Surgery & Diagnostic Recovery Report – EMBARGOED UNTIL 11:30AM JUNE 17, 2021

Addressing the Surgery

and Diagnostic Backlog:
A Path to Recovery

June 17, 2021

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Surgery & Diagnostic Recovery Report – EMBARGOED UNTIL 11:30AM JUNE 17, 2021

Summary: Surgery & Diagnostic Recovery Plan

The health system’s pandemic response has resulted in Doctors Manitoba applauds the government’s investments to
multiple slow downs of surgical and diagnostic procedures. help address the backlog, including $2.5 million in contracts
and $50 million announced in Budget 2021. This is a strong
We estimate the backlog is over 110,000 surgical and start, but a more comprehensive and accountable plan is
diagnostic procedures, and growing: needed to reassure Manitobans about when and how the
backlog will be fully addressed.
• Over 39,000 surgical procedures
Recommendations
• Over 44,000 diagnostic imaging tests
1. A provincial commitment is needed to fully address the
• Over 32,000 other procedures, including endoscopies,
pandemic backlog by a fixed date, including ensuring
allergy testing and mammograms
all the necessary funding is available.
While some progress was made in February and March, the (example, by Dec. 31, 2022)
backlog is growing again because of the third wave.
2. Create a Surgery and Diagnostic Recovery Task Force
The backlog is having a significant impact on patients who are to lead the immediate and sustained task of
waiting longer. For patients, this has meant: addressing the backlog. The Task Force should
include health system leaders as well as frontline
• Pain and discomfort with longer waits physicians, nurses, technologists and others to
collaboratively address barriers, such as the nursing
• Minor health concerns turning into larger issues that require
shortage, and consider models of care that support an
more complex procedures and treatment
expedited and safe recovery.
• Patient harm (delayed diagnosis, disability or death)
3. Provide monthly public reports on progress, including
The surgical slow downs have not only affected quality of life the size of the backlog, a breakdown by procedure,
procedures, such as cataract surgeries and hip replacements, and details on plans and actions to address the issue.
but cardiac and cancer surgeries have also been affected.
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Research & Methods

This report relies on extensive research:
→ Doctors Manitoba survey of physicians
Conducted April 1 to 11, 2021
1,022 responses, including 238 surgeons, radiologists and anesthetists.

→ Probe Research survey of Manitoba adults

Conducted April 5 to 14, 2021
1,000 responses

→ Literature Review and Jurisdictional Scan

→ Manitoba data and updates, where available

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How Big is the
Backlog?
Surgery & Diagnostic Recovery Report – EMBARGOED UNTIL 11:30AM JUNE 17, 2021

Pandemic Impact on Surgeries and Diagnostics

Like other provinces, Manitoba postponed many Surgery space, such as recovery rooms, have been
elective and non-urgent surgeries and diagnostic used for ICU patients and surgical staff have been
testing during the first wave, as a precaution while redeployed to provide care for COVID-19 patients.
experts learned more about COVID-19.
Diagnostic imaging was not as significantly affected
Manitoba was forced to decrease surgery volumes during the second and third waves.
again during the second wave. This time the move
How big is the backlog?
was not a precaution, but resources were needed to
Estimating the backlog for surgery and diagnostics is
support a surge in COVID-19 hospital admissions
challenging because of inconsistent and incomplete
and the need for more critical care capacity.
public reporting. Over the next several pages, we
Surgeries are being disrupted again to support the
estimate the backlog using a variety of sources.
ICU response during the third wave.

Mar 23, 2020 Apr 24, 2020 Nov 2, 2020 Jan 11, 2021 May 8, 2021
Most Some Most Some Most
Surgeries Surgeries Surgeries Surgeries Surgeries
Postponed Resume Postponed Resume Postponed

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May

2020 2021
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Estimating the Pandemic Surgery Backlog

To estimate the full size of the surgery backlog generated
during the pandemic, we considered several factors:
• Shared Health’s public statement that the backlog from
the first and second waves had reached 16,000 cases.
• CIHI’s comprehensive reporting on surgery volumes
Estimated changes during just the first wave of COVID-19, which
Surgery Backlog: found a 35% decrease in surgical volumes (12,011
cases) in Manitoba.

39,000 • Manitoba Health’s monthly public reporting of cataract,

hip/knee and cardiac procedure volumes (down 32%).

CASES • Surgeons’ estimates of a 40% decrease in surgery

volumes, and their estimate of their growing wait list.
(estimated at 35,000 – 45,000 elective procedures).
and counting
• Physicians’ estimates that they have decreased
referrals for surgery by 11% during pandemic. This is a
potential “hidden” backlog not captured elsewhere,
which we have incorporated into our estimate.
Pandemic backlog estimate covers March 2020 to May 2021.
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Surgery Backlog for Cataract, Hip/Knee & Cardiac

Cataract, hip/knee and cardiac procedures are reported publicly, so they offer a view into how surgeries have been
impacted by the slow downs. Surgical volumes decreased the most during the first and second waves, but they also
never fully recovered between waves. COVID-19 precautions add additional time to each procedure, which means a
return to 100% of “normal” OR time does not result in 100% of “normal” surgery volumes.

80%

60%
Cardiac Surgery
Wave 1 Wave 2 Wave 3 Volume:  13%
40%
Backlog:  163
20%

0%
Cardiac
Cataract Surgery
-20% Cataract Volume:  19%
-40%
Backlog:  3,273
-60% Hip/Knee
Hip/Knee Surgery
-80%
Volume:  56%
-100% Backlog:  6,001
Cardiac Cataract Hip/Knee
-120%
% change in surgery volume compared to same month from pre-pandemic period 2019/2020
Source: Manitoba Health

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Surgery & Diagnostic Recovery Report – EMBARGOED UNTIL 11:30AM JUNE 17, 2021

Change in surgery Reported Decrease in Surgical Volumes

0% 10% 20% 30% 40% 50% 60%
volumes during Obstetrics and Gynaecology 55%

pandemic Cardiovascular Surgery 50%

ENT (Head and Neck) 50%

40% Plastic Surgery

Neurosurgery
45%

42%

Vascular Surgery 42%

Surgeons estimate their
Orthopaedic Surgery 39%
surgical volumes are
Thoracic Surgery 38%
down 40% overall
General Surgery 30%

Ophthalmology 19%

Urology 17%

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Estimating the Diagnostic Pandemic Backlog

The diagnostic imaging backlog is much easier to
calculate as volumes are reported publicly on a
monthly basis by Manitoba Health.
Estimated The decrease in volume during the pandemic includes:
Diagnostic
Testing Backlog: • 5,472 CT Scans
•
44,300
23,484 Ultrasounds
• 14,234 MRI Scans

CASES • 1,116 Myocardial Perfusion Studies

(heart stress tests)

Pandemic backlog estimate covers March 2020 to April 2021.

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Diagnostic Volume Changes

Diagnostic volumes dropped significantly during the first wave, but they recovered more over the summer than
surgery and they were less impacted by the second wave. There is still an enduring net loss in diagnostic volumes
during the pandemic, however, and it is unclear how the third wave will impact on efforts to catch up.

30%

20%
Wave 1 Wave 2 Wave 3
CT Scans
CT
10%  2% (5,472 scans)
0%
MRI
-10%
Ultrasound MRI
Myocardial Perf.
-20%  13% (14,234 scans)
-30%

-40%
Ultrasound
 10% (23,484 scans)
-50%

-60%
Myocardial Perfusion
-70%
MRI CT Myocardiac Perfusion Studies Ultrasound  17% (1,116 studies)
-80%
% change in diagnostic imaging volume compared to same month from pre-pandemic period 2019/2020
Source: Manitoba Health

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Pandemic Backlog for Other Procedures

There are several other diagnostics that have been
impacted. The following estimates were developed
based on issues identified by physicians.
Estimated The pandemic backlog based on decreased volumes
Backlog for and wait list analysis includes:
Other Diagnostics
• 1,889 Allergy Tests

29,591 • 10,200 Endoscopies

CASES • 20,502 Mammograms

Pandemic backlog estimate covers March 2020 to March 2021

for allergy tests and mammograms. For endoscopies, it covers
March 2020 to May 2021.

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Surgery & Diagnostic Recovery Report – EMBARGOED UNTIL 11:30AM JUNE 17, 2021

Other Procedures Volume Changes

Other diagnostics, including mammograms, diagnostic endoscopies and allergy tests, saw sharp decreases in
volume during the first wave, with some recovery over the summer and smaller decreases during the second wave.

40% Mammograms
Allergy Testing Diagnostic Endoscopy Mammography
 19% (20,502 scans)
20%
Wave 1 Wave 2
Mammograms Diagnostic
0%
Endoscopies
Endoscopies
Allergy tests
-20%  20% (7,200 scopes)
-40%
Allergy Tests
-60%  13% (1,889 tests)

-80%

-100%

% change in diagnostic volumes compared to same month from pre-pandemic period 2019/2020
Source: Doctors Manitoba review of physician claims data

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Impact of Backlog
Surgery & Diagnostic Recovery Report – EMBARGOED UNTIL 11:30AM JUNE 17, 2021

Surgery Wait Lists More Than Double

Reported Change in Wait List

WAIT LIST
0% 50% 100% 150% 200% 250% 300%

Neurosurgery 243%

108%
Cardiovascular Surgery 204%
Cardiac and
Neurosurgery wait
General Surgery 177% lists have more
Vascular Surgery 173% than tripled
Orthopaedic Surgery 158%

Thoracic Surgery 101%

Surgeons estimate their ENT (Head & Neck) 97%

wait lists have more than Obstetrics and Gynaecology 87%

doubled during the Family Practice - Rural 86%

Plastic Surgery 64%

pandemic, up 108%. Ophthalmology 54%

Urology 42%

Estimate is based on survey of surgeons conducted in April 2021

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“My patients live with debilitating pain. Everyday month that

their surgery is delayed, is another month longer they have to
suffer, avoid activity, and be non-productive in society.”
Impact on Patients (Orthopedic Surgeon)
Physicians described a wide range of impacts the
backlog and growing wait is having on their
patients. This includes: “I currently spend more time talking to patients about
wait times then I do actually caring for them.” (Surgeon)
→ Prolonged pain and discomfort with longer
waits
“My patients are going blind, losing the ability to live
→ Minor health concerns turning into larger independently, enjoy activities, drive and take their
issues that require more complex procedures medications safely. ” (Ophthalmologist)
and treatment
→ Patient harm (delayed diagnosis, disability or
“The uncertainty and frequent cancellations are
death)
causing anxiety. Patients are depressed not knowing
→ Negative impacts on: when their wait will be over.” (Family Physician)

• Quality of life
• Physical health (decreased mobility) “Patients are experiencing decreasing mobility with
impacts on health and major decrease in quality of life.
• Mental health (stress, anxiety, depression Some are turning to narcotics.” (Surgeon)
and suicidal ideation)
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“Patients are waiting longer for bladder cancer

surveillance and surgery. ” (Urologist)
Concerning Impacts
When most surgeries were paused due to the pandemic, “We have had deaths on the waitlist and an alarming
provincial officials have repeatedly stressed that only number of patients over waitlist benchmarks with
non-urgent and elective procedures would be affected. symptomatic deterioration .” (Cardiac Surgeon)
However, some physicians have reported concerning
cancellations and delays for cardiac and cancer
surgeries. “My patient has endometrial cancer and her surgery was
delayed. She started on chemotherapy which should not
For cardiac patients, physicians have identified have been the case. Patient very distraught and
significant deterioration among patients waiting for heart depressed for fear of cancer spread. ” (Family Physician)
surgery, including at least two patient deaths on the wait
list.
For cancer patients, physicians provided many examples “Some patient cancers are not confirmed and
of delayed biopsies and surgeries, resulting in cancers operated on in time.” (Family Physician)
advancing in stage, spreading, and requiring additional
treatments.
“We have seen a stage shift where cancers have
CIHI’s analysis of surgical impacts from the first wave progressed. That leads to having to treat more patients
found a 16% decrease in cardiac surgeries and a 9% with radiotherapy or chemo.” (Family Physician)
decrease in cancer surgeries.
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Impact on Children
We estimate the surgery backlog for children and youth
to be 3,500 to 5,000 cases.
Pediatric specialists have reported extended delays for many
procedures, with many children waiting well-beyond the
recommended wait times.
For some children, the delays lead to more complex surgeries
which, in turn, require much longer hospital stays for recovery. In
some cases, this has led to cancer advancing and spreading.
While most children’s hospitals across Canada were able to
address their backlogs by increasing their capacity above 100%,
Manitoba’s Children’s Hospital hasn’t been able to get above 60-
80% of normal capacity due to ongoing nursing shortages.
Prioritizing surgeries will be a critical part of recovery, and an
emerging framework from Pediatric Surgical Chiefs of Canada can
be used to help guide the process.

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Impact on Women’s Health

Physicians raised serious concerns about the impact on Women’s
Health. For example:
• Obstetrician/gynecologists estimate a 55% decrease to their
surgical volumes during the pandemic.
• Many surgical procedures have been postponed, including a
40%-70% drop in uro-gynecology surgeries and a 24% drop in
hysterectomies.
• Surgeries for pregnancy loss or fetal demise have been delayed,
as has surgical abortion.
• Women have experienced delays in diagnosing and treating
cancers, leading to spread and more difficult treatments. In
some cases, surgery was no longer a treatment option.
• There have been 20,000 fewer mammograms during the
pandemic.
Surgical slow downs at Women’s Hospital have been extensive.
This is also the case at St. Boniface, which became the centre for
uro-gynecology after hospital consolidation, leaving women
languishing with pain and incontinence issues.
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Manitobans are Incidence of cancellations among Manitobans

concerned, too.
of Manitobans are
81% concerned the pandemic
might delay a medical test
or surgery if they need
one.

Manitobans are feeling the impact of the

disruptions, with 12% reporting they had a
diagnostic test cancelled and 6% reporting a
surgery cancellation.

Source: Probe Research Survey

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Addressing the
Backlog
Surgery & Diagnostic Recovery Report – EMBARGOED UNTIL 11:30AM JUNE 17, 2021

Barriers to Addressing
Surgery Backlog
While the provincial government has pledged $50
million to address the backlog in surgeries, the barriers
to addressing it require thorough planning and
collaboration.

In addition to sufficient funding, the barriers to

addressing the backlog include insufficient nursing
resources and a lack of OR time and recovery space.
These issues were identified before the third wave
arrived in Manitoba, and they have only been
exacerbated as recovery space and surgery nurses
were redirected to support expanded critical care
capacity.

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Physician Capacity to
Help with Recovery
of surgeons surveyed are
97% able to pick up additional
slates to help address the
backlog.
On average, surgeons indicated
they have capacity to pick up 4 to 5
slates each per month.

of anesthesiologists surveyed
100% are able to pick up additional
slates as well.

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Flexibility for
Additional Slates
Surgeons would prefer to pick up additional
slates during weekdays and during
traditional slowdown periods, preferred by
86% and 66% respectively.

87% are willing to work at other hospitals

within their primary health region, and 74%
would pick up additional slates in private
surgical facilities if needed.

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Addressing the Diagnostic Backlog

While diagnostic tests and procedures saw significant volume decreases during the first
wave, they recovered more than surgery over the summer, and they have been less
impacted by the second and third waves.

Radiologists identified three significant barriers to addressing the backlog for diagnostic
imaging:

• 83% identified insufficient technologists.

• 88% agree that additional equipment will be needed, and/or there may be opportunities to
expand operating hours for some existing equipment.

Radiologists are willing to increase their workload to address the backlog.

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What is Needed?
All provinces had to suspend surgeries and
diagnostics due to the pandemic. However,
the plans to address the resulting backlogs
vary greatly by province.
In BC, for example, a comprehensive
surgery renewal plan was launched in May
2020. The plan was upfront, noting it could
take 17-24 months to address the backlog.
Regular public progress reports followed,
and in March 2021, the province reported
that 95% of the backlog in cases had
already been completed.

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Addressing Doctors are ready. They are willing to work more

to address the backlog in surgery and diagnostic
the Backlog procedures, and they’re ready now.
Manitoba is now in its third wave of COVID-19, and surgical 2. Create a Surgery and Diagnostic Recovery Task Force to
services are now facing their third disruption. The backlog for lead the immediate and sustained task of addressing the
surgery and diagnostics is over 110,000 cases and catching up is backlog. The Task Force should include health system
a mammoth task. leaders and frontline physicians, nurses, technologists
and others to work collaboratively on this priority.
Doctors Manitoba offers the following recommendations to help
chart a constructive path for surgical and diagnostic recovery: The backlog is massive. It will require strong leadership and
collaboration to ensure this issue becomes a top priority. It
1. Commit to fully addressing the pandemic backlog by a will require addressing the nursing shortage and revisiting
fixed date (e.g. Dec 31, 2022), including ensuring all the models of care. Health system leaders must work with those
necessary funding and resources are available. on the front line to identify and address the barriers together.

The government has committed funding to start addressing 3. Provide monthly public reports on progress, including
the backlog, though more may be needed. The next step is to the size of the backlog, a breakdown by procedure, and
get specific, with a commitment to fully address the backlog details on plans and actions to address the issue.
by a specified date. The date and required funding should be
decided following further planning by health system leaders. Accountability and transparency are essential for a plan to
have credibility with the thousands of patients waiting for a
surgery or diagnostic test.

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