72,000 fewer surgeries performed in Ontario over six weeks of the COVID-19 pandemic

There were 72,000 fewer surgeries performed in Ontario during a six-week period of the COVID-19 pandemic compared to a year prior, according to data released by the province's central health-care agency. There were also more than 130,000 fewer CT scans and MRIs done for diagnosing cancer and other ailments.

The data was included in the framework Ontario Health released to hospitals last week to help them prepare for the resumption of scheduled surgeries and procedures. The province's Chief Medical Officer of Health, Dr. David Williams, directed hospitals in mid-March to ramp down elective surgeries and procedures — an order that remains in place today — to create capacity for the surge in COVID-19 cases that was expected.

Hospitals responded to the March directive in different ways, stated the framework document titled "A Measured Approach to Planning for Surgeries and Procedures During the COVID-19 Pandemic" and sent from Ontario Health President and CEO Matthew Anderson to hospital CEOs. While some hospitals "significantly" reduced surgical volumes to 10-20 per cent of their regular activity, others maintained half of their usual volume.

As a result, there were 72,392 fewer surgeries between March 16 and April 26 compared to the number of surgeries performed during the same time period last year:

• 2,039 fewer adult cancer surgeries (34-per-cent reduction)
• 1,033 fewer adult vascular surgeries (73-per-cent reduction)
• 609 fewer cardiac surgeries (44-per-cent reduction)
• 62,614 fewer adult non-oncology surgeries (93-per-cent reduction)
• 6,097 fewer pediatric surgeries (93-per-cent reduction)

There were also 134,351 fewer CT scans and MRIs:

• 8,697 fewer CT scans for cancer staging and diagnosis (25-per-cent reduction)
• 61,896 fewer CT scans for other reasons (52-per-cent reduction)
• 2,051 fewer MRIs for cancer staging and diagnosis (25-per-cent reduction)
• 1,317 fewer MRIs for breast cancer screening (89-per-cent reduction)
• 60,390 fewer MRIs for other reasons (64-per-cent reduction)

Ontario Health also provided data on the number of surgeries in each of the categories that were performed during the six-week period this year and in 2019.

Several doctors told QP Briefing that while they're not surprised by the reduction in surgeries, they do find the numbers concerning and are worried about the increased backlog in a system that was already plagued by long wait times.

A spokesperson for Ontario Health noted that the data on surgery and imaging volumes doesn't provide the number of surgeries that were scheduled for that period. But Chris Simpson, chair of Ontario Health's surgical and procedural planning committee and vice-dean of Queen’s University’s School of Medicine, said volumes for some surgeries, like bypass and certain cancer surgeries, are predictable with small increases expected because of population growth. The data, he said, could be interpreted to reflect more than 72,000 people whose procedures did not happen during the time period, but would have happened had it not been for COVID-19.

"I’m not surprised at all that this has accumulated so quickly, I think we knew this would be the consequence," Simpson said. "The challenge now is going to be...we have to learn how to live with COVID-19 in our midst...we simply can’t let people whose care can be scheduled wait forever — just because we call it elective, doesn’t mean it’s discretionary."

Cancer surgeries saw the smallest percentage reduction — 34 per cent — with non-cancer surgeries that don't include cardiac or vascular surgeries accounting for the highest percentage reduction — 93 per cent.

"The way the stats show themselves should give people confidence that the way we’ve triaged these is probably right," said Simpson. "I know it’s bad to have painful hips and not to be able to see properly, I’m not diminishing that at all, but when you have to choose between that and somebody who has to have a tumour removed that’s growing, that poses the choice quite starkly."

Dr. David Naylor, professor of medicine and president emeritus at the University of Toronto, said it's similar to what happened during the 2003 SARS outbreak where urgent surgeries including cancer and cardiac procedures were prioritized.

But Naylor, who led the federal review of the SARS outbreak, also noted that despite thousands of surgeries being backlogged at the time, SARS was "nothing like this in scope."

"(SARS) was a lot simpler because the virus simply went away, there’s not a lot of indication this virus is going away," he said. "When the (SARS) epidemic cleared, we could simply ramp up to double speed, here everything is going to take more time." This is because of the need for more personal protective equipment, for example, and other "layers of protection" for each surgical procedure, Naylor said.

"I think it’s quite frightening," said Dr. Samantha Hill, president of the Ontario Medical Association and a cardiac surgeon, on the QP Briefing podcast last week. She said the idea that fewer cardiac patients had been "taken care of over the last period of time is very concerning." According to Ontario Health data, 775 cardiac surgeries were performed during the six-week period this year compared to 1,384 surgeries during the same time last year.

"In general cardiac surgery is not elective, it may not always be emergent, but we only offer cardiac surgery in general because it prolongs life and improves patients' symptoms and morbidity," she said, but adding that she thinks the province made the right move in deferring some care to create COVID-19 capacity.

Ramping up surgeries will require careful thinking because the health-care system doesn't have the ability to "simply ramp up next month and do 610 extra patients."

"We don’t have the hospital beds, we don’t have the nurses, we don’t have the (operating room) time and it just isn’t feasible, so we really need to sit down together and figure out how to make that happen because Ontario patients are counting on us," she said.

Simpson, a cardiologist, said the province has had a "sophisticated triage structure" for cardiac procedures. While there are some people who could wait for bypass surgery, the issue becomes that those who could wait six weeks ago have since seen their disease progress.

"At some point they’re going to become more urgent simply by virtue of the fact that they’ve waited for such a long time," he said. "So I think that it was okay to delay that relatively small number of cardiac procedures, but all 600 of those people are going to have to be done soon now and they’re going to have to be done at the same time as all the new people coming on the list are being done, and so that’s the worry."

Simpson along with several other doctors noted that the long wait-times for non-emergent care have been a "perennial problem" in Canada even prior to COVID-19.

Comparing the volume of surgeries this year to the same period last year "really shows how much worse it has become over the last few weeks," Simpson said. "So now [we] have this situation where we’ve accumulated in a fairly short time this very large backlog of tens of thousands, probably over 100,000 patients who are going to need to be done, on top of all the patients who are still yet to be put on the list, and it’s going to be a real challenge figuring out in this time of COVID-19 and the need for hospitals to be COVID-19-ready a way to do these procedures at much faster rates than we ever have before just to catch up on the backlog."

Dr. David Urbach, chief of surgery at Women’s College Hospital and professor of surgery with the University of Toronto, said he thinks this will be unlikely in the near future.

"We don’t have the staff, we don’t have the resources to even do what we would normally be doing in a non-crisis time, forget 150 per cent or 200 per cent," Urbach said. "It’s unlikely that we will ever get there in the foreseeable future because the hospitals are still grappling with COVID-19 and they’re still concerned with PPE and the supply of drugs and the nursing staff."

Urbach, whose hospital has been doing 20-30 per cent of the surgeries it would typically do, said he thinks the province will be "grappling with a huge demand for surgical services as well as other medical services and too little supply to be able to meet the need and that’s going to put us in a bind for quite a while."

Naylor noted that Canada also has long wait times for specialist appointments and what the Ontario Health numbers don't show are people who are "going to wait much longer for that first visit to a specialist for a diagnosis and perhaps a referral for a procedure."

"Now we have a two-stage problem: it’s going to take much longer to get to see a specialist and if the specialist has in mind an investigation or a surgical procedure, that’s going to take longer," he said. "This diagnostic chain is also now being stretched and lengthened in very challenging ways...and every part of that process is now going to be backlogged."

But the "slight silver lining" in the fact that family doctor or specialist appointments will be slower moving is that "you can work on clearing these backlogs before the flow of referrals starts to add to them," said Naylor.

A few of the ideas being floated to reduce the backlog include having patients go to a different hospital for surgery or having surgeons operate at another hospital if they can't operate in their own, but none of this will be simple, he said.

"We know many patients are very unhappy about moving out of region to have procedures done and we also know that surgeons moving outside of an (operating room) setup where they’re comfortable and a team with whom they’ve operated for years are also going to be less comfortable," he said.

Stuart Edmonds, executive vice-president of mission for the Canadian Cancer Society, said while the numbers are "shocking," they’re not surprising.

"We completely understand the situation that the health system has put itself in or the decisions that have been made, but we can’t forget that cancer is still an issue that many people in this country are living with right now," Edmonds said.

He added that it's not just about surgeries, noting the large decline in breast cancer screening. When it comes to cancer, much emphasis is put on the time of diagnosis and the stage of the cancer — factors that dictate treatment.

"We’re perhaps going through a time now where there will be much much fewer diagnoses of cancer and so what effects that will have longer term we’re not clear of that," he said. "Certainly there is some concern of how the health-care system is going to manage that backlog of treatment, but also screening as well."

Meanwhile, both the NDP and the Green Party of Ontario shared their worries about the supply of personal protective equipment, with NDP health critic France Gélinas saying she's concerned that the "shortage of PPE" could slow down a hospital's ability to ramp up elective surgeries.

According to the framework released last week, before hospitals resume elective surgeries, they would need to ensure they are operating at a maximum capacity of 85 per cent to keep room for possible COVID-19 patients, have a rolling 30-day supply of PPE and have an adequate supply of medications and staff.

"My concern is that too much responsibility is being placed on hospitals to meet criteria for resuming surgeries without a commitment from the province to get them the supplies they need," said Green Party Leader Mike Schreiner, referring to PPE, medications and others supplies. "We know that cancer and cardiac diseases will not wait for COVID-19 to subside. The province should be taking a more proactive approach to getting supplies to hospitals so they can ramp up surgery and screening capacity."

-With files from Jessica Smith Cross

Photo Credit: Canadian Medical Association

Note: This article was updated on May 14 to reflect Dr. Samantha Hill's title of cardiac surgeon, instead of cardiologist.