Alberta doctors speak out against AHS review recommendations targeting surgery

Some Alberta doctors are pushing back against recommendations in the recently released Alberta Health Services performance review that call for cutbacks and even the removal of government funding for dozens of surgeries.

One section of the $2-million report, conducted by Ernst and Young for the Alberta government, takes aim at a list of 44 surgeries (more than 50,000 cases) defined by the U.K.'s National Health Service as "of limited clinical value."

The report recommends a targeted reduction could result in $47 million to $100 million in savings.

The review also recommends working to remove these procedures from Alberta's list of insured services — something the province is now saying won't happen.

Adult abdominal hernia repairs, which were performed 8,658 times in Alberta in 2018-19, top that list.

"This section of the report paints a picture that's not accurate at all,"  said Dr. Parveen Boora, a general surgeon at the Chinook Regional Hospital in Lethbridge.

According to Boora, the NHS recommendations cited in the report — and used to justify targeted cuts — contain the same criteria doctors here in Alberta already use.

Surgeons, he says, are fixing hernias only when it's medically necessary.

"It doesn't say not to fix them. It doesn't say fixing them all is of limited clinical value. It basically says that if they are of a certain subtype or if they are symptomatic or if they have caused complications, they should fix them," he said.

"And that's already the criteria we use to decide on fixing hernias."

The AHS review defines "limited clinical value" as "procedures where the evidence of clinical effectiveness is deemed to be weak or absent. Many times, alternative therapeutic approaches exist that reduce the risk of patient harm and promote more efficient use of OR capacity."

It goes on to say that detailed clinical reviews "alongside AHS's clinical experts" are required to adequately assess the appropriateness of the procedures.

Boora says its clear to him that the authors of the report are not doctors and don't understand Alberta's medical system.

"They did not go and audit 8,700 charts and determine whether or not it met the NHS's criteria. They just word matched," he said.

"People who work in the field of medicine would see something like that and right away they'd be like, 'you're not interpreting that right. There's something wrong here.' So when you see something like that in a report, it would suggest to me that  there wasn't somebody there who knew how to interpret the guideline."

'Life-saving' surgery

Dr. Sean Gregg, a Red Deer surgeon, has similar concerns.

"I did two hernia surgeries last week. Both of those patients would have died within several days because their bowel was dead. It was stuck in their hernia, How could you ever say that's not of clinical value?" said Gregg.

"Those lives were saved."

According to Gregg, most, if not all, of the abdominal hernia surgeries performed in Alberta are medically necessary. 

"I am extremely pessimistic about the ability to translate these recommendations into the kind of numbers that they're predicting because the low value care that they're talking about. It just doesn't exist in real life," he said, pointing to the report's suggestion that a targeted reduction of this surgery list could net a savings of up to $100 million.

Gregg believes that while the AHS performance review may contain some important recommendations, it missed the mark when it comes to surgery.

Tubal ligation

The list also includes female sterilization (tubal ligation), a procedure that was conducted 1,095 times in Alberta last year

"My first response was disbelief. My second was anger," said Dr. Fiona Mattatall, a Calgary-based gynecologist who was shocked when she read the report.  

"'Limited clinical value' would be the opposite of how I would describe this surgery. It's of significant clinical value both for a woman to be able to control her birth control but also … risk reduction for ovarian cancer."

According to Mattatall, tubal ligation is done mostly for contraception in women for whom other forms of birth control have failed and also for women who can't afford other birth control methods.

Tubal ligation is the only funded form of birth control for women in Alberta

"I think it's important both for reproductive freedom for women but particularly for women of limited socio-economic status," she said

Mattatall says the criteria recommended by the NHS and cited in the report as a reason for reducing these surgeries are already being used by physicians who perform tubal ligations.

She notes the Alberta health-care system is different.

"What's different in the NHS  is that under their program, all contraception is paid for by the NHS. So a woman can have an IUD, or birth control pill, condoms, tubal, her partner can have a vasectomy — all at no cost to the patient. Very different here in Alberta."

No plans to delist

Alberta's Health Minister, Tyler Shandro, insists the province has no plans to stop funding the surgeries listed in the report.

In a statement emailed to CBC News, Shandro's press secretary, Steve Buick wrote: " We're not de-insuring hernia repairs, mastectomies or any of the procedures listed in the report."

Buick said the list reflects the NHS's concerns about inappropriate use or overuse of some procedures in the U.K. and "the AHS review recommends that AHS continue its own work to ensure appropriate care in Alberta, in consultation with clinicians."

He pointed to work that's been done for years by AHS and doctors to reduce the use of MRIs, CT scans and anti-psychotic drugs in continuing care as examples.

"Decisions on the appropriateness of surgery for a patient will continue to be made by medical professionals at AHS, not by politicians," he said.

Opposition not convinced

Despite the minister's commitment to maintain coverage for the surgeries, NDP Leader Rachel Notley continues to raise questions about the aim of the report.

"I'm very concerned that we're actually looking at delisting or reducing coverage for any kind of health-care procedure that makes a difference in the lives of Albertans," she said.

"They're identifying them as procedures that they need to look at whether they'll continue to offer," Notley said. "If they're not offering them, then presumably people will have to buy them.… I'm not at all comforted by the assurances of the minister."

The review is now in the hands of AHS officials, who have been given until May 13 to develop an implementation plan.

For his part, Boora says the problems he sees with the report's recommendations on surgery are making him question the work behind dozens of other recommendations found in the review.

"It does make me then wonder: So what else in this report is being put forward without an understanding of how to interpret recommendations, for example, or how to actually provide health care. That's … what stood out to me."