesana, MD, Chief of Cardiovascular Surgery, University of Ottawa Heart Institute
Sven Pallie, MD, Cardiologist, Niagara Health Systems
Mackenzie Quantz, MD, Cardiac Surgeon, London Health Sciences Centre
Carmen Salmon, VP, Programs and Planning, Rouge Valley Health System
Chris Simpson, MD, Cardiologist, Kingston General Hospital
Nancy Walton, PhD, Associate Professor, School of Nursing, Ryerson University
Randal Watson, MD, Cardiologist, Trillium Health Centre


Ex-Officio:
Kevin Glasgow, MD, Chief Executive Officer, Cardiac Care Network of Ontario
Rosalind Tarrant, Program Consultant, Ministry of Health and Long-Term Care, Operational
Support Branch
Ben Vozzolo, Director of Operations and Business Affairs, Cardiac Care Network of Ontario




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Appendix 8 – CCN Board of Directors


Matt Anderson                VP                Chief Information Officer, University Health
                                               Network
Adalsteinn Brown                               Assistant Deputy Minister, Health System Strategy,
                                               Ministry of Health and Long-Term Care
Sarah Chow                   CFO               St. Michael’s Hospital
Patricia Daniels             Chair             RCCC Committee, St. Michael’s Hospital
Christopher Feindel          MD                Medical Director, Heart & Circulation Program,
                                               University Health Network
David Fell                   MD                Physician Leader/Medical Program Director of
                                               Regional Cardiac Program, Southlake Regional
                                               Health Centre
Anthony Graham               MD                Division of Cardiology, St. Michael’s Hospital
Andreas Laupacis             MD                President and Chief Executive Officer, Institute for
                                               Clinical Evaluative Sciences
Charles Lazzam               MD                Cath Lab Director, Trillium Health Centre
Mary Catherine Lindberg      Exec Director     CAHO
Bernadette MacDonald         VP                Surgery Clinical Business Unit, London Health
                                               Sciences Centre
John McCans                  MD                Chief of Medicine, Queen’s University
Manish Maingi                MD                Medical Director, Cardiology Program, Credit Valley
                                               Hospital
Lonny Rosen                  Partner           Gardiner Roberts
Heather Sherrard             VP                Clinical Services, University of Ottawa Heart
                                               Institute
Leo Steven                   President and     Sunnybrook Health Sciences Centre
                             CEO
Grace St. Jean               Admin Director    Critical Care Program, Hôpital Régional de Sudbury
                                               Regional Hospital
Kevin Teoh                   MD                Chief of Cardiac Surgery, Hamilton Health Sciences
                                               Centre
Kenneth White (Chair)        President and     Trillium Health Centre
                             CEO


Corporate Secretary:
Kevin Glasgow, MD, Chief Executive Officer, Cardiac Care Network of Ontario




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