Clearing the surgical backlog caused by COVID-19 in Ontario: a time series modelling study

Higher Post-Acute Health Care Costs Following SARS-CoV-2 Infection Among Adults in Ontario, Canada

Purpose and Introduction

Growing evidence suggests SARS-CoV-2 infection increases the risk of long term cardiovascular, neurological, and other effects. However, post-acute health care costs following SARS-CoV-2 infection are not known.

Patients and Statistical Methods

Beginning 56 days following SARS-CoV-2 polymerase chain reaction (PCR) testing, we compared person-specific total and component health care costs (2020 CAD$) for the first year of follow-up at the mean and 99th percentiles of health care costs for matched test-positive and test-negative adults in Ontario, Canada, between January 1, 2020, and March 31, 2021. Matching included demographics, baseline clinical characteristics, and two-week time blocks.

Results

For 531,182 people, mean person-specific total health care costs were $513.83 (95% CI $387.37-$638.40) higher for test-positive females and $459.10 (95% CI $304.60-$615.32) higher for test-positive males, which were driven by hospitalization, long-term care, and complex continuing care costs. At the 99th percentile of each subgroup, person-specific health care costs were $12,533.00 (95% CI $9008.50-$16,473.00) higher for test-positive females and $14,604.00 (95% CI $9565.50-$19,506.50) for test-positive males, driven by hospitalization, specialist (males), and homecare costs (females). Cancer costs were lower. Six-month and 1-year cost differences were similar.

Conclusion

Post-acute health care costs after a positive SARS-CoV-2 PCR test were significantly higher than matched test-negative individuals, and these increased costs persisted for at least one year. The largest increases health care costs came from hospitalizations, long-term care, complex continuing care, followed by outpatient specialists (for males) and homecare costs (for women). Given the magnitude of ongoing viral spread, policymakers, clinicians, and patients should be aware of higher post-acute health care costs following SARS-CoV-2 infection.

Turbulence in the system: Higher rates of left-without-being-seen emergency department visits and associations with increased risks of adverse patient outcomes since 2020

Objective

To examine risks of severe adverse patient outcomes shortly after a left-without-being-seen emergency department (LWBS ED) visit since 2020.

Methods

In this retrospective study using linked administrative data, we examined temporal trends in monthly rates of ED and LWBS visits for adults in Ontario, Canada, 2014‒2023. In patient-level analyses restricted to the first eligible LWBS ED visit, we used modified Poisson regression to compare the composite outcome of 7-day all-cause mortality or hospitalization following a LWBS ED visit for April 1, 2022‒March 31, 2023 (recent period) to April 1, 2014‒March 31, 2020 (baseline period), adjusted for age, sex, and Charlson comorbidity index.

Results

Despite fewer monthly ED visits since 2020, temporal trends revealed sustained increases in monthly LWBS rates. LWBS ED visits after April 1, 2020 exceeded the baseline period's single-month LWBS maximum of 4.0% in 15 out of 36 months. The composite outcome of 7-day all-cause mortality or hospitalization was 3.4% in the recent period versus 2.9% in the baseline period (adjusted risk ratio [aRR] 1.14, 95% confidence interval [CI] 1.11‒1.18) and remained elevated at 30 days (6.2% vs. 5.8%, respectively; aRR 1.05, 95% CI 1.03‒1.07), despite similar rates of post-ED outpatient visits (7-day recent and baseline: 38.9% and 39.7%, respectively, p = 0.38; 30-day: 59.4% and 59.7%, respectively, p = 0.05).

Conclusions

The rate of short-term mortality or hospitalization after a LWBS ED visit has recently increased, despite fewer ED visits/month and similar proportion of post-ED outpatient encounters. This concerning signal should prompt interventions to address system- and population-level causes.

Same Day Total Hip and Knee Arthroplasty Performed at Canada's First Academic Ambulatory Surgical Center Is Safe and Effective: Population Level Results

BACKGROUND

Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are being increasingly performed as an outpatient procedure. Performing these procedures at an ambulatory surgical center (ASC) has been proposed as a way to create greater access to surgical care, improve efficiency, and contain costs. The purpose of this review was to analyze the introduction of a same-day THA and TKA program at Canada's first academic ASC.

METHODS

An inpatient THA and TKA cohort and ASC cohort were developed with aggregate data collected from the Canadian Institute for Health Information and Canadian Joint Replacement Registry spanning January 2019 to March 2021. Quality was assessed via patient length of stay, 30-day readmissions, emergency department visits, and revision surgeries. Costs were assessed utilizing methodology and data provided by Canadian Institute for Health Information. Statistical analysis was performed comparing patient cohorts via Chi-square and t-tests.

RESULTS

Patients in the ASC cohort were significantly younger, more medically complex, and less likely to visit the emergency department within 30 days of surgery (P ≤ 0.001). Overall, 3.7% of patients failed same-day discharge and required a short stay. There was substantial cost savings of 1,721 Canadian Dollars per total joint arthroplasty (TJA) in cases performed at the ASC (P ≤ 0.001).

CONCLUSIONS

A THA and TKA performed at an academic-based ASC reduced costs and additional health care utilization within 30 days of surgery. This model of same-day surgery at an ambulatory center could help improve timely access to care for a proportion of Canadian patients.

The impact of COVID-19 on pancreaticoduodenectomy outcomes in a hepatopancreatobiliary centre of excellence

BACKGROUND

At the beginning of the COVID-19 pandemic, access to "planned" surgical care was restricted as the health care system responded to the coronavirus. We hypothesized that the pandemic resulted in diagnostic and therapeutic delays, leading to stage migration among patients with malignancies treated with a Whipple procedure.

METHODS

This study is a retrospective review of adults who underwent surgical exploration for a planned pancreaticoduodenectomy for malignancy at St. Joseph's Health Centre between March 11, 2019, and March 11, 2021.

RESULTS

We included 180 patients in the study. Baseline characteristics, pathologic diagnoses, and perioperative outcomes were similar between the 2 cohorts. The post-COVID group had longer median wait times from date of consent (p < 0.001), and from computed tomography (CT) scan (p < 0.001), to surgery. There were increased rates of R1 margin positivity in the post-COVID group (p = 0.01). We saw an association between higher wait times from consent and the last CT scan to the date of operation, and increased rates of R1 margin positivity in the first year of the pandemic.

CONCLUSION

This study demonstrated the importance of prioritizing care during a pandemic and provided evidence for potential long-term consequences when there are delays in surgery for aggressive gastrointestinal malignancies.

Impact of the COVID-19 Prioritization Recommendations on Pathological Stages of Urologic Malignancies: A Real-World Analysis at a High-Volume Referral Institution

Background: In response to the COVID-19 pandemic, the European Association of Urology (EAU) Guidelines defined priority groups to guide the prioritization of surgery for urological malignancies. The objective of this study was to evaluate the impact of the COVID-19 prioritization recommendations on tumor pathological characteristics in a real-world setting at our academic referral institution. Methods: We compared baseline and pathological tumor features of all patients with urological malignancies treated during the pandemic period (2020-2021) versus in the post-pandemic period (2022-2023). Our institution adhered to the international recommendations and prioritized those cases defined as "high-risk". Results: Data from 9196 patients treated for urological malignancies were reviewed and grouped according to period of surgery (4401 in the pandemic period vs. 4785 in the post-pandemic period). The overall number of surgical procedures was comparable for all diseases except for the number of radical prostatectomies (1117 vs. 1405; p = 0.03) and partial nephrectomies (609 vs. 759; p = 0.02), which were significantly lower in the pandemic period. Regarding tumor pathological features, none of the recorded variables were found to differ according to period of surgery, including disease stage, tumor grading, presence of necrosis, lymphovascular invasion, and histological variants. Conclusions: A correct policy of prioritization of oncological pathologies during emergency periods and a centralization of oncological cases in reference centers reduce the possible risk of worsening cancer disease features related to the reorganization of healthcare resources.

Improving Operating Room Efficiency in Otolaryngology-Head and Neck Surgery: A Scoping Review

OBJECTIVE

One minute of operating room (OR) time costs $36 to 37. However, ORs are notoriously inefficient. There is growing literature on improving OR efficiency, but no formal review of this topic within otolaryngology has been performed. This study reviews and synthesizes the current literature on improving OR efficiency within otolaryngology.

DATA SOURCES

MEDLINE, EMBASE, Web of Science, CINAHL, Cochrane Library, preprints.org, and medRxiv were searched on November 4, 2022.

REVIEW METHODS

Published English studies were included if they reported on metrics for improving OR efficiency within otolaryngology. There were no publication date restrictions. Articles were screened by 2 reviewers. Preferred Reporting Items for Systematic Reviews and Meta-analysis reporting for scoping reviews was followed.

RESULTS

The search yielded 9316 no-duplicate articles; 129 articles were included. Most of the studies reported on head and neck procedures (n = 52/129). The main tactics included surgical considerations: hemostatic devices, techniques, and team/simultaneous approaches; anesthetic considerations: local anesthetic and laryngeal mask airways; procedure location considerations: procedures outside of the OR and remote technologies; standardization: equipment, checklists, and personnel; scheduling considerations: use of machine learning for booking, considering patient/surgeon factors, and utilizing dedicated OR time/multidisciplinary teams for on-call cases.

CONCLUSION

The current literature brings to attention numerous strategies for improving OR efficiency within otolaryngology. Applying these strategies and implementing novel techniques to manage surgical cases may assist in offloading overloaded health care systems and improving access to care while facilitating patient safety and outcomes. Anticipated barriers to implementation include resistance to change, funding, and the current strain on health care systems and providers.

The Impact of the COVID-19 Pandemic on Case Volume and Wait Times of Elective Hand Procedures: A Retrospective Chart Review Study

Introduction: The COVID-19 pandemic has decreased the number of surgeries performed in North America. The purpose of this study was to compare the number of elective hand surgeries performed during the pandemic to a corresponding pre-pandemic time period and to quantify the impact to the surgical backlog in hand surgery. Methods: Patient health records for individuals who underwent surgical management of carpal tunnel syndrome (CTS), Dupuytren's disease (DD) or stenosing tenosynovitis (time periods: March 11, 2018 to July 1, 2019 [pre-pandemic] and March 11, 2020 to July 1, 2021 [pandemic]) were retrieved from two academic institutions. The primary outcome was number of surgeries performed in each time period. Secondary outcomes included wait times for each time period; and variables as predictors of wait times, including a) age; b) gender; c) socioeconomic status; d) geographic location; and, e) comorbidities. Results: Seven-hundred-and-fifteen cases were included (447 CTR cases, 135 fasciotomy/subtotal palmar fasciectomy cases and 133 pulley release/tendon release cases). Two-hundred-and-sixty-four elective hand procedures were performed during the COVID-19 time period, compared to 451 in the pre-pandemic time period (n = 187 surgeries, 41.5%). Mean surgical wait times decreased for CTS and DD and increased for stenosing tenosynovitis during the pandemic compared to the corresponding pre-pandemic time period. No association or variation in wait times was found in regard to the aforementioned variables. Conclusions: During the pandemic, a decreased total number of elective hand surgeries were performed when compared to the corresponding pre-pandemic period. This contributes to a backlog of elective surgical procedures.

Consequences of delaying non-urgent surgeries during COVID-19: a population-based retrospective cohort study in Alberta, Canada

OBJECTIVES

To ensure sufficient resources to care for patients with COVID-19, healthcare systems delayed non-urgent surgeries to free capacity. This study explores the consequences of delaying non-urgent surgery on surgical care and healthcare resource use.

DESIGN

This is a population-based retrospective cohort study.

SETTING

This study took place in Alberta, Canada, from December 2018 to December 2021.

PARTICIPANTS

Adult patients scheduled for surgery in Alberta during the study period were included.

PRIMARY AND SECONDARY OUTCOMES MEASURES

The proportion of surgeries completed and surgery wait time were the primary outcomes. The secondary outcomes were healthcare resource use (hospital length of stay, emergency room visits and physician visits). The association between the primary outcomes and patient and surgery-related variables was explored using regression.

RESULTS

There were 202 470 unique patients with 259 677 scheduled surgeries included. Fewer surgeries were completed throughout the pandemic compared with before; in the fourth wave, there was a decrease from 79% pre-COVID-19 to 67%. There was a decrease in wait time for those who had surgery completed during COVID-19 (from 105 to 69 days). Having surgery completed and the wait for surgery were associated with the geographical zone, COVID-19 wave, and the surgery type and priority. There was a decrease in all measures of healthcare resource use and an increase in hospital and all-cause mortality during COVID-19 compared with before COVID-19.

CONCLUSIONS

The change in the proportion of scheduled surgeries completed and the wait time for completed surgery was modest and associated with COVID-19 wave and surgery-related variables, which was aligned with policies enacted during COVID-19 for surgery. The decrease in healthcare resource use suggests the effects of the COVID-19 pandemic may be delayed and may result in many patients presenting with advanced disease requiring surgical care.

Longer-term impacts of the COVID-19 pandemic on obstructive sleep apnoea (OSA)-related healthcare: a province-based study

RATIONALE

Following marked reductions in sleep medicine care early in the COVID-19 pandemic, there is limited information about the recovery of these services. We explored long-term trends in obstructive sleep apnoea (OSA) health services and service backlogs during the pandemic compared with pre-pandemic levels in Ontario (the most populous province of Canada).

METHODS

In this retrospective population-based study using Ontario (Canada) health administrative data on adults, we compared rates of polysomnograms (PSGs), outpatient visits and positive airway pressure (PAP) therapy purchase claims during the pandemic (March 2020 to December 2022) to pre-pandemic rates (2015-2019). We calculated projected rates using monthly seasonal time series auto-regressive integrated moving-average models based on similar periods in previous years. Service backlogs were estimated from the difference between projected and observed rates.

RESULTS

Compared with historical data, all service rates decreased at first during March to May 2020 and subsequently increased. By December 2022, observed service rates per 100 000 persons remained lower than projected for PSGs (September to December 2022: 113 vs 141, 95% CI: 121 to 163) and PAP claims (September to December 2022: 50 vs 60, 95% CI: 51 to 70), and returned to projected for outpatient OSA visits. By December 2022, the service backlog was 193 078 PSGs (95% CI: 139 294 to 253 075) and 57 321 PAP claims (95% CI: 27 703 to 86 938).

CONCLUSION

As of December 2022, there was a sustained reduction in OSA-related health services in Ontario, Canada. The resulting service backlog has likely worsened existing problems with underdiagnosis and undertreatment of OSA and supports the adoption of flexible care delivery models for OSA that include portable technologies.

Trends of Ophthalmic Surgery Cancellations at a County Hospital Before and During COVID-19: A 10-Year Retrospective Study

PURPOSE

Despite several publications on ophthalmic surgical cancellations discussing preventative causes in academic institutions, there remains a paucity of similar studies for safety-net hospitals. This study analyzed cancellation rates at a county hospital over a 10-year period.

METHODS

This retrospective, open cohort study investigated a total of 11,350 surgeries scheduled at a tertiary-level county hospital between January 1, 2012 and December 31, 2021. Surgical cancellation reasons were collected from chart review and categorized into eight groups to allow for analyses. Cancellation rates were then calculated per year and per subspecialty. The primary statistical analyses were paired, 2-tailed t test and χ2 test.

RESULTS

The most common reason for cancellation overall was institution-related (1065 surgeries), which was also the most common reason per year from 2012 to 2019 (range: 37.4% - 60.6%). In 2020, during COVID-19 stay-at-home mandates, the most common reason became COVID-related rescheduling, and in 2021, it was patient-driven. The cancellation rate in 2020 was significantly higher than 2019 (+9.27%,95% CI:4.96%-13.6%,p = .05), and significantly lower from 2021 to 2020 (-22.8%,95% CI:-26.8%-(-)18.7%,p = .001). Pediatric surgery had the highest cancellation rate overall (36.4%), but oculoplastics had the highest cancellation rate in 2020 (48.9%).

CONCLUSION

The most common reason for cancellation over the 10-year period was institution-related, in contrast to other publications based in academic centers. The study also had a higher cancellation rate than previously reported, again suggesting the difference between county and academic centers. The COVID-19 pandemic had a significant impact on cancellations, even after the COVID-19 stay-at-home orders were eased.

Surgical waitlist management: Perspectives from surgeons on surgical prioritization at a paediatric hospital

Globally exacerbated surgical waitlists have provided the opportunity to reflect on prioritization and resource allocation decisions. The unique circumstances of paediatric surgery and consequences of surgical delay prompted the study reported in this paper. As part of a larger project to attend to prioritization in our surgical waitlists, we conducted a Quality Improvement study, the purpose of which is to understand surgeon's perspectives regarding the ethical and practical realities of surgical prioritization at our institution. The study comprises semi-structured interviews with nine full-time paediatric surgeons from a variety of subspecialties conducted at our institution, which is a tertiary paediatric hospital with ten surgical subspecialties in a publicly funded healthcare system. Participants articulated how they prioritize their waitlists, and how they understand ethical prioritization. These findings resonate with the growing public concern for ethical practice in healthcare delivery and transparency in prioritization and resource allocation practices. Specifically, more transparency, consistency, and support is required in prioritization practices. This work highlights the importance of institutional dialogue regarding surgical case prioritization. Because quality improvement work is necessarily site-specific, concrete generalizations cannot be offered. However, the insights gleaned from these interviews and the process by which they were gleaned are a valuable knowledge-sharing resource for any institution that is interested in ongoing quality improvement work. The objectives here were to clarify the goals of prioritization within the institution, improve prioritization practices, and make them more ethical and transparent.

Fixation of Distal Radius Fractures Under Wide-Awake Local Anesthesia: A Systematic Review

BACKGROUND

The purpose of this systematic review was to analyze the available literature on fixation of distal radius fractures (DRFs) under wide-awake local anesthesia no-tourniquet (WALANT), and to examine postoperative pain scores and functional outcomes, operative data including operative time and blood loss, and the frequency of adverse events.

METHODS

Embase, MEDLINE, Web of Science, and SCOPUS were searched from inception until May 2022 for relevant studies. Studies were screened in duplicate, and data on pain scores, functional outcomes, and adverse events were recorded. Due to methodological and statistical heterogeneity, the results are presented in a descriptive fashion.

RESULTS

Ten studies were included comprising 456 patients with closed, unilateral DRFs, of whom 226 underwent fixation under WALANT. These patients had a mean age of 52.8 ± 8.3 years, were 48% female, and had a mean follow-up time of 11.6 months (range: 6-24). Operative time for WALANT patients averaged 60.4 ± 6.5 minutes, with mean postoperative pain scores of 1.4 ± 0.6 on a 10-point scale. Studies that compared WALANT to general anesthesia found shorter hospital stays with most WALANT patients being sent home the same day, decreased postoperative pain scores, and decreased costs to the healthcare system. No adverse events were reported for WALANT patients.

CONCLUSIONS

A growing body of literature reports that for closed, unilateral DRF, surgical fixation under WALANT is a safe and effective option. It allows patients to have surgery sooner, with improved pain scores and good functional outcomes, with a very low incidence of adverse events.

Comparing Emergency Nursing Measures Before and During COVID-19: A Retrospective Study of Assessment, Triage, and Workflow

Background

The COVID-19 pandemic significantly impacted emergency department (ED) operations and patient care. Understanding its effects on nursing processes, triage accuracy, and wait times is pivotal for optimizing outcomes.

Objectives

This study aimed to analyze the differences in nursing processes, triage accuracy, and wait times before and during the COVID-19 pandemic.

Design

A retrospective cohort study.

Methods

The study analyzed 224 electronic medical records from a single ED, with 120 records from the pre-pandemic period (January 2019-February 2020) and 104 records from the pandemic period (March 2020-March 2021). Dependent variables included missed nursing care per validated scales, triage accuracy per Emergency Severity Index, and wait times for nursing triage and physician examination. Independent factors encompassed sociodemographic, clinical characteristics, and organization dynamics.

Results

Sociodemographic and clinical profiles were comparable between periods. Triage accuracy remained high except for older patients. Nursing triage wait times differed little, yet physician examination and urgent case waits decreased amidst the pandemic. Nursing documentation completeness, such as recording patient status and mental state, augmented during this crisis period.

Conclusion

This evaluation identified differences in triage accuracy, wait times, and documentation completeness before and during the COVID-19 pandemic period at a single institution. Patient age and clinical status influenced some metrics. Lessons from comparing precrisis benchmarks to intra-pandemic nursing performance may guide pandemic preparedness strategies. Further research is warranted to optimize emergency processes and outcomes during public health emergencies, as well as examine strategies through multicenter investigations comparing prepandemic to intra-pandemic performance to provide broader insights into challenges and inform efforts to bolster emergency care through future crises.

Evaluating Perceptions of Head and Neck Surgeons on the Role of Single-Entry Models in Managing Surgical Waitlists in Ontario: A Qualitative Study

BACKGROUND

Long surgical wait times have long plagued health systems in Canada and abroad. This backlog and associated strain on health human resources has been exacerbated by the COVID-19 pandemic, affecting surgeries of varying degrees of urgency across all surgical specialties, including head and neck surgery. Single-entry models (SEMs) are being increasingly studied as one possible strategy to help manage surgical wait times, and a growing number of health systems have implemented SEMs within departments such as otolaryngology-head and neck surgery. We sought to evaluate the views of head and neck surgeons at all 8 designated head and neck cancer centers across Ontario on the role of SEMs in managing surgical backlogs.

RESULTS

We interviewed 10 Ontario head and neck surgeons on the role of SEMs in managing wait times within the field. The following themes were elicited from interview transcripts: (1) anticipated positive impact, (2) barriers to implementation, (3) patient experience, and (4) roadmap to implementation. Participants agreed that SEMs may have utility for certain types of surgeries if implemented to address local needs. They also believe this model would have the greatest impact if employed together with other approaches, such as increasing operating room time or nursing availability.

CONCLUSION

Our results highlighted the necessity for a nuanced approach to single-entry model implementation in head and neck surgery. While participants recognized the utility of SEMs for high-volume and low-variation surgeries, participants remained divided on the optimal approach to triaging patients necessitating more complex oncologic treatments. Deliberate collaboration among stakeholder organizations and senior surgeons will be critical if SEMs are to succeed in an intricate and political healthcare environment.

Scheduled and urgent inguinal hernia repair in Ontario, Canada between 2010 and 2022: Population-based cross sectional analysis of trends and outcomes

INTRODUCTION

We examine trends in inguinal hernia repairs with respect to the COVID-19 pandemic and secular trends in Ontario, Canada.

METHODS

This was a retrospective cohort study. Hernia repairs performed January 1, 2010-December 31, 2022 were captured from health administrative inpatient and outpatient databases. Patients managed in three clinical settings were examined: public hospital in-patient, semi-private hospital in-patient (Shouldice Hospital), and public hospital out-patient. We examined the effect of the COVID-19 pandemic on surgical volumes, clinical setting, patient characteristics by setting, time from diagnosis until surgery, hospital length-of-stay, and patient outcomes (90-day readmissions, 1-year reoperations). We used multivariable logistic regression to examine whether patient outcomes were comparable between the COVID-19 period and the pre-pandemic period, adjusted sociodemographic and clinical factors. Shouldice Hospital is the only semi-private hospital in Ontario specializing in hernia repair (patients pay for the mandated admission, but not for the procedure).

RESULTS

During the pandemic (March 2020-December 2022), there were 8,162 fewer (15%) scheduled inguinal hernia repairs than expected, but the age-sex standardized rate of urgent repairs remained unchanged. Shouldice Hospital performed more surgeries in the COVID-19 era than pre-pandemic and had a shorter average LOS by 24 hours, despite treating more patients with older age, higher ASA score [adjusted odds ratio (aOR) 2.13 (1.93-2.35) III vs I-II] and greater comorbidity [aOR 1.36 (1.08-1.70) for 2 vs none] than pre-pandemic. Patients treated in the COVID-19 era experienced a longer time until surgery, being the longest in 2022 (median 133 days). Ninety-day readmissions and 1-year reoperations were lower in the COVID-19 era and lower for patients receiving surgery at Shouldice Hospital.

CONCLUSION

During the COVID-19 pandemic, there were 8,162 fewer scheduled hernia repairs than expected, longer wait-times until surgery, shorter length-of-stay, and more patients with comorbidities, but outcomes were not worse compared with the pre-pandemic period.

Delivery and Prioritization of Surgical Care in Canada During COVID-19: An Environmental Scan

BACKGROUND

During COVID-19 healthcare systems had to make concessions to make room for the surge of COVID-19 patients requiring hospital and intensive care. Postponing surgeries was a common strategy; however, it is unclear how surgical care was delivered during this time of constraint. The objective of this study was to understand how surgical care was delivered and prioritized during the COVID-19 pandemic response.

METHODS

This was an environmental scan following the Canadian Agency for Drugs and Technologies in Health methodology. This study was conducted in Canada; a universal, publicly funded healthcare system. Evidence sources on policies pertaining to the provision of surgical care between January 2020 and October 2022 were obtained from ministries of health, health services agencies and publicly funded hospitals across all 10 provinces and three territories. We synthesized the evidence sources using framework analysis.

RESULTS

We identified 205 evidence sources that described six themes about the provision of surgical care during the COVID-19 pandemic: the cycle of postponement and resumption; guidelines for triaging and prioritizing surgical cases; Infection Prevention and Control (IPAC), and safety measures for surgical care during COVID-19, patient-centred care, and looking forward (recovery planning, leadership, and decision-making).

CONCLUSION

This study provides a comprehensive understanding of how surgical care was disrupted and innovated during COVID-19 which can inform future strategies for providing effective and efficient surgical care during times of healthcare constraint.

Recommandations pour des soins préventifs pour promouvoir l’équité en matière de santé

Contexte:

Malgré des investissements importants dans un système de soins de santé public qui comprend des services préventifs, on continue d’observer des disparités évitables en matière de santé au Canada. L’équipe avait pour objectif de formuler des recommandations pour des soins de santé préventifs qui puissent améliorer l’équité en matière de santé par la priorisation des interventions efficaces à l’intention des groupes défavorisés.

Méthodes:

La ligne directrice a été élaborée par un comité composé de spécialistes en soins primaires et de membres de la patientèle, avec la contribution d’un groupe de patientes-et patientspartenaires ayant vécu diverses expériences. Après avoir sélectionné les sujets à prioriser, nous avons recensé les revues systématiques, les essais randomisés et contrôlés récents sur les méthodes de dépistage et d’autres études pertinentes sur l’efficacité du dépistage et de la prise en charge. Nous avons utilisé l’approche GRADE (Grading of Recommendations, Assessment, Development and Evaluation) pour formuler les recommandations et avons suivi le guide AGREE II (Appraisal of Guidelines for Research and Evaluation) pour rédiger le rapport. Il en a été de même avec les principes du Guidelines International Network pour la gestion des intérêts concurrents. Les recommandations ont été passées en revue par un comité externe d’experts en contenu avant d’être distribuées à des intervenants à l’échelle nationale pour approbation.

Recommandations:

Nous avons formulé 15 recommandations concernant le dépistage et d’autres soins préventifs et 1 recommandation de nature politique visant à améliorer l’accès aux soins primaires. Ainsi, nous recommandons de prioriser une stratégie de communication pour le dépistage du cancer colorectal à partir de l’âge de 45 ans et pour l’évaluation du risque de maladie cardiovasculaire pour lutter contre les iniquités en matière de santé et promouvoir la santé. Les interventions particulières qui devraient être déployées pour lutter contre les iniquités comprennent l’autodépistage du virus du papillome humain (VPH) et du VIH, et le test de libération de l’interféron γ pour l’infection tuberculeuse. Le dépistage de la dépression, de la toxicomanie, de la violence conjugale et de la pauvreté devrait également permettre aux personnes touchées d’accéder plus facilement à des interventions éprouvées. Nous recommandons une prise de contact systématique avec des professionnels de la santé en soins primaires pour les personnes défavorisées.

Interprétation:

Les interventions préventives éprouvées peuvent aider à combattre les iniquités en matière de santé si la priorité est accordée aux personnes défavorisées. Les médecins, les organisations de santé et les gouvernements devraient adopter des mesures fondées sur des données probantes et en faire le suivi s’ils veulent promouvoir l’équité en matière de santé partout au Canada.

Backlog in ophthalmic surgeries associated with the COVID-19 pandemic in Ontario 2020

OBJECTIVE

To assess the volume of deferred ophthalmic surgeries in Ontario associated with the COVID-19 pandemic from March to December 2020 and suggest strategies and time required to clear the backlog.

DESIGN

Cross-sectional study.

PARTICIPANTS

Ontarians eligible for the Ontario Health Insurance Plan in 2017-2020.

METHODS

Backlog and clearance time for ophthalmic surgeries associated with the COVID-19 pandemic were estimated from time-series forecasting models and queuing theory.

RESULTS

From March 16 to December 31, 2020, the estimated ophthalmic surgical backlog needing operating rooms was 92,150 surgeries (95% prediction interval, 71,288-112,841). Roughly 90% of the delayed surgeries were cataract surgeries, and a concerning 4% were retinal detachment surgeries. Nearly half the provincial backlog (48%; 44,542 of 92,150) was in patients from the western health region. In addition, an estimated 23,755 (95% prediction interval, 14,656-32,497) anti-vascular endothelial growth factor injections were missed. Estimated provincial clearance time was 248 weeks (95% CI, 235-260) and 128 weeks (95% CI, 121-134) if 10% and 20% of operating room surgical capacity per week were added, respectively, based on the weekly ophthalmic surgical volume in 2019.

CONCLUSIONS

Ontario data demonstrate that the magnitude of the ophthalmic surgical backlog in 2020 alone raises serious concerns for meeting the ophthalmic surgical needs of patients. As the pandemic continues, the accrued backlog size is likely to increase. Planning and actions are needed urgently to better manage the collateral impacts of the pandemic on the ophthalmic surgical backlog.

Prioritization of surgical patients during the COVID-19 pandemic and beyond: A qualitative exploration of patients' perspectives

INTRODUCTION

During the COVID-19 pandemic, prioritizing certain surgical patients became inevitable due to limited surgical capacity. This study aims to identify which factors patients value in priority setting, and to evaluate their perspective on a decision model for surgical prioritization.

METHODS

We enacted a qualitative exploratory study and conducted semi-structured interviews with N = 15 patients. Vignettes were used as guidance. The interviews were transcribed and iteratively analyzed using thematic analysis.

RESULTS

We unraveled three themes: 1) general attitude towards surgical prioritization: patients showed understanding for the difficult decisions to be made, but demanded greater transparency and objectivity; 2) patient-related factors that some participants considered should, or should not, influence the prioritization: age, physical functioning, cognitive functioning, behavior, waiting time, impact on survival and quality of life, emotional consequences, and resource usage; and 3) patients' perspective on a decision model: usage of such a model for prioritization decisions is favorable if the model is simple, uses trustworthy data, and its output is supervised by physicians. The model could also be used as a communication tool to explain prioritization dilemmas to patients.

CONCLUSION

Support for the various factors and use of a decision model varied among patients. Therefore, it seems unrealistic to immediately incorporate these factors in decision models. Instead, this study calls for more research to identify feasible avenues and seek consensus.

Preventive care recommendations to promote health equity

BACKGROUND

Avoidable disparities in health outcomes persist in Canada despite substantial investments in a publicly funded health care system that includes preventive services. Our objective was to provide preventive care recommendations that promote health equity by prioritizing effective interventions for people experiencing disadvantages.

METHODS

The guideline was developed by a primary care provider-patient panel, with input from a patient-partner panel with diverse lived experiences. After selecting priority topics, we searched for systematic reviews and recent randomized controlled trials of screening and other relevant studies of screening accuracy and management efficacy. We used the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach to develop recommendations and followed the Appraisal of Guidelines for Research and Evaluation (AGREE II) reporting guidance. We managed competing interests using the Guideline International Network principles. The recommendations were externally reviewed by content experts and circulated for endorsement by national stakeholders.

RECOMMENDATIONS

We developed 15 screening and other preventive care recommendations and 1 policy recommendation on improving access to primary care. We recommend prioritized outreach for colorectal cancer screening starting at age 45 years and for cardiovascular disease risk assessment, to help address inequities and promote health. Specific interventions that should be rolled out in ways that address inequities include human papillomavirus (HPV) self-testing, HIV self-testing and interferon-γ release assays for tuberculosis infection. Screening for depression, substance use, intimate partner violence and poverty should help connect people experiencing specific disadvantages with proven interventions. We recommend automatic connection to primary care for people experiencing disadvantages.

INTERPRETATION

Proven preventive care interventions can address health inequities if people experiencing disadvantages are prioritized. Clinicians, health care organizations and governments should take evidence-based actions and track progress in promoting health equity across Canada.

The impact of the early COVID-19 pandemic on healthcare system resource use and costs in two provinces in Canada: An interrupted time series analysis

INTRODUCTION

The aim of our study was to assess the initial impact of COVID-19 on total publicly-funded direct healthcare costs and health services use in two Canadian provinces, Ontario and British Columbia (BC).

METHODS

This retrospective repeated cross-sectional study used population-based administrative datasets, linked within each province, from January 1, 2018 to December 27, 2020. Interrupted time series analysis was used to estimate changes in the level and trends of weekly resource use and costs, with March 16-22, 2020 as the first pandemic week. Also, in each week of 2020, we identified cases with their first positive SARS-CoV-2 test and estimated their healthcare costs until death or December 27, 2020.

RESULTS

The resources with the largest level declines (95% confidence interval) in use in the first pandemic week compared to the previous week were physician services [Ontario: -43% (-49%,-37%); BC: -24% (-30%,-19%) (both p<0.001)] and emergency department visits [Ontario: -41% (-47%,-35%); BC: -29% (-35%,-23%) (both p<0.001)]. Hospital admissions declined by 27% (-32%,-23%) in Ontario and 21% (-26%,-16%) in BC (both p<0.001). Resource use subsequently rose but did not return to pre-pandemic levels. Only home care and dialysis clinic visits did not significantly decrease compared to pre-pandemic. Costs for COVID-19 cases represented 1.3% and 0.7% of total direct healthcare costs in 2020 in Ontario and BC, respectively.

CONCLUSIONS

Reduced utilization of healthcare services in the overall population outweighed utilization by COVID-19 patients in 2020. Meeting the needs of all patients across all services is essential to maintain resilient healthcare systems.

The influence of the COVID-19 pandemic on total hip and knee arthroplasty in Ontario: a population-level analysis

BACKGROUND

The effects of the COVID-19 pandemic on elective orthopedic surgery have yet to be reported at the population level in Canada. We sought to detail the effect of the pandemic on patients who underwent total hip arthroplasty (THA) and total knee arthroplasty (TKA), and on surgeons with respect to surgical volume, wait times and health care quality.

METHOD

We compared patient length of hospital stay, revisions, readmissions and emergency department presentations between pre-pandemic (April 2019 to February 2020) and postpandemic (April 2020 to February 2021) cohorts of patients who underwent inpatient THAs or TKAs. Wait times for THA and TKA in Ontario were similarly collected.

RESULTS

Case volumes for THA and TKA decreased by 30% during the pandemic. There were significantly fewer medically complex cases during this time period (p < 0.001). Length of hospital stay was reduced from 2.2 to 1.8 days (p < 0.001). Patients were less likely to visit the emergency department within 30 days of surgery (p < 0.001). Patients who underwent TKA were also more likely to be discharged directly home (p = 0.025). There was no difference in rate of revision surgery or readmission within 30 days. The proportion of patients meeting the standard benchmark wait time in Ontario was significantly lower (p < 0.001). The corresponding wait time to treatment increased significantly (p < 0.001).

CONCLUSION

The effects of the COVID-19 pandemic on elective THA and TKA case volumes and wait times was significant. Patients having surgery during the pandemic were less medically complex, had shorter length of hospital stays and had significantly less health care utilization.

A reinforcement learning-based optimal control approach for managing an elective surgery backlog after pandemic disruption

Contagious disease pandemics, such as COVID-19, can cause hospitals around the world to delay nonemergent elective surgeries, which results in a large surgery backlog. To develop an operational solution for providing patients timely surgical care with limited health care resources, this study proposes a stochastic control process-based method that helps hospitals make operational recovery plans to clear their surgery backlog and restore surgical activity safely. The elective surgery backlog recovery process is modeled by a general discrete-time queueing network system, which is formulated by a Markov decision process. A scheduling optimization algorithm based on the piecewise decaying [Formula: see text]-greedy reinforcement learning algorithm is proposed to make dynamic daily surgery scheduling plans considering newly arrived patients, waiting time and clinical urgency. The proposed method is tested through a set of simulated dataset, and implemented on an elective surgery backlog that built up in one large general hospital in China after the outbreak of COVID-19. The results show that, compared with the current policy, the proposed method can effectively and rapidly clear the surgery backlog caused by a pandemic while ensuring that all patients receive timely surgical care. These results encourage the wider adoption of the proposed method to manage surgery scheduling during all phases of a public health crisis.

Utilising a non-surgical intervention in the knee osteoarthritis care pathway: a 6-year retrospective audit on NHS patients

Background

Knee osteoarthritis (OA) is a chronic, debilitating, musculoskeletal condition that affects millions. The increase in prevalence and its economic impact on healthcare and society raise the need for additional non-surgical interventions.

Objective

To assess the referral rates to secondary care consultation and clinical outcomes in patients with severe knee OA treated with a home-based, non-surgical intervention.

Design

This was a retrospective audit on 571 patients with knee OA who met the clinical criteria for total knee replacement (TKR) and received the service between October 2015 and March 2020.

Methods

Patients were treated with a non-surgical, home-based, biomechanical intervention that aims to reduce pain and improve function, involving a foot-worn device for gait rehabilitation. The device is adjusted to the patient based on their gait patterns and clinical symptoms. Patients are advised to use the device at home or work and continue their routine. Patients are also advised to return to follow-up appointments to readjust the device and treatment plan. The primary outcome measure was the referral rates to secondary care consultation. Secondary outcomes included patient-reported outcome measures to assess pain and function and a computerised gait test. Follow-up time was between 1 and 6 years post-treatment initiation with a mean follow-up time of 1308.1 (SD = 473.4) days (i.e. 3.5 years.).

Results

There were 65 (11.4%) referrals for secondary consultation with an average follow-up of 3.5 years. The mean days to referral was 480.9 (SD = 399.2) days. Of all referrals, 48% (n = 31) occurred during the first year of treatment, and 32% (n = 21) occurred during the second year. The rest were after more than 2 years of treatment.Significant improvements were seen in all clinical outcomes, including a reduction in pain and an improvement in function and gait patterns (p < 0.05 for all).

Conclusion

Utilising this intervention as a non-surgical option for patients with knee OA who met the clinical criteria for TKR led to a significant reduction in pain and improvement in function after 3 months that was maintained for up to 3 years. Most patients (89%) did not proceed to secondary care consultation during their time in treatment for up to 6 years.

Associations between self-reported healthcare disruption due to covid-19 and avoidable hospital admission: evidence from seven linked longitudinal studies for England

OBJECTIVES

To examine whether there is an association between people who experienced disrupted access to healthcare during the covid-19 pandemic and risk of an avoidable hospital admission.

DESIGN

Observational analysis using evidence from seven linked longitudinal cohort studies for England.

SETTING

Studies linked to electronic health records from NHS Digital from 1 March 2020 to 25 August 2022. Data were accessed using the UK Longitudinal Linkage Collaboration trusted research environment.

PARTICIPANTS

Individual level records for 29 276 people.

MAIN OUTCOME MEASURES

Avoidable hospital admissions defined as emergency hospital admissions for ambulatory care sensitive and emergency urgent care sensitive conditions.

RESULTS

9742 participants (weighted percentage 35%, adjusted for sample structure of longitudinal cohorts) self-reported some form of disrupted access to healthcare during the covid-19 pandemic. People with disrupted access were at increased risk of any (odds ratio 1.80, 95% confidence interval 1.39 to 2.34), acute (2.01, 1.39 to 2.92), and chronic (1.80, 1.31 to 2.48) ambulatory care sensitive hospital admissions. For people who experienced disrupted access to appointments (eg, visiting their doctor or an outpatient department) and procedures (eg, surgery, cancer treatment), positive associations were found with measures of avoidable hospital admissions.

CONCLUSIONS

Evidence from linked individual level data shows that people whose access to healthcare was disrupted were more likely to have a potentially preventable hospital admission. The findings highlight the need to increase healthcare investment to tackle the short and long term implications of the pandemic, and to protect treatments and procedures during future pandemics.

Bariatric Surgery Performed at a Tertiary Care Hospital and an Ambulatory Hospital: A 5 Year Comparison of Outcomes, OR Efficiencies and Costs

PURPOSE

To explore change in 30-day post-operative complications, operative times, operating room (OR) efficiencies for bariatric surgery performed at a tertiary care hospital (TH) and an ambulatory hospital with overnight stay (AH) within one hospital network over 5 years; and to compare perioperative costs at the TH and AH.

MATERIALS AND METHODS

We performed a retrospective analysis of existing data from a cohort of consecutive adult patients who underwent primary laparoscopic Roux-en-Y gastric bypass (LRYGB) and sleeve gastrectomy (LSG) between September 2016 and August 2021 at TH and AH.

RESULTS

A total of 805 patients (762 LRYGB, 43 LSG) had surgery at AH, while 109 (92 LRYGB, 17 LSG) at TH. OR times for LRYGB and LSG performed at AH were significantly shorter versus TH (150 ± 24 vs 178 ± 51 min; p < 0.01) and (123 ± 24 vs 147 ± 34 min; p = 0.01). OR turnovers (19.2 ± 6.0 min vs 28.1 ± 6.1 min; p < 0.01) and Post Anesthetic Care Unit (PACU) times (2.4 ± 0.6 h vs 3.1 ± 1.5 h; p < 0.01) were significantly faster at AH versus TH. Proportion of patients requiring transfer for a complication from AH to TH remained constant over time (range 1.5-6.2%/year; p = 0.14). 30-day complication rates were similar between AH and TH (5.5-11% vs 0-15%; p = 0.12). LRYGB and LSG costs were similar between AH and TH (8,855 ± 1,328CAD vs 8,799 ± 2,729CAD; p = 0.91 and 8,763 ± 1,449CAD vs 7,857 ± 1,825CAD; p = 0.41).

CONCLUSION

There was no difference in 30-day post-operative complications for LRYGB and LSG performed at AH and TH. Performing bariatric surgery at AH has the benefit of improved OR efficiency without a significant difference in total perioperative costs.

Patients' experiences undergoing cancer surgery during the COVID-19 pandemic: a qualitative study

PURPOSE

This study aimed to understand patients' experiences undergoing cancer surgery during the COVID-19 pandemic. In response to COVID-19, many elective cancer surgeries were delayed creating a massive backlog of cases. Patients' experiences with surgical delays may inform healthcare systems' responses to the backlog of cases and guide preparations for future healthcare emergencies.

METHODS

This was a qualitative description study. Patients undergoing general surgery for cancer at two university-affiliated hospitals between March 2020 and January 2021 were invited to one-to-one interviews. Patients were purposefully selected using quota sampling until interviews produced no new information (i.e., thematic saturation). Interviews were conducted using a semi-structured guide and analyzed according to inductive thematic analysis.

RESULTS

Twenty patients were included [mean age 64 ± 12.9; male (n = 10); surgical delay (n = 14); cancer sites: breast (n = 8), skin (n = 4), hepato-pancreato-biliary (n = 4), colorectal (n = 2), and gastro-esophageal (n = 2)]. When determining their willingness to undergo surgery, patients weighed the risk of COVID-19 infection against the urgency of their disease. Changes to the hospital environment (e.g., COVID-19 preventative measures) and deviations from expected treatment (e.g., alternative treatments, remote consultations, rescheduled care) caused diverse psychological responses, ranging from increased satisfaction to severe distress. Patients employed several coping strategies to mitigate distress, including eliciting reassurance from care providers, seeking information from unconventional sources, and reframing care interruptions.

CONCLUSIONS

Changes in care during the pandemic elicited diverse psychological responses from patients undergoing cancer surgery. Coping was facilitated by consistent communication with providers, emphasizing the importance of patient-centered expectation setting as we prepare for the future within and beyond the pandemic.

Comparative evaluation of 90-day patient outcomes and healthcare encounters following extended day surgery urethroplasty

INTRODUCTION

Most centers have shifted to an extended day surgery (XDS ) model for urethroplasty. Our study characterizes outcomes and unplanned healthcare encounters of patients undergoing XDS urethroplasty compared to case-matched inpatient controls.

METHODS

We conducted a retrospective, two-surgeon, single-center study of patients undergoing XDS urethroplasty (discharge <24 hrs) from November 2020 to November 2021. Patients were case-control matched based on age, stricture length, location, and etiology to patients who had previously undergone inpatient urethroplasty. Data was analyzed using descriptive and univariable statistics. Multivariable analysis by Cox proportional hazard regression was used to identify associations with postoperative complications.

RESULTS

Ninety patients (mean age=53.8 years) underwent XDS urethroplasty during the study period. Mean stricture length was 4.4 cm (standard deviation [SD ] 2.4). Rates of postoperative complications were similar between XDS (17%, n=15) and admitted patients (21%, n=19), and XDS was not associated with increased risk on univariable analysis (odds ratio [OR ] 0.65, 95% confidence interval [CI] 0.31-1.3, p=0.36). When stratifying by location, penile stricture (OR 4.21, 95% CI 1.3-13.8, p=0.02) and lichen sclerosus (OR 2.91, 95% CI 0.79-9.9, p=0.08) were associated with increased risk of postoperative complication. On multivariable analysis, only penile stricture was identified as significant (OR 4.78, 95% CI 1.2-19.4, p=0.03). Forty-eight percent (n=43) of patients had unplanned healthcare encounters postoperatively, with similar numbers of phone calls (n=37) and emergency department visits (n=36) between groups.

CONCLUSIONS

Our study shows that XDS urethroplasty is not associated with increased rates of complications relative to inpatient admission. This data supports using an XDS pathway for resource-efficient treatment of urethral strictures in a universal healthcare setting.

The burden of osteoarthritis: Is it a rising problem?

The objective of this review is to provide an overview of the current status of osteoarthritis (OA) as one of the most common joint disorders worldwide. Despite being the 11th cause of disability globally, there has been an increase in the prevalence, annual incidence, and years lived with disability of OA, particularly in developed and developing countries. Erosive hand OA, which affects approximately 10% of the general population, has been associated with a higher clinical burden compared to non-erosive hand OA. Patients with knee and hip OA, but not hand OA, are also at an increased risk of cardiovascular disease and all-cause mortality. Furthermore, OA has a significant contribution to healthcare costs in most countries. The recent COVID-19 pandemic has further exacerbated the disease burden of OA patients due to limited access to medical and surgical treatment. With increasing life expectancy and the aging of the global population, the burden of OA is expected to worsen. Therefore, this review highlights the importance of improving population and policymaker awareness of risk factors, such as obesity and injury, as well as early intervention and management of OA to control the future burden of the disease.

A Cross-Sectional Assessment of Parental Concerns in the Pediatric Surgery Department during the COVID-19 Pandemic

The COVID-19 pandemic has impacted various aspects of healthcare, including pediatric surgery. This study aimed to assess parental concerns and stress levels in pediatric surgery during the COVID-19 pandemic, identify factors associated with increased parental anxiety or concern, and provide recommendations for healthcare providers. A cross-sectional study was conducted in a tertiary pediatric hospital in Timisoara, Romania, involving 174 parents of pediatric patients requiring elective or emergency surgery, with a mean age of 37.6 (25-47) years, out of which 89.1% of respondents were women. Parental concerns were assessed using the Parental Concerns Questionnaire (PCQ), the Hospital Anxiety and Depression Scale (HADS), and the Perceived Stress Scale (PSS-10). Parents of children undergoing emergency surgery (n = 108) reported higher levels on the practical impact domain of the PCQ scale (3.4 vs. 2.2, p < 0.001), emotional impact (2.7 vs. 2.2, p = 0.002), and total PCQ score (9.5 vs. 7.7, p < 0.001) compared to parents of children undergoing elective surgery (n = 66). Parents in the emergent surgery group also reported higher anxiety scores on the HADS questionnaire (7.9 vs. 6.5, p = 0.009) and higher perceived stress and total score on the PSS-10 survey (7.8 vs. 5.6, p = 0.046) (10.5 vs. 9.1, p = 0.047), respectively. A significantly higher proportion of parents in the emergent surgery group were concerned about restricted visitation policies (p = 0.013) and reported delaying or considering delaying their child's surgery due to the pandemic (p = 0.036). The results demonstrate heightened concerns, anxiety, and stress among parents of children undergoing emergency surgery during the COVID-19 pandemic. Healthcare providers should address parental concerns, provide clear communication, and ensure adequate support for families. Recommendations include enhancing information about COVID-19 precautions, reassuring parents about personal protective equipment availability, and facilitating family support within visitation restrictions.

Association between the COVID-19 pandemic and first cancer treatment modality: a population-based cohort study

BACKGROUND

Physicians were directed to prioritize using nonsurgical cancer treatment at the beginning of the COVID-19 pandemic. We sought to quantify the impact of this policy on the modality of first cancer treatment (surgery, chemotherapy, radiotherapy or no treatment).

METHODS

In this population-based study using Ontario data from linked administrative databases, we identified adults diagnosed with cancer from January 2016 to November 2020 and their first cancer treatment received within 1 year postdiagnosis. Segmented Poisson regressions were applied to each modality to estimate the change in mean 1-year recipient volume per thousand patients (rate) at the start of the pandemic (the week of Mar. 15, 2020) and change in the weekly trend in rate during the pandemic (Mar. 15, 2020, to Nov. 7, 2020) relative to before the pandemic (Jan. 3, 2016, to Mar. 14, 2020).

RESULTS

We included 321 535 people diagnosed with cancer. During the first week of the COVID-19 pandemic, the mean rate of receiving upfront surgery over the next year declined by 9% (rate ratio 0.91, 95% confidence interval [CI] 0.88-0.95), and chemotherapy and radiotherapy rates rose by 30% (rate ratio 1.30, 95% CI 1.23-1.36) and 13% (rate ratio 1.13, 95% CI 1.07-1.19), respectively. Subsequently, the 1-year rate of upfront surgery increased at 0.4% for each week (rate ratio 1.004, 95% CI 1.002-1.006), and chemotherapy and radiotherapy rates decreased by 0.9% (rate ratio 0.991, 95% CI 0.989-0.994) and 0.4% (rate ratio 0.996, 95% CI 0.994-0.998), respectively, per week. Rates of each modality resumed to prepandemic levels at 24-31 weeks into the pandemic.

INTERPRETATION

An immediate and sustained increase in use of nonsurgical therapy as the first cancer treatment occurred during the first 8 months of the COVID-19 pandemic in Ontario. Further research is needed to understand the consequences.

A North Star Vision: Results from a Deliberative Dialogue to Identify Policy Strategies to Improve Value in Healthcare

We hosted a deliberative dialogue with citizens (n = 3), policy researchers (n = 3), government decision makers (n = 3) and health system leaders (n = 3) to identify evidence-informed policy options to improve the value of Canadian healthcare. The analysis resulted in three themes: (1) the need for a vision to guide reforms, (2) community-based care and (3) community-engaged care. Results suggest the need for a new paradigm: community-focused health systems. Such a paradigm could serve as a North Star guiding healthcare transformation, improving value by aligning citizen and healthcare system goals, prioritizing spending on services that address the social determinants of health and improving quality and equity.

Impact of COVID-19-related health care disruptions on pathologic cancer staging during the first pandemic year: a retrospective cohort study from March 2018 to March 2021

BACKGROUND

The COVID-19 pandemic has created major disruptions in cancer care, with reductions in diagnostic tests and treatments. We evaluated the impact of these health care-related changes on cancer staging by comparing cancers staged before and during the pandemic.

METHODS

We performed a retrospective cohort study at London Health Sciences Centre and St. Joseph's Health Care London, London, Ontario, Canada. We evaluated all pathologically staged breast, colorectal, prostate, endometrial and lung cancers (the 5 most common cancers by site, excluding nonmelanoma skin cancer) over a 3-year period (Mar. 15, 2018-Mar. 14, 2021). The pre-COVID-19 group included procedures performed between Mar. 15, 2018, and Mar. 14, 2020, and the COVID-19 group included procedures performed between Mar. 15, 2020, and Mar. 14, 2021. The primary outcome was cancer stage group, based on the pathologic tumour, lymph node, metastasis system. We performed univariate analyses to compare demographic characteristics, pathologic features and cancer stage between the 2 groups. We performed multivariable ordinal regression analyses using the proportional odds model to evaluate the association between stage and timing of staging (before v. during the pandemic).

RESULTS

There were 4055 cases across the 5 cancer sites. The average number of breast cancer staging procedures per 30 days increased during the pandemic compared to the yearly average in the pre-COVID-19 period (41.3 v. 39.6), whereas decreases were observed for endometrial cancer (15.9 v. 16.4), colorectal cancer (21.8 v. 24.3), prostate cancer (13.6 v. 18.5) and lung cancer (11.5 v. 15.9). For all cancer sites, there were no statistically significant differences in demographic characteristics, pathologic features or cancer stage between the 2 groups (p > 0.05). In multivariable regression analysis, for all cancer sites, cases staged during the pandemic were not associated with higher stage (breast: odds ratio [OR] 1.071, 95% confidence interval [CI] 0.826-1.388; colorectal: OR 1.201, 95% CI 0.869-1.661; endometrium: OR 0.792, 95% CI 0.495-1.252; prostate: OR 1.171, 95% CI 0.765-1.794; and lung: OR 0.826, 95% CI 0.535-1.262).

INTERPRETATION

Cancer cases staged during the first year of the COVID-19 pandemic were not associated with higher stage; this likely reflects the prioritization of cancer procedures during times of reduced capacity. The impact of the pandemic period on staging procedures varied between cancer sites, which may reflect differences in clinical presentation, detection and treatment.

Forecasting ICU Census by Combining Time Series and Survival Models

Capacity planning of ICUs is essential for effective management of health safety, quality of patient care, and the allocation of ICU resources. Whereas ICU length of stay (LOS) may be estimated using patient information such as severity of illness scoring systems, ICU census is impacted by both patient LOS and arrival patterns. We set out to develop and evaluate an ICU census forecasting algorithm using the Multiple Organ Dysfunction Score (MODS) and the Nine Equivalents of Nursing Manpower Use Score (NEMS) for capacity planning purposes.

DESIGN

Retrospective observational study.

SETTING

We developed the algorithm using data from the Medical-Surgical ICU (MSICU) at University Hospital, London, Canada and validated using data from the Critical Care Trauma Centre (CCTC) at Victoria Hospital, London, Canada.

PATIENTS

Adult patient admissions (7,434) to the MSICU and (9,075) to the CCTC from 2015 to 2021.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We developed an Autoregressive integrated moving average time series model that forecasts patients arriving in the ICU and a survival model using MODS, NEMS, and other factors to estimate patient LOS. The models were combined to create an algorithm that forecasts ICU census for planning horizons ranging from 1 to 7 days. We evaluated the algorithm quality using several fit metrics. The root mean squared error ranged from 2.055 to 2.890 beds/d and the mean absolute percentage error from 9.4% to 13.2%. We show that this forecasting algorithm provides a better fit when compared with a moving average or a time series model that directly forecasts ICU census. Additionally, we evaluated the performance of the algorithm using data during the global COVID-19 pandemic and found that the error of the forecasts increased proportionally with the number of COVID-19 patients in the ICU.

CONCLUSIONS

It is possible to develop accurate tools to forecast ICU census. This type of algorithm may be important to clinicians and managers when planning ICU capacity as well as staffing and surgical demand planning over a short time horizon.

The effect of the COVID-19 pandemic on hospital admissions and outpatient visits in Ontario, Canada

INTRODUCTION

The wave-over-wave effect of the COVID-19 pandemic on hospital visits for non-COVID-19-related diagnoses in Ontario, Canada remains unknown.

METHODS

We compared the rates of acute care hospitalizations (Discharge Abstract Database), emergency department (ED) visits, and day surgery visits (National Ambulatory Care Reporting System) during the first five "waves" of Ontario's COVID-19 pandemic with prepandemic rates (since January 1, 2017) across a spectrum of diagnostic classifications.

RESULTS

Patients admitted in the COVID-19 era were less likely to reside in long-term-care facilities (OR 0.68 [0.67-0.69]), more likely to reside in supportive housing (OR 1.66 [1.63-1.68]), arrive by ambulance (OR 1.20 [1.20-1.21]) or be admitted urgently (OR 1.10 [1.09-1.11]). Since the start of the COVID-19 pandemic (February 26, 2020), there were an estimated 124,987 fewer emergency admissions than expected based on prepandemic seasonal trends, representing reductions from baseline of 14% during Wave 1, 10.1% in Wave 2, 4.6% in Wave 3, 2.4% in Wave 4, and 10% in Wave 5. There were 27,616 fewer medical admissions to acute care, 82,193 fewer surgical admissions, 2,018,816 fewer ED visits, and 667,919 fewer day-surgery visits than expected. Volumes declined below expected rates for most diagnosis groups, with emergency admissions and ED visits associated with respiratory disorders exhibiting the greatest reduction; mental health and addictions was a notable exception, where admissions to acute care following Wave 2 increased above prepandemic levels.

CONCLUSIONS

Hospital visits across all diagnostic categories and visit types were reduced at the onset of the COVID-19 pandemic in Ontario, followed by varying degrees of recovery.

Examining the Spatial Varying Effects of Sociodemographic Factors on Adult Cochlear Implantation Using Geographically Weighted Poisson Regression

OBJECTIVE

To (i) demonstrate the utility of geographically weighted Poisson regression (GWPR) in describing geographical patterns of adult cochlear implant (CI) incidence in relation to sociodemographic factors in a publicly funded healthcare system, and (ii) compare Poisson regression and GWPR to fit the aforementioned relationship.

STUDY DESIGN

Retrospective study of provincial CI Program database.

SETTING

Academic hospital.

PATIENTS

Adults 18 years or older who received a CI from 2020 to 2021.

INTERVENTIONS

Cochlear implant.

MAIN OUTCOME MEASURES

CI incidence based on income level, education attainment, age at implantation, and distance from center, and spatial autocorrelation across census metropolitan areas.

RESULTS

Adult CI incidence varied spatially across Ontario (Moran's I = 0.04, p < 0.05). Poisson regression demonstrated positive associations between implantation and lower income level (coefficient = 0.0284, p < 0.05) and younger age (coefficient = 0.1075, p < 0.01), and a negative association with distance to CI center (coefficient = -0.0060, p < 0.01). Spatial autocorrelation was significant in Poisson model (Moran's I = 0.13, p < 0.05). GWPR accounted for spatial differences (Moran's I = 0.24, p < 0.690), and similar associations to Poisson were observed. GWPR further identified clusters of implantation in South Central census metropolitan areas with higher education attainment.

CONCLUSIONS

Adult CI incidence demonstrated a nonstationary relationship between implantation and the studied sociodemographic factors. GWPR performed better than Poisson regression in accounting for these local spatial variations. These results support the development of targeted interventions to improve access and utilization to CIs in a publicly funded healthcare system.

Imaging and physician visits at cancer diagnosis: COVID -19 pandemic impact on cancer care

BACKGROUND

Little is known about the COVID-19 pandemic impact on the provision of diagnostic imaging and physician visits at cancer diagnosis.

METHODS

We used administrative databases from Ontario, Canada, to identify MRI/CT/ultrasound scans and in-person/virtual physician visits conducted with cancer patients within 91 days around the date of diagnosis in 2016-2020. In separate segmented regression procedures, we assessed the trends in weekly volume of these services per thousand cancer patients in prepandemic (June 26, 2016 to March 14, 2020), the change in mean volume at the start of the pandemic, and the additional change in weekly volume during the pandemic (March 15, 2020, to September 26, 2020).

RESULTS

Totally, 403,561 cancer patients were included. On March 15, 2020 (COVID-19 arrived), mean scan volume decreased by 12.3% (95% CI: 6.4%-17.9%) where ultrasound decreased the most by 31.8% (95% CI: 23.9%-37.0%). Afterward, the volume of all scans increased further by 1.6% per week (95% CI: 1.3%-2.0%), where ultrasound increased the fastest by 2.4% (95% CI: 1.8%-2.9%). Mean in-person visits dropped by 47.4% when COVID-19 started (95% CI: 41.6%-52.6%) while virtual visits rose by 55.15-fold (95% CI: 4927%-6173%). In the pandemic (until September 26, 2020), in-person visits increased each week by 2.6% (95% CI: 2.0%-3.2%), but no change was observed for virtual visits (p -value = 0.10).

CONCLUSIONS

Provision of diagnostic imaging and virtual visits at cancer diagnosis has been increasing since the start of COVID-19 and has exceeded prepandemic utilization levels. Future work should monitor the impact of these shifts on quality of delivered care.

Pediatric Surgical Waitlist in Low Middle Income Countries during the COVID-19 Pandemic

Purpose

COVID-19 led to significant reduction in surgery worldwide. Studies, however, of the effect on surgical volume for pediatric patients in low- and middle-income countries (LMICs) are limited.

Methods

A survey was developed to estimate waitlists in LMICs for priority surgical conditions in children. The survey was piloted and revised before it was deployed over email to 19 surgeons. Pediatric surgeons at 15 different sites in 8 countries in Sub-Saharan Africa and Ecuador completed the survey from February 2021 to June 2021. The survey included the total number of children awaiting surgery and estimates for specific conditions. Respondents were also able to add additional procedures.

Results

Public hospitals had longer wait times than private facilities. The median waitlist was 90 patients and the median wait time was 2 months for elective surgeries.

Conclusion

Lengthy surgical wait times affect surgical access in LMICs. COVID-19 had been associated with surgical delays around the world, exacerbating existing surgical backlogs. Our results revealed significant delays for elective, urgent and emergent cases across Sub-Saharan Africa. Stakeholders should consider approaches to scale the limited surgical and perioperative resources in LMICs, create mitigation strategies for future pandemics, and establish ways to monitor waitlists on an ongoing basis.

First Canadian experience with same-day discharge after robot-assisted radical prostatectomy

INTRODUCTION

We aimed to evaluate the feasibility and safety of implementing a sameday discharge (SD ) protocol for robot-assisted radical prostatectomy (RARP) and pelvic lymph node dissection.

METHODS

We performed a prospective cohort study including all consecutive eligible patients undergoing RARP in 2021 following initiation of SDD RARP protocol in April. Baseline characteristics were compared using t-tests, Mann-Whitney U tests, and odds ratios (OR ) calculated using multiple logistic regression to assess for predictors of SD success.

RESULTS

A total of 117 patients underwent RARP in 2021 following initiation of the SDD protocol. Fifty-seven patients were initiated on the SD pathway and 60 patients underwent surgery as an inpatient (IP-RARP). Of those on the SD pathway (SD-RARP), 33 (58%) were successfully discharged the same day of surgery, while 24 (42%) failed SD . Baseline demographics were well-balanced between cohorts. Case order, increased patient age, and distance travelled to the hospital were factors associated with selection of patients for the IP-RARP protocol. In total, 12 SD and 12 IP patients presented to the emergency department (p=1.0), and none within 24 hours of discharge. There were no hospital admissions in the SD cohort, with four readmissions in the IP cohort (p=0.1). Multiple logistic regression revealed that case order (first case) was the only predictive factor for SD success (OR 4.08, 95% confidence interval 1.59-11.62, p=0.005).

CONCLUSIONS

Implementation of an SD pathway following RARP is feasible, with no increase in rates of complications, unscheduled visits, or readmissions.

Estimation of Oncologic Surgery Case Volume Before and After the COVID-19 Pandemic in France

IMPORTANCE

COVID-19 has had a major effect on health care activities, especially surgery. At first, comparisons were proposed using 2019 activities as the highest standard. However, while such an approach might have been suitable during the first months of the pandemic, this might no longer be the case for a longer period.

OBJECTIVE

To examine approaches that may better assess the use of cancer surgeries.

DESIGN, SETTING, AND PARTICIPANTS

In a cross-sectional design, the nationwide French hospital facility data (Medicalised Information System Program) were used to assess cancer surgery for 6 cancer site categories in adults from January 1, 2010, to December 31, 2021.

EXPOSURE

Estimated cancer surgery activity during the COVID-19 pandemic.

MAIN OUTCOMES AND MEASURES

Three models were proposed to assess the expected number of surgical procedures between 2020 and 2021 and make a comparison with those observed in earlier years.

RESULTS

In France, cancer removal surgeries account for approximately 7000 hospitalizations per year for liver cancer; 4000 for pancreatic cancer; 7700 for ovarian cancer; 1300 for esophagus cancer; 23 000 for ear, nose, and throat (ENT) cancer; 78 000 for breast cancer; and 16 600 for thoracic cancers. For most cancer sites, the number of surgical procedures increased from 2010 to 2019: liver, 14%; pancreas, 38%; ovary, 14%; esophagus, 18%; breast, 8%; and thoracic, 29%. Assuming stability, these values underestimate the gap in activity observed in 2020-2021. For other procedures, a decrease was observed: stomach, -10%, and ENT, -6%. Assuming stability, these values overestimate the gap in activity observed in 2020-2021. At the end of 2021, according to the model, the gap in activity observed in 2020-2021 was estimated at between -1.4% and 1.7% for breast, -6.6% and -7.3% for thoracic, -3.1% and -2.5% for ovarian, -4.2% and -1.7% for pancreas, -6.7% and 5.9% for stomach, and -13.0% and -13.9% for esophageal cancers. For ENT, liver, and urologic cancers, because the trend was different before and after 2015, it was necessary to opt for modeling using only the most recent period. The cumulative gap in activity observed in 2020-2021 was estimated at -1.0% for ENT cancers, -5.3% for liver cancers, and -2.9% for urologic cancers.

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that short- and medium-term trends must be considered to estimate COVID-19 cancer surgery activities. Breast cancer is the site for which the activity showed the smallest decrease during the pandemic, with almost full recovery in 2021.

The impact of delaying surgery during the COVID-19 pandemic in Alberta: a qualitative study

BACKGROUND

The COVID-19 pandemic overwhelmed health care systems, leading many jurisdictions to reduce surgeries to create capacity (beds and staff) to care for the surge of patients with COVID-19; little is known about the impact of this on patients whose surgery was delayed. The objective of this study was to understand the patient and family/caregiver perspective of having a surgery delayed during the COVID-19 pandemic.

METHODS

Using an interpretative descriptive approach, we conducted interviews between Sept. 20 and Oct. 8, 2021. Adult patients who had their surgery delayed or cancelled during the COVID-19 pandemic in Alberta, Canada, and their family/caregivers were eligible to participate. Trained interviewers conducted semistructured interviews, which were iteratively analyzed by 2 independent reviewers using an inductive approach to thematic content analysis.

RESULTS

We conducted 16 interviews with 15 patients and 1 family member/caregiver, ranging from 27 to 75 years of age, with a variety of surgical procedures delayed. We identified 4 interconnected themes: individual-level impacts on physical and mental health, family and friends, work and quality of life; system-level factors related to health care resources, communication and perceived accountability within the system; unique issues related to COVID-19 (maintaining health and isolation); and uncertainty about health and timing of surgery.

INTERPRETATION

Although the decision to delay nonurgent surgeries was made to manage the strain on health care systems, our study illustrates the consequences of these decisions, which were diffuse and consequential. The findings of this study highlight the need to develop and adopt strategies to mitigate the burden of waiting for surgery during and after the COVID-19 pandemic.

Potentially avoidable admissions to general internal medicine at an academic teaching hospital: an observational study

BACKGROUND

Identifying potentially avoidable admissions to Canadian hospitals is an important health system goal. With general internal medicine (GIM) accounting for 40% of hospital admissions, we sought to develop a method to identify potentially avoidable admissions and characterize patient, provider and health system factors.

METHODS

We conducted an observational study of GIM admissions at our institution from August 2019 to February 2020. We defined potentially avoidable admissions as admissions that could be managed in an appropriate and safe manner in the emergency department or ambulatory setting and asked staff physicians to screen admissions daily and flag candidates as potentially avoidable admissions. For each candidate, we prepared a case review and debriefed with members of the admitting team. We then reviewed each candidate with our research team, assigned an avoidability score (1 [low] to 4 [high]) and identified contributing factors for those with scores of 3 or more.

RESULTS

We screened 601 total admissions and staff physicians flagged 117 (19.5%) of these as candidate potential avoidable admissions. Consensus review identified 67 candidates as potentially avoidable admissions (11.1%, 95% confidence interval 8.8%-13.9%); these patients were younger (mean age 65 yr v. 72 yr), had fewer comorbidities (Canadian Institute for Health Information Case Mix Group+ 0.42 v. 1.14), had lower resource-intensity weighting scores (0.72 v. 1.50) and shorter hospital lengths of stay (29 h v. 105 h) (p < 0.01). Common factors included diagnostic and therapeutic uncertainty, perceived need for short-term monitoring, government directive of a 4-hour limit for admission decision-making and subspecialist request to admit.

INTERPRETATION

Our prospective method of screening, flagging and case review showed that 1 in 9 GIM admissions were potentially avoidable. Other institutions could consider adapting this methodology to ascertain their rate of potentially avoidable admissions and to understand contributing factors to inform improvement endeavours.

Impact of COVID-19 on access to cancer care in Rwanda: a retrospective time-series study using electronic medical records data

INTRODUCTION

The COVID-19 pandemic has caused disruptions in access to routine healthcare services worldwide, with a particularly high impact on chronic care patients and low and middle-income countries. In this study, we used routinely collected electronic medical records data to assess the impact of the COVID-19 pandemic on access to cancer care at the Butaro Cancer Center of Excellence (BCCOE) in rural Rwanda.

METHODS

We conducted a retrospective time-series study among all Rwandan patients who received cancer care at the BCCOE between 1 January 2016 and 31 July 2021. The primary outcomes of interest included a comparison of the number of patients who were predicted based on time-series models of pre-COVID-19 trends versus the actual number of patients who presented during the COVID-19 period (between March 2020 and July 2021) across four key indicators: the number of new patients, number of scheduled appointments, number of clinical visits attended and the proportion of scheduled appointments completed on time.

RESULTS

In total, 8970 patients (7140 patients enrolled before COVID-19 and 1830 patients enrolled during COVID-19) were included in this study. During the COVID-19 period, enrolment of new patients dropped by 21.7% (95% prediction interval (PI): -31.3%, -11.7%) compared with the pre-COVID-19 period. Similarly, the number of clinical visits was 25.0% (95% PI: -31.1%, -19.1%) lower than expected and the proportion of scheduled visits completed on time was 27.9% (95% PI: -39.8%, -14.1%) lower than expected. However, the number of scheduled visits did not deviate significantly from expected.

CONCLUSION

Although scheduling procedures for visits continued as expected, our findings reveal that the COVID-19 pandemic interrupted patients' ability to access cancer care and attend scheduled appointments at the BCCOE. This interruption in care suggests delayed diagnosis and loss to follow-up, potentially resulting in a higher rate of negative health outcomes among cancer patients in Rwanda.

Historical and future trends in emergency pituitary referrals: a machine learning analysis

PURPOSE

Acute pituitary referrals to neurosurgical services frequently necessitate emergency care. Yet, a detailed characterisation of pituitary emergency referral patterns, including how they may change prospectively is lacking. This study aims to evaluate historical and current pituitary referral patterns and utilise state-of-the-art machine learning tools to predict future service use.

METHODS

A data-driven analysis was performed using all available electronic neurosurgical referrals (2014-2021) to the busiest U.K. pituitary centre. Pituitary referrals were characterised and volumes were predicted using an auto-regressive moving average model with a preceding seasonal and trend decomposition using Loess step (STL-ARIMA), compared against a Convolutional Neural Network-Long Short-Term Memory (CNN-LSTM) algorithm, Prophet and two standard baseline forecasting models. Median absolute, and median percentage error scoring metrics with cross-validation were employed to evaluate algorithm performance.

RESULTS

462 of 36,224 emergency referrals were included (referring centres = 48; mean patient age = 56.7 years, female:male = 0.49:0.51). Emergency medicine and endocrinology accounted for the majority of referrals (67%). The most common presentations were headache (47%) and visual field deficits (32%). Lesions mainly comprised tumours or haemorrhage (85%) and involved the pituitary gland or fossa (70%). The STL-ARIMA pipeline outperformed CNN-LSTM, Prophet and baseline algorithms across scoring metrics, with standard accuracy being achieved for yearly predictions. Referral volumes significantly increased from the start of data collection with future projected increases (p < 0.001) and did not significantly reduce during the COVID-19 pandemic.

CONCLUSION

This work is the first to employ large-scale data and machine learning to describe and predict acute pituitary referral volumes, estimate future service demands, explore the impact of system stressors (e.g. COVID pandemic), and highlight areas for service improvement.

Enhance Access to Kidney Transplantation and Living Kidney Donation (EnAKT LKD): Statistical Analysis Plan of a Registry-Based, Cluster-Randomized Clinical Trial

BACKGROUND

Enhance Access to Kidney Transplantation and Living Kidney Donation (EnAKT LKD) is a quality improvement intervention designed to enhance access to kidney transplantation and living kidney donation. We conducted a cluster-randomized clinical trial to evaluate the effect of the intervention versus usual care on completing key steps toward receiving a kidney transplant.

OBJECTIVE

To prespecify the statistical analysis plan for the EnAKT LKD trial.

DESIGN

The EnAKT LKD trial is a pragmatic, 2-arm, parallel-group, registry-based, open-label, cluster-randomized, superiority, clinical trial. Randomization was performed at the level of the chronic kidney disease (CKD) programs (the "clusters").

SETTING

Twenty-six CKD programs in Ontario, Canada.

PARTICIPANTS

More than 10 000 patients with advanced CKD (ie, patients approaching the need for dialysis or receiving maintenance dialysis) with no recorded contraindication to receiving a kidney transplant.

METHODS

The trial data (including patient characteristics and outcomes) will be obtained from linked administrative health care databases (the "registry"). Stratified covariate-constrained randomization was used to allocate the 26 CKD programs (1:1) to provide the intervention or usual care from November 1, 2017, to December 31, 2021 (4.17 years). CKD programs in the intervention arm received the following: (1) support for local quality improvement teams and administrative needs; (2) tailored education and resources for staff, patients, and living kidney donor candidates; (3) support from kidney transplant recipients and living kidney donors; and (4) program-level performance reports and oversight by program leaders.

OUTCOMES

The primary outcome is completing key steps toward receiving a kidney transplant, where up to 4 unique steps per patient will be considered: (1) patient referred to a transplant center for evaluation, (2) a potential living kidney donor begins their evaluation at a transplant center to donate a kidney to the patient, (3) patient added to the deceased donor transplant waitlist, and (4) patient receives a kidney transplant from a living or deceased donor.

ANALYSIS PLAN

Using an intent-to-treat approach, the primary outcome will be analyzed using a patient-level constrained multistate model adjusting for the clustering in CKD programs.

TRIAL STATUS

The EnAKT LKD trial period is November 1, 2017, to December 31, 2021. We expect to analyze and report the results once the data for the trial period is available in linked administrative health care databases.

TRIAL REGISTRATION

The EnAKT LKD trial is registered with the U.S. National Institute of Health at clincaltrials.gov (NCT03329521 available at https://clinicaltrials.gov/ct2/show/NCT03329521).

STATISTICAL ANALYTIC PLAN

Version 1.0 August 26, 2022.

Post-acute health care burden after SARS-CoV-2 infection: a retrospective cohort study

BACKGROUND

The post-acute burden of health care use after SARS-CoV-2 infection is unknown. We sought to quantify the post-acute burden of health care use after SARS-CoV-2 infection among community-dwelling adults in Ontario by comparing those with positive and negative polymerase chain reaction (PCR) test results for SARS-CoV-2 infection.

METHODS

We conducted a retrospective cohort study involving community-dwelling adults in Ontario who had a PCR test between Jan. 1, 2020, and Mar. 31, 2021. Follow-up began 56 days after PCR testing. We matched people 1:1 on a comprehensive propensity score. We compared per-person-year rates for health care encounters at the mean and 99th percentiles, and compared counts using negative binomial models, stratified by sex.

RESULTS

Among 531 702 matched people, mean age was 44 (standard deviation [SD] 17) years and 51% were female. Females who tested positive for SARS-CoV-2 had a mean of 1.98 (95% CI 1.63 to 2.29) more health care encounters overall per-person-year than those who had a negative test result, with 0.31 (95% CI 0.05 to 0.56) more home care encounters to 0.81 (95% CI 0.69 to 0.93) more long-term care days. At the 99th percentile per-person-year, females who tested positive had 6.48 more days of hospital admission and 28.37 more home care encounters. Males who tested positive for SARS-CoV-2 had 0.66 (95% CI 0.34 to 0.99) more overall health care encounters per-person-year than those who tested negative, with 0.14 (95% CI 0.06 to 0.21) more outpatient encounters and 0.48 (95% CI 0.36 to 0.60) long-term care days, and 0.43 (95% CI -0.67 to -0.21) fewer home care encounters. At the 99th percentile, they had 8.69 more days in hospital per-person-year, with fewer home care (-27.31) and outpatient (-0.87) encounters.

INTERPRETATION

We found significantly higher rates of health care use after a positive SARS-CoV-2 PCR test in an analysis that matched test-positive with test-negative people. Stakeholders can use these findings to prepare for health care demand associated with post-COVID-19 condition (long COVID).

The Lasting Impact of the COVID-19 Pandemic on Surgical Key Indicator Cases for Otolaryngology Residency Education

OBJECTIVES

Early on during the COVID-19 pandemic, the US Centers for Medicare & Medicaid Services (CMS) and other government as well as medical institutions recommended that surgeons postpone nonessential surgeries. The aim of our study is to examine the impact of the COVID-19 pandemic on otolaryngology surgical training by evaluating changes in surgical volumes through various time points relative to the height of the pandemic.

METHODS

We performed a retrospective review of all surgical cases performed by the Otolaryngology-Head and Neck Surgery department at a tertiary care academic center from 3 time periods: July 1st, 2018, to June 30th, 2019; July 1st, 2019, to June 30th, 2020; and July 1st, 2020, to June 30th, 2021.

RESULTS

From the 2018-19 period to the 2020-21 period, the total number of overall cases decreased by 9.9%, from 2386 to 2148 cases. During this same time duration, the number of key indicator cases decreased by 13.4%, from 1715 to 1486 cases. Relative to other cases, ethmoidectomy, rhinoplasty, and stapes/OCR cases decreased the most during the 2019-20 period by 41.9%, 41.8%, and 29.5%, respectively. From the 2018-19 period to the 2020-21 period, thyroid/parathyroid cases decreased the most by 35.4%. Only ethmoidectomy and oral cavity cases showed increases during this period at 9.7% and 24.4%, respectively.

CONCLUSIONS

Although case volumes have stayed relatively constant, key indicator case volumes at the present tertiary care academic center have not yet fully recovered from the COVID-19 pandemic. Efforts must be made to determine how this has impacted residency surgical education.

Pre-surgical Nasal Decolonization of Staphylococcus aureus: A Health Technology Assessment

BACKGROUND

Staphylococcus aureus (S. aureus) is the most common cause of surgical site infections, and the nose is the most common site for S. aureus colonization. Pre-surgical (in the days prior to surgery) nasal decolonization of S. aureus may reduce the bacterial load and prevent the organisms from being transferred to the surgical site, thus reducing the risk of surgical site infection. We conducted a health technology assessment of nasal decolonization of S. aureus (including methicillin-susceptible and methicillin-resistant strains) with or without topical antiseptic body wash to prevent surgical site infection in patients undergoing scheduled surgery, which included an evaluation of effectiveness, safety, cost-effectiveness, the budget impact of publicly funding nasal decolonization of S. aureus, and patient preferences and values.

METHODS

We performed a systematic literature search of the clinical evidence to retrieve systematic reviews and selected and reported results from one review that was recent, of high quality, and relevant to our research question. We complemented the chosen systematic review with a literature search to identify randomized controlled trials published since the systematic review was published in 2019. We used the Risk of Bias in Systematic Reviews (ROBIS) tool to assess the risk of bias of each included systematic review and the Cochrane risk-of-bias tool for randomized controlled trials to assess the risk of bias of each included primary study. We assessed the quality of the body of evidence according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Working Group criteria. We performed a systematic economic literature search and conducted both cost-effectiveness and cost-utility analyses using a decision-tree model with a 1-year time horizon from the perspective of Ontario's Ministry of Health. We also analyzed the budget impact of publicly funding nasal decolonization of S. aureus in pre-surgical patients in Ontario. To contextualize the potential value of nasal decolonization, we spoke with people who had recently undergone surgery, some of whom had received nasal decolonization, and one family member of a person who had recently had surgery. We also engaged participants through an online survey.

RESULTS

We included one systematic review and three randomized controlled trials in the clinical evidence review. In universal decolonization, compared with placebo or no intervention, nasal mupirocin alone may result in little to no difference in the incidence of overall and S. aureus-related surgical site infections in pre-surgical patients undergoing orthopaedic, cardiothoracic, general, oncologic, gynaecologic, neurologic, or abdominal digestive surgeries, regardless of S. aureus carrier status (GRADE: Moderate to Very low). Compared with placebo, nasal mupirocin alone may result in little to no difference in the incidence of overall and S. aureus-related surgical site infections in pre-surgical patients who are S. aureus carriers undergoing cardiothoracic, vascular, orthopaedic, gastrointestinal, general, oncologic, gynaecologic, or neurologic surgery (GRADE: Moderate to Very low). In targeted decolonization, compared with placebo, nasal mupirocin combined with chlorhexidine body wash lowers the incidence of S. aureus-related surgical site infection (risk ratio: 0.32 [95% confidence interval: 0.16-0.62]) in pre-surgical patients who are S. aureus carriers undergoing cardiothoracic, vascular, orthopaedic, gastrointestinal, or general surgery (GRADE: High). Compared with no intervention, nasal mupirocin combined with chlorhexidine body wash in pre-surgical patients who are not S. aureus carriers undergoing orthopaedic surgery may have little to no effect on overall surgical site infection, but the evidence is very uncertain (GRADE: Very low). Most included studies did not separate methicillin-susceptible and methicillin-resistant strains of S. aureus. No significant antimicrobial resistance was identified in the evidence reviewed; however, the existing literature was not adequately powered and did not have sufficient follow-up time to evaluate antimicrobial resistance.Our economic evaluation found that universal nasal decolonization using mupirocin combined with chlorhexidine body wash is less costly and more effective than both targeted and no nasal decolonization. Compared with no nasal decolonization treatment, universal and targeted nasal decolonization using mupirocin combined with chlorhexidine body wash would prevent 32 and 22 S. aureus-related surgical site infections, respectively, per 10,000 patients. Universal nasal decolonization would lead to cost savings, whereas targeted nasal decolonization would increase the overall cost for the health care system since patients must first be screened for S. aureus carrier status before receiving nasal decolonization with mupirocin. The annual budget impact of publicly funding universal nasal decolonization in Ontario over the next 5 years ranges from a savings of $2.98 million in year 1 to a savings of $15.09 million in year 5. The annual budget impact of publicly funding targeted nasal decolonization ranges from an additional cost of $0.08 million in year 1 to an additional cost of $0.39 million in year 5.Our interview and survey respondents felt strongly about the value of preventing surgical site infections, and most favoured a universal approach.

CONCLUSIONS

Based on the best evidence available, decolonization of S. aureus using nasal mupirocin combined with chlorhexidine body wash prior to cardiothoracic, vascular, orthopaedic, gastrointestinal, or general surgery lowers the incidence of surgical site infection caused by S. aureus in patients who are S. aureus carriers (including methicillin-susceptible and methicillin-resistant strains) (i.e., targeted decolonization). However, nasal mupirocin alone may result in little to no difference in overall surgical site infections and S. aureus-related surgical site infections in pre-surgical patients prior to orthopaedic, cardiothoracic, general, oncologic, gynaecologic, neurologic, or abdominal digestive surgeries, regardless of their S. aureus carrier status (i.e., universal decolonization). No significant antimicrobial resistance was identified in the evidence reviewed.Compared with no nasal decolonization treatment, universal nasal decolonization with mupirocin combined with chlorhexidine body wash may reduce S. aureus-related surgical site infections and lead to cost savings. Targeted nasal decolonization with mupirocin combined with chlorhexidine body wash may also reduce S. aureus-related surgical site infections but increase the overall cost of treatment for the health care system. We estimate that publicly funding universal nasal decolonization using mupirocin combined with chlorhexidine body wash would result in a total cost savings of $45.08 million over the next 5 years, whereas publicly funding targeted nasal decolonization using mupirocin combined with chlorhexidine body wash would incur an additional cost of $1.17 million over the next 5 years.People undergoing surgery value treatments aimed at preventing surgical site infections.