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- Page navigation anchor for RE: Canadian Health Care Should Be Better.RE: Canadian Health Care Should Be Better.
Because “Wait times for surgery were unacceptably long even before the pandemic”, Urbach and Martin refer to TRANSFORMATIONAL CHANGE (1). By definition this would completely and irreversibly alter current operating structure. Yet they only recommend further depersonalizing Canadian healthcare by centralizing waiting lists, with the probability someone you never met will do your surgery. What if months later the assigned surgeon reviews the case and thinks the risks outweigh the potential benefit (2). Or imagine immediately after a procedure a surgeon meeting a spouse and family for the first time, to inform them their loved one is dead. While there are low risk procedures where who does what may not matter there will be legal risks.
Shuffling wait lists will not add more nurses or OR time, the bedrock of the system, but will add administration to record and manage individual lists for numerous different procedures, further diverting funds from front line care. The ability to set up reliable computerized systems is also unassured, e.g. the federal pay debacle. Plus preparing for any surgery and recovery can be stressful and very personal, particularly if complicated. Everyone in my COVID-19 bubble wants to meet their surgeon and discuss a number of issues including risks, and the authors’ comparisons to the amusement and airline industries (1) are peculiar as the customer can usually select provider and day of service on short notice.
In spite of numerous com...
Show MoreCompeting Interests: None declared.References
- Urbach DR, Martin D. Confronting the COVID-19 surgery crisis: Time for transformational change. CMAJ 2020;192:15-18.
- Raj S, Zachary K, Bheeshma R, et al. Relation between surgeon age and postoperative outcomes: a population-based cohort study. CMAJ 2020;192:E385-E392.
- www.commonwealthfund.org > 2017 > may > international profiles
- Page navigation anchor for Transforming Cataract Surgery Practice Post COVID-19Transforming Cataract Surgery Practice Post COVID-19
The capacity to perform elective surgeries amidst COVID-19 has been severely constrained. Urbach and Martin recommend implementing a single-entry model as a solution to optimize waitlist management (1). This model has the potential to reduce wait times by allowing patients to be put in a single queue and receive their operation by the first available surgeon (1). While promising for some procedures, this model is not as likely to be effective for cataract surgery, where patient choice is highly valued. Instead, in the context of cataract surgery, it is important to think about how to better evaluate the appropriateness of referrals, and then prioritize patients in a shared decision-making model. Waitlist 1 (‘referral to consultation’) can be optimized by education and filtering out unnecessary referrals, and then prioritizing referrals for patients with significant comorbidity from their cataracts. Waitlist 2 (‘decision for surgery to surgery’) prioritization is often done on a first-come, first-served basis, although going forward post COVID-19, we should incorporate patient-reported outcomes in determining priority. Previous studies have shown that monocular visual acuity may not be enough to determine the benefit of cataract surgery as it may not represent the day-to-day visual disability for that patient (2). As such, incorporation of patient-reported outcome measures will likely ensure those who stand to benefit most from the surgery receive it in a timely manner.
...Show MoreCompeting Interests: None declared.References
- David R. Urbach, Martin D. Confronting the COVID-19 surgery crisis: time for transformational change | CMAJ. CMAJ. 2020;192(21):E585–6.
- Zhu X, Ye H, He W, Yang J, Dai J, Lu Y. Objective functional visual outcomes of cataract surgery in patients with good preoperative visual acuity. Eye. 2017 Mar;31(3):452–9.
- Prasad S, Tanner V, Patel CK, Rosen P. Optimisation of outpatient resource utilisation in cataract management. Eye. 1998 May;12(3):403–6.
- Grzybowski A, Kanclerz P. Do we need day-1 postoperative follow-up after cataract surgery? Graefes Arch Clin Exp Ophthalmol. 2019 May 1;257(5):855–61.
- Lam FC, Lee RMH, Liu CSC. ‘Bilateral same-day cataract surgery should routinely be offered to patients’ – Yes. Eye. 2012 Aug;26(8):1031–2
- Page navigation anchor for RE: Transformational change in surgeryRE: Transformational change in surgery
Kudos to Drs. Urbach and Martin for their courage to speak to fundamental issues affecting delivery of surgical services in Canada. Our regional hospital's General Surgery division began a pooled referral process several years ago. The results: balancing of workload, less variation in practice, a more cohesive team, shorter waits overall and fewer wasted resources.
As the senior surgeon in the group at the time of transition, I shared concerns about patient willingness to see junior colleagues. However (to my reluctant satisfaction), only 10-20% of patients or referring physicians expressed a preference for a surgeon if it might result in a longer wait for consultation and/or surgery.
I believe it is also important to bring remuneration into the discussion; fear of loss of income drives much (or most) of the reluctance to change. Thus alternate payment models, especially in an era of reduced efficiency/turnover/volume, hold some promise (and some challenges).Competing Interests: None declared.References
- David R. Urbach, Danielle Martin. Confronting the COVID-19 surgery crisis: time for transformational change. CMAJ 2020;192:E585-E586.
- Page navigation anchor for High fatality is expected in patients who have COVID-19 during postoperative periodHigh fatality is expected in patients who have COVID-19 during postoperative period
Since COVID-19 was declared as a pandemic by WHO on Mar 11, 2020, many professional societies have recommended elective surgery should ideally be postponed before it seems necessary with the goals to minimize disease spread and maintain healthcare capacity. Even so, the provision of surgery will continue to be an essential part of our healthcare system throughout the pandemic [1]. For patients who need surgeries during the pandemic, what risk will they take if infected with SARS-CoV-2 postoperatively? So far, little is known about the impact of COVID-19 on the fatality of patients during the postoperative period, however. I searched PubMed for articles published up to May 13, 2020, using the search term “novel coronavirus”, “2019-nCoV”, “COVID-19” or “SARS-CoV-2” with no language or time restriction. Three articles including 19 patients who have COVID-19 perioperatively are found [2-4].
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Of the 19 patients, 11 are male (57.9%). The mean age is 60.3 years old. The operations include general surgery, gynecology surgery and thoracic surgery. Among them, 12 patients have records about timing of COVID-19 symptoms onset; 9 patients (75%) present pneumonia symptoms within 7 days after surgery and the other 3 have symptoms more than 7 days following surgery. The case fatality rate is 36.8% (7/19).
Data presented here suggest that patients infected with COVID-19 in the perioperative period do have increased risk of fatality. Based on current literatures and statistics,...Competing Interests: None declared.References
- 1. David R. Urbach, Danielle Martin. Confronting the COVID-19 surgery crisis: time for transformational change. CMAJ 2020;10.1503/cmaj.200791.
- 2. Aminian A, Safari S, Razeghian-Jahromi A, et al. COVID-19 outbreak and surgical practice: unexpected fatality in perioperative period. Ann Surg 2020 March. 26. [Epub ahead of print]. doi: 10.1097/SLA.0000000000003925.
- 3. Yang S, Zhang Y, Cai J, et al. Clinical characteristics of COVID-19 after gynecologic oncology surgery in three women: a retrospective review of medical records. Oncologist 2020 April. 7. [Epub ahead of print]. doi: 10.1634/theoncologist.2020-0157
- 4. Li YK, Peng S, Li LQ, et al. Clinical and transmission characteristics of Covid-19-A retrospective study of 25 cases from a single thoracic surgery department. Curr Med Sci 2020; 40: 295-300.
- 5. Zhou F, Yu T, Du R, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet 2020; 395:1054-1062.
- Page navigation anchor for RE: Urbach and MartinRE: Urbach and Martin
Regarding the "Who gives a "F" who does my surgery approach to medicine. Good luck with that. Patients care who does their surgery. And this approach assumes that there is even more than one surgeon who can competently perform the procedure - a failed assumption.
And this article completely ignores that there is simply for too little resource to address an over taxed system no matter who does the surgery.Competing Interests: None declared.References
- David R. Urbach, Danielle Martin. Confronting the COVID-19 surgery crisis: time for transformational change. CMAJ 2020;10.1503/cmaj.200791.
- Page navigation anchor for RE: Confronting the COVID-19 surgery crisis: time for transformational changeRE: Confronting the COVID-19 surgery crisis: time for transformational change
Drs Urbach and Martin highlight the issue of access to elective surgeries during the COVID-19 crisis. However, their solution-- a single-entry care model—is overly simplistic and will do little to address patient wait times for many elective surgeries, such as cataract surgery. Even before COVID-19, surgeons across Canada had unacceptably long wait times, over 1 year in several regions.
A single-entry model would be useful in hospitals where surgeons performing the same procedure have large variations in wait times. But even in this scenario, patients having elective procedures like cataract surgery may want to preserve some choice. A more reasonable solution would be a centralized referral system so that patients can choose either the shortest wait time or a specific surgeon. I perform cataract surgery out of Saint Mary's General Hospital in Kitchener, Ontario, where all 9 cataract surgeons have unacceptably long wait times. To address this, before COVID-19 we worked with regional partners to adopt a centralized referral system that would allow referring providers to see surgeon wait times. We also published periodic hospital newsletters highlighting current surgeon wait times for cataract surgery. These solutions empower the patient and referring provider to use wait-time information to influence their surgeon of choice without removing their autonomy.
An essential COVID-19 issue for elective surgery not addressed in the commentary is the compounding...
Show MoreCompeting Interests: None declared.References
- David R. Urbach, Danielle Martin. Confronting the COVID-19 surgery crisis: time for transformational change. CMAJ 2020;10.1503/cmaj.200791.
- Page navigation anchor for RE: Central IntakeRE: Central Intake
Drs. Urbach and Martin. Thank you for your timely and well written article. I have an example of how this approach is achievable.
The Orthopedic Service at Eastern Health in St. John's, NL has had a orthopedic central intake (OCI) for all elective referrals for over 10 years now. All 12 surgeons participate in the intake model. We triage all referrals on an urgency scale and assure the patient ends up with the proper subspecialist if appropriate. The referring physicians have provided excellent feedback. They appreciate the one common referral form and the fact we direct the patient to the most appropriate provider. The option still exists for a specific surgeon if the patient or family doctor desires. Often we will suggest more investigations to be completed before the clinic visit, making it much more productive. The list of advantages of our intake model, both predicted and unforeseen, is long.
The efficiency achieved has certainly outweighed the resources invested. Once we had buy in for all stakeholders, the system has provided advantages for all. No one would go back to the old way. Our guiding principle has always been "the right patient, in the right place, at the right time."Competing Interests: None declared.References
- David R. Urbach, Danielle Martin. Confronting the COVID-19 surgery crisis: time for transformational change. CMAJ 2020;10.1503/cmaj.200791.