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Medicine and Public Policy |

A Survey of Provider Experiences and Perceptions of Preferential Access to Cardiovascular Care in Ontario, Canada

David A. Alter, MD; Antoni S.H. Basinski, MD, PhD; and C. David Naylor, MD, DPhil
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From Sunnybrook Health Science Centre, The Institute for Clinical Evaluative Sciences, and University of Toronto, Toronto, Ontario, Canada. Disclaimer: The Institute for Clinical Evaluative Sciences is supported in part by a grant from the Ontario Ministry of Health. The results, conclusions, and opinions are those of the authors, and no endorsement by the Ministry is intended or should be inferred. Acknowledgments: The authors thank Ms. Kathy Sykora for statistical advice and Ms. Wendy Cooke for administrative support in the conduct of the survey. They also thank the many Ontario physicians and hospital chief executives who responded forthrightly and promptly to a survey on a controversial issue. Grant Support: By the Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada. Dr. Alter is supported by a Heart and Stroke Scientific Research Corporation of Canada Fellowship. Dr. Naylor was a Career Scientist of the Ontario Ministry of Health and is currently a Senior Scientist of the Medical Research Council of Canada. Requests for Reprints: C. David Naylor, MD, G-106, Sunnybrook Health Science Centre, 2075 Bayview Avenue, North York, Ontario M4N 3M5, Canada. Current Author Addresses: Drs. Alter, Basinski, and Naylor: G-106, Sunnybrook Health Science Centre, 2075 Bayview Avenue, North York, Ontario M4N 3M5, Canada.


Copyright ©2004 by the American College of Physicians


Ann Intern Med. 1998;129(7):567-572. doi:10.7326/0003-4819-129-7-199810010-00011
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Background: The public health insurance system in Canada is predicated on equal access to care for persons in need.

Objective: To determine the views and experiences of Ontario physicians and hospital administrators in providing patients with preferential access to specialized cardiovascular care on the basis of nonclinical factors.

Design: Survey with self-administered questionnaire.

Setting: Ontario, Canada.

Participants: All Ontario cardiologists (n = 268), cardiac surgeons (n = 68), and hospital chief executives (n = 218) and random samples of internists (n = 300) and family physicians (n = 300).

Measurements: Elicited responses (yes or no) to questions on whether and why preferential access occurred and whether the respondents had been personally involved in such a situation.

Results: After undeliverable surveys and respondents no longer involved with acute care were excluded, the eligible response rate was 71.3% (788 of 1105 respondents). More than 80% of physicians and 53% of hospital chief executives had been personally involved in managing a patient who had received preferential access on the basis of factors other than medical need. Patients deemed most likely to receive such treatment were those with personal ties to the treating physicians (93% [95% CI, 91% to 95%]), high-profile public figures (85% [CI, 82% to 87%]), and politicians (83% [CI, 80% to 86%]). Physicians were significantly more likely than chief executives to indicate that hospital board members (81% and 68%; P < 0.001) and donors to hospital foundations (63% and 42%; P < 0.001) would receive preferential access. Most respondents indicated that preferential access was more likely to be provided if patients or families were well informed, aggressive, or potentially litigious. The survey did not permit estimation of the frequency of episodes of preferential access.

Conclusions: Although equality of access is a cornerstone principle of Canada's universal health care system, some access to specialized cardiovascular services occurs preferentially on the basis of factors other than clinical need. The actual magnitude and consequences of this phenomenon remain unknown.

Figures

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Figure 1.
Participant response rate.

The eligible response rate is calculated by subtracting the number of respondents who deemed themselves ineligible from both the total respondents (numerator) and the potential recipients (denominator). CEO = chief executive officer.

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