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- Page navigation anchor for Transitioning to Outpatient Arthroplasty during the COVID-19 Pandemic: It’s Time to PivotTransitioning to Outpatient Arthroplasty during the COVID-19 Pandemic: It’s Time to Pivot
To The Editor,
The paper by Wang et al. highlights the significant surgical backlog in Ontario resulting from the first wave of the COVID-19 pandemic.(1) We are currently in the midst of the second wave and, as predicted, its impact on inpatient resources has exacerbated the surgical backlog even further. The total joint arthroplasty (TJA) program at Sinai Health recently introduced an enhanced recovery after surgery (ERAS) bundle,(2) which has enabled us to pivot quickly to an outpatient TJA program in response restrictions on inpatient surgery.
After careful review of epidemiological forecasts and resources available early during the pandemic,(3) our surgical services team anticipated that to continue to be able to perform TJA procedures throughout future waves of the COVID-19 pandemic, we would need to quickly establish a hybrid outpatient/inpatient arthroplasty program.(4) An internal needs assessment was performed. Results highlighted the need to develop an evidence-based patient-centred outpatient pathway.(5) New interventions included: 1) well-defined outpatient selection criteria; 2) modification of anesthetic to facilitate early ambulation; 3) outpatient recovery education materials; and 4) virtual postoperative care follow-up. By January 2021 our program evolved into a hybrid TJA program with over 25% of primary TJA patients being outpatient. This outpatient pathway was well-appreciated by patients and hospital leadership alike.
With an ou...
Show MoreCompeting Interests: None declared.References
- Jonathan Wang, Saba Vahid, Maria Eberg, et al. Clearing the surgical backlog caused by COVID-19 in Ontario: a time series modelling study. CMAJ 2020;192:E1347-E1356.
- Gleicher Y, Siddiqui N, Mazda Y, Matelski J, Backstein DJ, Wolfstadt JI. Reducing Acute Hospitalization Length of Stay After Total Knee Arthroplasty: A Quality Improvement Study. The Journal of Arthroplasty. 2020 Oct 8.
- O’Connor CM, Anoushiravani AA, DiCaprio MR, Healy WL, Iorio R. Economic recovery after the COVID-19 pandemic: resuming elective orthopedic surgery and total joint arthroplasty. The Journal of Arthroplasty. 2020 Apr 18.
- Tuite AR, Fisman DN, Greer AL. Mathematical modelling of COVID-19 transmission and mitigation strategies in the population of Ontario, Canada. CMAJ. 2020 May 11;192(19):E497-505.
- Bodrogi A, Dervin GF, Beaulé PE. Management of patients undergoing same-day discharge primary total hip and knee arthroplasty. CMAJ. 2020 Jan 13;192(2):E34-9.
- Page navigation anchor for Using Pathology Data to Evaluate Surgical Backlogs: Considerations for Resource PlanningUsing Pathology Data to Evaluate Surgical Backlogs: Considerations for Resource Planning
Wang et al provided valuable insight into the impact of COVID-19, estimating a backlog of 148,364 surgeries in Ontario from Mar-Jun 2020.(1) Expanding on the issues they raised, we would like to highlight important additional considerations.
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We reviewed surgical pathology and CCO summary data from the London Health Sciences Centre and St. Joseph’s Health Care in London, ON. In Apr 2020, the total number of accessioned specimens decreased compared to April 2019 by 67.5% (2820 vs 8668), while resection specimens decreased by 51.4% (524 vs 1078). CCO report submissions, largely reflecting newly staged cancer cases, decreased by 30.5% (169 vs 243). The relatively modest drop in resections and CCO submissions relative to total specimens likely reflects efforts to prioritize cancer surgeries.
In the Apr-Jun 2020 period, the gap compared to 2019 decreased as surgeries resumed. Total specimens were reduced by 47.4% (13,842 vs 26,303), compared to 30.9% for resections (2304 vs 3335) and 11.3% for CCO submissions (643 vs 725). Of note, reductions in CCO submissions varied between disease sites. While volumes were comparable for breast cancer (170 vs 171) and colon cancer (73 vs 76), there were drops of 71.6% (19 vs 67) and 53.2% (29 vs 62) for lung and prostate cancers, respectively. These differences may be due to triaging based on patient, clinical, safety and resource factors.(2) We suspect regional variations and surgery reductions have limited cancer procedures to h...Competing Interests: None declared.References
- 1 Jonathan Wang, Saba Vahid, Maria Eberg, et al. Clearing the surgical backlog caused by COVID-19 in Ontario: a time series modelling study. CMAJ 2020;192:E1347-E1356.
- 2 https://www.ontariohealth.ca/sites/ontariohealth/files/2020-04/Ontario%20Health%20Cancer%20Care%20Ontario%20COVID-19%20Supplemental%20Clinical%20Guidance%20for%20Patients%20with%20Cancer_29Mar20%20PDF.pdf
- Page navigation anchor for RE: Unless Canada implements best European approaches wait lists will never be rationalized.RE: Unless Canada implements best European approaches wait lists will never be rationalized.
In “Clearing the surgical backlog caused by COVID-19 in Ontario…” (1) the authors’ estimate of 84 weeks to take care of 148,364 cancelled surgeries is problematic because of very wide confidence intervals. In addition to the harshness of these supposedly prioritized, at risk and/or in pain individuals waiting an additional year and a half, this duration is optimistic. A number of variables and uncertainties not taken into account are enumerated, including personnel shortages. In fact, many nurses and other frontline workers have died, been incapacitated, or burned out; new patients are again being added, and we are in a second COVID-19 wave.
Further “clearing” in the title may be falsely reassuring, as it only refers to the “incremental” additions of patients whose procedures were scheduled and then cancelled. It ignores the more than million who were never even booked, and continue to face what before COVID-19 were already egregious and growing delays in treatment (2).
There are also a number of what appear to be judgmental statements including: “optimal priority scheduling of patients to improve operating room use”, “surgical volumes are appropriately indicated for surgery, which may not be true”, “prioritization of patients for surgery based on survival and quality-of-life”, “for time-sensitive surgeries only” and “cannot get back to business as usual, but rather must employ innovative system-based solutions”.
This implies that pre-COVID-19 th...
Show MoreCompeting Interests: OsteoarthritisReferences
- Wang J, Vahid S, Eberg M, et al. Clearing the surgical backlog caused by COVID-19 in Ontario: a time series modelling study. CMAJ 2020;192:E1347-E1356.
- Tyers GFO. Canadian health care should be better. Posted CMAJ October 28, 2020 in response to “Confronting the COVID-19 surgery crisis: time for transformational change”. CMAJ 2020;192:15-18.
- Page navigation anchor for Surgical Backlog; a Nuanced Cancer PerspectiveSurgical Backlog; a Nuanced Cancer Perspective
Wang et al provide an opportune modeling study estimating an 84 week surgical backlog recovery in Ontario.1 We would like to highlight some nuances in the data that pertain particularly to cancer patients and it’s recovery plan implications.
Data on cancer-directed surgeries remain incomplete, as acknowledged by the authors. To date, the most complete records arise from the Discharge Abstract and Same Day Surgery Databases both from the Canadian Institute of Health Information, for which there is a lag.2 Nonetheless, even revisions to model input with real-world complete data are likely to demonstrate a significant backlog.
Estimates of the cancer surgical backlog is far more complex than the presented model. Provincial screening programs, diagnostic imaging and procedures were all nearly shut down during the early pandemic months, now with their own backlog. Access to primary care was at an all time low. In some jurisdictions the emergency department was used 42% less during COVID than similar historical time periods which is associated at least in part with patients fear of presenting to hospitals.3 These factors have led to delays in diagnosis, stage migration, and potential a drop in surgical wait lists given some patients are no longer resectable.
These potential lives lost require further study and may lead to a major disruption in cancer survival outcomes for years to come. We therefore strongly agree with the retort by Wang et al tha...
Show MoreCompeting Interests: None declared.References
- Jonathan Wang, Saba Vahid, Maria Eberg, et al. Clearing the surgical backlog caused by COVID-19 in Ontario: a time series modelling study. CMAJ 2020;10.1503/cmaj.201521.
- https://www.theglobeandmail.com/canada/article-ontario-appoints-jane-philpott-to-lead-pandemic-data-effort/
- https://www.cdc.gov/mmwr/volumes/69/wr/mm6923e1.htm
- Page navigation anchor for A team-based care approach in primary care can alleviate the burden created by COVID-19 surgical backlog for Canadians suffering with hip and knee OsteoarthritisA team-based care approach in primary care can alleviate the burden created by COVID-19 surgical backlog for Canadians suffering with hip and knee Osteoarthritis
Wang et al provide a timely contribution highlighting the sizeable surgical backlog created by COVID-19. They estimate it will take 84 weeks in Ontario to clear this backlog with a significant investment of resources.1 We would like to add to this discussion about how best to optimize the health and quality of life for the thousands of individuals left in limbo while waiting for a rescheduled surgery.
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Osteoarthritis (OA) is associated with $1.4 billion annually in direct health care costs.2 With more than 137,000 hip and knee total joint replacements (TJR) performed annually,2 this group makes up a sizable component of the COVID-19 surgical backlog. We propose that primary care clinicians, including physicians and physiotherapists, can work together to reduce pain and improve the quality of life for those with OA waiting for TJR.
International best practice guidelines for hip and knee OA strongly recommend patient education, exercise therapy, and weight control (if necessary) as essential treatments.3 Even individuals with severe OA have potential to improve their quality of life with comprehensive non-surgical management.4 Unfortunately, only half of Canadians with OA receive this care. In a landmark study (MEDIC), patients with severe knee OA who were eligible for TJR were randomized to either 1) TJR followed by 12 weeks of non-surgical treatment or 2) only 12 weeks of non-surgical treatment, which was delivered by physiotherapists and dieticians and consi...Competing Interests: None declared.References
- Jonathan Wang, Saba Vahid, Maria Eberg, et al. Clearing the surgical backlog caused by COVID-19 in Ontario: a time series modelling study. CMAJ 2020;10.1503/cmaj.201521.
- Canadian Institute for Health Information. Hip and Knee Replacements in Canada: CJRR Annual Statistics Summary, 2018-2019. Ottawa, On; CIHI; 2020.
- Kolasinski SL, Neogi T, Hochberg MC, Oatis C, Guyatt G, Block J, et al. 2019 American College of Rheumatology / Arthritis Foundation Guideline for the management of osteoarthritis of the hand, hip, and knee. 2020;72(2):220–33.
- Skou S, Roos E, Lauresen M, Rathleff M, Arendt-Nielsen L, Simonsen O, et al. A randomized controlled trial of total knee replacement. N Engl J Med. 2015;373:1597–606.
- Davis A, Kennedy D, Wong R, Robarts S, Skou S, McGLasson R, et al. Cross-cultural adaptation and implementation of Good Life with osteoarthritis in Denmark (GLA:D): group education and exercise for hip and knee osteoarthritis is feasible in Canada. Osteoa