Surgical backlog ‘catastrophic,’ doctors say
Ontario urged to act as experts fear soaring wait-lists for procedures will take years to clear
As the crushing pressure from the Omicron wave eases, Ontario hospitals must now confront a massive surgical backlog that has forced hundreds of thousands of people to wait for scheduled surgeries, including joint replacements, cataract surgeries and some cancer procedures.
Surgical shutdowns during the pandemic — needed to free up hospital resources for COVID-19 patients — have created system-wide disruptions and a backlog of surgeries that experts say will take years to clear.
And despite efforts to catch up in between pandemic waves, experts say the wait-lists for many non-urgent surgeries and procedures have continued to swell. They warn the province must not only fund additional system capacity, but rethink how it offers surgical care.
“This is a catastrophic problem the health-care system will face for at least the next five years,” said Dr. David Gomez, an acute care and trauma surgeon at St. Michael’s Hospital in Toronto.
“Unless we redesign surgical care in the province, many, many Ontarians are not going to get their surgeries. There’s going to be a significant impact to people’s lives, but also to their mobility, fertility and quality of life.
“A lot of people will just not be eligible for surgery given the fact these delays continue to grow.”
The province on Thursday lifted Directive 2 — put in place in early January when COVID patients were streaming into hospitals — to allow hospitals to gradually resume non-urgent surgeries and procedures.
This was the third provincially mandated surgical slowdown to redirect hospital resources to COVID patients. Hospitals were directed to pause non-urgent surgeries in March 2020 and again in April 2021 during the third wave when Delta cases were soaring.
In a statement to the Star, an Ontario Health spokesperson said it was not possible to provide the number of surgeries postponed since the beginning of the pandemic. However, the agency did provide figures that highlight the surgical care gap in the province.
Between March 15, 2020, and Jan. 23, 2022, 883,815 scheduled adult and pediatric surgeries (including cancer and cardiac surgeries) were performed in the province.
In comparison, 1,219,800 scheduled adult and pediatric surgeries were completed in “the comparable period pre-pandemic.” That suggests a gap of about 336,000 scheduled surgeries that did not take place during the pandemic.
Dr. Chris Simpson, executive vicepresident of medical at Ontario Health, said the agency is still calculating the number of postponed surgeries during Omicron.
However, data suggests the gap is likely narrower than 336,000 scheduled surgeries because fewer people were listed for surgery during the pandemic and some people on wait-lists have chosen to pursue non-surgical alternatives to their conditions, he said.
Still, he said, it’s clear the pandemic has left many patients waiting for scheduled procedures.
“We know these directives have resulted in an accumulation of people who are now waiting for longer than they should — longer than the maximum recommended wait time or target,” Simpson said, noting that patients who have waited past provincial benchmarks will be prioritized as hospitals resume non-urgent surgeries.
“If you’re on the list right now waiting for a hip replacement, the maximum acceptable wait time is six months; that’s the target,” Simpson said. “If somebody has been waiting three months, they can still reasonably wait for three more months. But if somebody has been waiting for a hip for nine months now, then those people need to be seen as quickly as possible and need to be prioritized.”
Throughout the pandemic — even during surgical shutdowns triggered by COVID patient surges — emergency surgeries went ahead and urgent cancer and cardiac procedures were prioritized.
Simpson said evidence shows cancer surgeries faced minimal disruptions during the pandemic because “resources were appropriately diverted” to those patients.
According to data provided by Ontario Health, nearly 95,000 scheduled adult cancer surgeries were completed in the province between March 15, 2020, and Jan. 23, 2022. In “the comparable period prepandemic,” 106,122 scheduled adult cancer surgeries were completed.
That leaves a gap of about 11,122 surgeries.
Dr. Antoine Eskander, a head and neck surgical oncologist at Michael Garron Hospital and Sunnybrook Health Sciences Centre, said Ontario’s surgical backlog is “far worse” for some conditions than for others. Research he is preparing for publication shows, for example, wait times for cancer surgeries dropped in Ontario during the pandemic because they were prioritized, he said.
“Everything else fell by the wayside; cataracts, hips and knees, benign, noncancerous surgeries, all of these surgeries that really impact people’s quality of life were left behind,” said Eskander, who is also an adjunct scientist at the non-profit research institute ICES.
“We have been getting through the most urgent surgeries, but there’s a whole bunch of other surgeries that are very important that have not been happening.”
As well, Eskander and other experts say they are concerned about the huge numbers of people not yet added to a surgical wait-list because pandemic disruptions mean they have not been seen in person by a doctor, undergone routine cancer screening or had a diagnostic test, such as a CT scan or MRI exam.
A recent study published by Eskander in the Journal of the National Comprehensive Cancer Network found that 12,601 fewer people were diagnosed with cancer in the first six months of the pandemic in Ontario.
“We saw a 30 per cent drop in cancer incidence and to this day we haven’t caught up,” he said. “So where are all those cases? These patients are either coming in now because cancers can take a year or two to grow to the point where you can’t ignore them. Or these cancers have become inoperable, with some patients having passed away.”
Last May, the Financial Accountability Office calculated there would be 419,200 surgeries and almost 2.5 million diagnostic procedures on provincial wait-lists by the end of September 2021 due to pandemic surgical shutdowns.
The independent watchdog said it would cost the province $1.3 billion to clear the backlogs and noted the Ontario government had only earmarked $610 million — less than half of what was needed — in the 2021 provincial budget.
Gomez, who is also an adjunct scientist at ICES who studies access to health care, said research has shown the province’s ability to catch up on surgeries after a pandemic shutdown “is limited.”
“After surgical slowdowns and directives are lifted, it takes almost a month to even recover to historic baselines,” he said. “Any procedures that we’ve looked at, we found incredibly limited capacity to overperform compared to historical volumes.”
An additional concern is that patients waiting for non-urgent surgeries can then require urgent surgeries for their conditions.
A recent study by Gomez and his colleagues published in Annals of Surgery found a 23 per cent reduction in the number of elective gallbladder surgeries completed in the first two pandemic waves in Ontario. This was linked to an increase in the number of urgent gallbladder removal surgeries in patients presenting to emergency departments.
Gomez said the province needs to add surgical capacity to hospitals, including a boost to health-care staff, along with creative solutions that go beyond scheduling surgeries on evenings and weekends to tackle the backlog.
“A lot of people will just not be eligible for surgery given the fact that these delays continue to grow,” he said. “And it’s not like people stop presenting for surgeries; we still have to deal with the baseline normal volume requirements.
“And now we also have to clear hundreds of thousands of procedures that were never done. This is an insurmountable task for a system that already operated near capacity.”
During this “Phase 2 of recovery,” the province has directed hospitals to slowly resume scheduled surgeries, asking them to go from about 40 per cent of their typical surgical rate to about 70 per cent, said Simpson. He noted hospitals facing fewer pandemic pressures may accelerate to 90 per cent of their typical surgical rate.
Anthony Dale, president of the Ontario Hospital Association, said to ensure there is system-wide equity in tackling the surgical backlog, patients waiting for a scheduled procedure may be asked to get care in a hospital outside their community.
This will help patients in areas hard-hit by the pandemic, where hospitals still struggle to cope, get their surgeries sooner, he said.
The most recent surgical shutdown helped hospitals cope in January when about 20 per cent of the entire acute care hospital system was occupied by COVID patients, he said.
“That’s not normal; you don’t see one disease dominating a hospital system so completely the way it did in January.”
We have been getting through the most urgent surgeries, but there’s a whole bunch of other surgeries that are very important that have not been happening.
DR. ANTOINE ESKANDER SURGICAL ONCOLOGIST