Impact of clinical urgency, physician supply and procedural capacity on regional variations in wait times for coronary angiography.
BACKGROUND
Despite universal health care, there continues to be regional access disparities to coronary angiography in Canada. Our objective was to evaluate the extent to which demand-side factors such as clinical urgency/need, and supply-side factors, as reflected by differences in physician and procedural supply account for these inequalities.


METHODS
Our cohort consisted of 74,254 consecutive patients referred for coronary angiography in Ontario, Canada between April 1st 2005 and March 31st 2006, divided into three urgency strata based on a clinical urgency scale. Cox-proportional hazard models were developed, adjusting for age, gender, socioeconomic status (SES), region, and urgency score, with greater hazard ratios (HR) indicating shorter wait times. To evaluate mediators of any residual wait-time differences, we examined the influence of the regional supply of cath lab facilities, invasive cardiologists and general practitioners (GP).


RESULTS
We found that the urgency score was a significant predictor of wait time in all three strata (urgent patients: HR 1.61 for each unit increase in patient urgency (95% Confidence interval (CI) 1.55-1.67); semi-urgent patients: HR 1.55 (95% CI 1.44-1.68); elective patients: HR 1.13 (95% CI 1.08-1.18)). After accounting for clinical need/urgency, regional wait time differences persisted; these were most consistently associated with variation in cath lab supply. The impact of invasive cardiologist supply was restricted to urgent patients while that of GP supply was confined to semi-urgent and elective patients.


CONCLUSIONS
We found that there remained significant regional disparities in access to coronary angiography after accounting for clinical need. These disparities are partially explained by variations in supply of both procedural capacity and physician services, most notably in elective and semi-urgent patients.
Wijeysundera
Harindra C
HC
Sunnybrook Health Sciences Center, 2075 Bayview Avenue, Toronto, Ontario, Canada. wijeysundera@sympatico.ca
Stukel
Therese A
TA
Chong
Alice
A
Natarajan
Madhu K
MK
Alter
David A
DA
D002170:Canada; D015331:Cohort Studies; D017023:Coronary Angiography; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D054625:Healthcare Disparities; D006801:Humans; D010820:Physicians / Q000600:supply & distribution*; D016016:Proportional Hazards Models; D014850:Waiting Lists