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Surgery Backlogs One Year Later: Beyond The Tipping Point

May 21, 2021 | Article No. 81

Surgery Backlogs One Year Later: Beyond The Tipping Point

May 21, 2021 | Article No. 81

Contributors

Ayesha Siddiqua MSc, PhD

Mohit Bhandari MD, PhD

Dr. Herman Johal is the lead contributor of this article. He is an Orthopaedic Surgeon and Associate Professor within the Department of Surgery at McMaster University, and clinical faculty with the Center for Evidence Based Orthopaedics. His clinical practice focuses on acute and delayed management for high and low energy orthopaedic trauma injuries, while his research interests focus on value based decision making in orthopaedic surgery. 

 


Insights


  • After a year of the COVID-19 pandemic, healthcare systems are nowhere close to catching up with surgery backlogs. 

  • There is a significant shortage of resources to effectively catch up with backlogs.

  • Clinicians fear the viability of “catching up strategies” considering the very high demand that will be placed on healthcare workers. 

  • While many surgeries are considered elective today and deferred to an unknown date in the future, it may not take much time for these to become emergency surgeries; many cancer and orthopaedic surgeries are treated as elective surgeries with dire implications. 

  • While much strides have been made to navigate through the surgery backlogs in a healthcare and public health context that is nothing like before, continued efforts are necessary to identify missed opportunities for improvement and improve efficiency. 


“Delayed surgeries now, they may be elective today, but they may be emergency surgeries tomorrow.” 

Peter Weltman (1)

“It's almost impossible to recover from this type of a backlog ... Even if we were to operate on Saturdays and Sundays and into the evenings every day, which we don't have the capacity for, we could not do that even if we wanted to.”

Dr. Antoine Eskander, surgical oncologist (2)

Shipwrecked: A Primer on Backlog

Over a period of 6 days this past March, the world witnessed just how quickly a backlog of activities can accumulate, and how far reaching the subsequent domino effect can be. On March 26, 2021 the Evergiven cargo ship became jammed in the Suez Canal, blocking one of the world’s most crucial shipping arteries (3). This resulted in a direct delay of the Evergiven’s roughly 20,000 shipping containers, but more importantly an instant backlog developed from the lack of transportation of goods and resources between east and west, impacting roughly 12% of global trade acutely and holding up nearly $10 billion/day in lost trade, and impacting supply chains for months, if not years (3). While this all occurred over the backdrop of the ongoing COVID-19 pandemic, it provided a microcosm of what happens when essential infrastructure is halted. Unfortunately, when it comes to COVID-19 and surgical delays, the “ship” of non-urgent or emergent surgeries is still stuck (14 months later) as restorative procedures remain on hold, or are being done at a substantially reduced capacity throughout many parts of the world. Most importantly, unlike delayed goods and resources, postponed surgeries have more than just monetary impacts given the toll placed on the quality of patient’s lives that as they continue to wait for surgical care. 


“Spurred by the pandemic, Ontario's surgery backlog is estimated at more than 257,000 cases and growing. The province instructed hospitals last month to suspend procedures deemed non-urgent to spare ICU beds as COVID-19 cases climbed. A similar move was made in the pandemic's first wave.”

“From March 15, 2020, to May 2, 2021, there were 232,574 fewer surgeries carried out overall than during the same period pre-pandemic. There were 6,225 fewer adult oncology surgeries.”

“From Jan. 1, 2021, to April 30, there were 42,052 fewer surgeries completed than during the same period in 2019.”

Mauro (2021) (4)

“When you have a cancer diagnosis, cancer literally cannot wait. It’s progressive, it does not sit there and say, OK, we’ll wait till COVID is gone and then we'll ramp up. it continues in the body… If you’re that patient being told your surgery is cancelled, knowing that you could be cured at that stage -- that’s not okay. And the psychological stress that incurred on some of my friends was just unbelievable.”

Patient diagnosed with cancer in March 2019 (2)

Still Frozen: Revisiting OE’s Original 2020 Model

Our initial OE Insight on the “Surgical Deep Freeze” from nearly a year ago offered a seemingly ominous estimate that surgical waitlists could balloon to unmanageable numbers. For example, OE’s models suggested that a 12-month recovery to 90% of pre-pandemic capacity would lead to approximately a 3.4 fold increase in surgical wait-times. Meaning that a pre-COVID surgical waitlist of 6 months to surgery would become a 21 month wait. Less optimistic models suggested our waitlists could grow up-to 7 times the size of those handled by most orthopaedic surgeons prior to the pandemic. This included the modelling of increased rates of failed non-op care, delayed referrals, patient deconditioning, the impact of mental health and substance abuse as well as secondary pandemic waves. 



As it may turn out, our worse case scenario is turning out to be a gross underestimate of the of those needing and waiting for surgical care. Updated models based on real-world data from over the past year offer forecasts that waitlists had already seen a 153-fold increase in length (5). While variable across subspecialty, trauma and orthopaedic surgery have been disproportionality effected. The Harvard Business Review estimates that the post-pandemic backlog of patients waiting for joint replacements and spinal fusions alone will grow by over one-million (6). A major challenge is that many of the primary factors fueling the tsunami of growing backlog are difficult to address but important to be aware of as we look towards emerging on the horizon (Exhibit 1).


Exhibit 1: Factors driving the “waves” of surgery backlog due to the COVID-19 pandemic


Waiting for Surgery: A State “Worse than Death”

Orthopaedic surgery patients have been disproportionately disadvantaged on cancelled surgeries. Often perceived as “elective” or “lifestyle” surgery, labels for joint replacement surgery, for example, have misrepresented the impacts on life and suffering. Many organizations are reframing orthopaedic surgery as ‘restorative’ surgery in lieu of ‘elective’ as a major shift in paradigm to educate policymakers and government officials. Evidence supporting the urgency and consequences of delays is also mounting.  In a recent study, 843 patients (THA n = 394, KA n = 449) from ten centres in the UK reported their EuroQol five dimension (EQ-5D) scores and completed a waiting list questionnaire (2020 group) (7). Patients scoring less than zero for their EQ-5D score were defined to be in a health state “worse than death” (WTD) (7). Over one-third waiting for a hip arthroplasty and nearly a quarter for knee arthroplasty were in a health state WTD, each additional month spent on the waiting list was independently associated with a decrease in quality of life.


“Some provinces, such as Alberta, Quebec and B.C., have already been using private clinics to provide government-funded procedures…One other tactic seems inevitable: offering surgery at unaccustomed times — on weekends and after hours. But specialists also worry about the impact of that overtime on nurses and surgeons already exhausted by the pandemic, and their own work-life balance.”

Blackwell (2021) (8)

The Tipping Point

As waitlists for functionally restorative surgery continue to rapidly grow, we are reaching the tipping point, beyond which recovery towards pre-pandemic waitlists is becoming less likely. With each passing month of decreased surgical capacity due to worsening pandemic waves, patients continue to functionally deteriorate at home, leading to increasing rates of deconditioning and complications requiring urgent or emergent surgical management (6). This creates demand for already scarce resources, leading to surgeons not only having to prioritize patients on their own lists, but also relative to those of other colleagues across surgical specialties, leading to further delay for those not deemed severe enough to warrant access to the limited resources being made available. This is on top of the background of a pandemic which continues to place health care systems around the world in a state of collapse due to uncontrollable variants and monstrous subsequent waves. While governments around the world struggle to react to the unpredictable pandemic, rollout delays and hesitancy around vaccines has blunted the impact of the most effective tool society has to reach a post-pandemic state. 



The constantly evolving and reactive nature of governmental policies, regulations and restrictions creates further confusion, uncertainty and mistrust among the public; ultimately leading to increased apathy and burnout amid patients and health care professionals alike (5). This manifests in multiple detrimental ways. On a public scale, we have seen a growing lack of compliance with important distancing regulations and quarantines, as well as growing mental health and substance misuse epidemics that have been silently worsening in the shadows of the pandemic. From the health care perspective, front-line workers are simply exhausted. Many have been working straight for the past 14 months, often redeployed, and with no real respite or time-away. As many re-opening plans call for solutions that extended operating room (OR) hours into the evening and weekends, many of the skilled personnel required to put these solutions in action are turning over at record rates or expressing concern over being able to further overextend themselves. Recent plans dependent on increased surgical capacity estimate that recovery efforts will take 2 to 3.5 years to address the additional surgical backlog from the pandemic, which is likely another underestimate given all of these variables (1,5,9,10). While rates of apathy and burnout may be contributing to the growing backlog due to decreased efficiency, it is even more concerning as we look to re-opening and finding dependable strategies to face the looming backlog. 


"It's really getting out of crisis first, then we can start to think about what the next phase looks like… We're going to have to run at a rate of surgeries and procedures that's at 110, 120 per cent of our usual rate of these things for some time if we're going to hope to catch up.”

Dr. Chris Simpson (4)

“Doctors need to determine those patients "whose prognosis is going to change immediately" and get them to operating rooms first…The danger and the fear of every oncologist is that we don't know exactly…We don't have great evidence to know what is safe and what is not in terms of these delays."

Dr. Shady Ashamalla (4)

The Road Ahead

Despite the dire situation, there is reason for hope as we look ahead. It does seem as if vaccination efforts are gaining traction, and health systems are beginning to formalize roadmaps as countries emerge from the pandemic in the coming months. This provides an important opportunity to implement what we have already learned over the past year regarding how we deliver care, and anticipate challenges while looking for innovative solutions. Leaps have been made in the areas of virtual care and remote monitoring to facilitate distancing guidelines while still providing care to patients in need. Early feedback has been extremely positive from both patients and clinicians, however key infrastructure and policies around virtual care contribute to its success. Likewise, remote monitoring requires key resources and technology to work, but if successfully implemented, it holds the potential to extend the capabilities of short stay and day surgery pathways, while preserving hospital capacity. Surgical procedures that limit dependence in inpatient resources and optimize outpatient pathways stand the best chance of being able to gain OR access, especially early on during many re-opening plans. Central to many strategies is the additional need for front-line workers to provide direct, hands on treatment. This provides a unique opportunity as many of the underemployed pool of surgeons in particular jurisdictions could be hired and integrated into the post-pandemic workforce that will potentially be needed to utilize extended OR hours or provide virtual/remote care. As many of these solutions come with a request for increased resource, it will be important to implement measures that help prioritize those waiting, including the development and application of functional scoring tool and generic quality of life tools for orthopedics patients. Being able to compare our patients to those competing for the same resources will aid in advocacy efforts that will be needed to lobby health policy makers in the post pandemic era; and most importantly help give our backlogged patients a voice at the table as we look to the path ahead. 


Exhibit 2: Strategies to clear the surgery backlog


Contributors

Ayesha Siddiqua MSc, PhD

Ayesha Siddiqua completed her graduate training from the Health Research Methodology Program in the Department of Health Research Methods, Evidence, and Impact at McMaster University. She is a Data Scientist at OrthoEvidence.

Mohit Bhandari MD, PhD

Dr. Mohit Bhandari is a Professor of Surgery and University Scholar at McMaster University, Canada. He holds a Canada Research Chair in Evidence-Based Orthopaedic Surgery and serves as the Editor-in-Chief of OrthoEvidence.

References

1.    BNN Bloomberg. Clearing surgery backlog to cost $1.3B as Ontario faces overall healthcare spending shortfall: FAO. (2021).
2.    Favaro, A., St. Philip, E. & Ho, S. Crisis brewing as COVID-19 derails life-saving surgeries at Canadian hospitals | CTV News. https://www.ctvnews.ca/health/coronavirus/crisis-brewing-as-covid-19-derails-life-saving-surgeries-at-canadian-hospitals-1.5347097.
3.    Russon, M.-A. The cost of the Suez Canal blockage. BBC News (2021).
4.    Mauro, E. & May 8, 2021 4:00 AM ET | Last Updated: Fear and frustration for cancer patients caught in Ontario’s surgery backlog | CBC News. CBC https://www.cbc.ca/news/canada/surgery-backlog-ontario-1.6017206 (2021).
5.    Carr, A., Smith, J. A., Camaradou, J. & Prieto-Alhambra, D. Growing backlog of planned surgery due to covid-19. BMJ n339 (2021) doi:10.1136/bmj.n339.
6.    Jain, A., Dai, T., Bibee, K. & Myers, C. G. Covid-19 Created an Elective Surgery Backlog. How Can Hospitals Get Back on Track? 7 (2020).
7.    Clement, N. D., Scott, C. E. H., Murray, J. R. D., Howie, C. R. & Deehan, D. J. The number of patients “worse than death” while waiting for a hip or knee arthroplasty has nearly doubled during the COVID-19 pandemic. The Bone & Joint Journal 103-B, 672–680 (2021).
8.    Blackwell, T. Surgery backlogs have become pandemic’s lingering collateral damage | Healthing.ca. https://www.healthing.ca/diseases-and-conditions/coronavirus/surgery-backlogs-have-become-pandemics-lingering-collateral-damage (2021).
9.    Jones, K. Surgical backlog in Ontario from COVID-19 will take 84 weeks to clear. Hospital News https://hospitalnews.com/surgical-backlog-in-ontario-from-covid-19-will-take-84-weeks-to-clear/ (2020).
10.  The Canadian Press. Ontario’s surgical backlog will take more than 3.5 years to clear, fiscal watchdog says | CTV News. https://toronto.ctvnews.ca/ontario-s-surgical-backlog-will-take-more-than-3-5-years-to-clear-fiscal-watchdog-says-1.5421321 (2021).
 

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