David Robert Urbach

Background: After-hours hand trauma care is associated with surgeon fatigue, a higher risk of complications, and increased staffing costs. Dedicated trauma operating rooms (DTORs) have been established in orthopaedic and trauma surgery to improve access to care and patient outcomes. The purpose of this study was to measure the impact of a DTOR for hand surgery on the proportion of after-hours cases and wait times from consultation to surgery at a Canadian urban tertiary-care center. Methods: This retrospective cohort study included adult patients undergoing hand trauma surgery during 2 periods: before DTOR implementation, from August 1, 2018, to January 31, 2020 (n = 599), and after DTOR implementation, from August 1, 2022, to January 31, 2024 (n = 541). The main outcomes were the proportion of emergency cases performed after hours and the wait times from consultation to surgery. A post hoc analysis examined total hospital costs. Multivariable logistic regression was used to estimate associations with binary outcomes, and multivariable negative binomial regression was used to estimate associations with continuous outcomes. Other outcomes, including caseload, surgical complications, and revision surgeries, were assessed using univariate analysis. Results: After DTOR implementation, after-hours cases decreased from 18% (109 of 599) to 8% (45 of 541). Adjusting for covariates, DTOR implementation was associated with fewer emergency hand surgeries being performed after hours (odds ratio, 0.47 [95% confidence interval (CI), 0.23 to 0.95]; p = 0.03). The median wait times were similar before and after DTOR implementation: 6 days before implementation and 8 days after it (rate ratio, 1.03 [95% CI, 0.91 to 1.16]; p = 0.64). DTOR implementation was associated with a 19% adjusted reduction in total hospital costs: in Canadian dollars, $2,578.66 before DTOR implementation and $2,220.98 after it (rate ratio, 0.81 [95% CI, 0.78 to 0.84]; p < 0.001). The hand trauma caseload was similar (p = 0.09) before and after DTOR implementation. Complications became less frequent after DTOR implementation (reduced from 5% to 2%; p = 0.03), whereas revision rates did not change (10% and 11%; p = 0.70). Conclusions: DTOR implementation was associated with fewer after-hours surgeries, lower complication rates, and meaningful hospital cost savings, without increasing wait times or revision rates. These findings support integrating DTORs to improve operational efficiency and patient outcomes in hand trauma care. Level of Evidence: Economic and Decision Analysis Level III . See Instructions for Authors for a complete description of levels of evidence.

Background: Telephone-based Cognitive Behavioral Therapy (Tele-CBT) has shown to reduce disordered eating and psychological distress after metabolic and bariatric surgery (MBS). However, it is currently unknown how Tele-CBT impacts outcomes long term, and if differences in weight loss trajectories following Tele-CBT emerge with a long-term follow-up. This study aimed to identify whether Tele-CBT remains effective at 18 months post-intervention for improving psychological distress and maladaptive eating, and mitigating recurrent weight gain. Methods: This large, multisite randomized control trial was conducted at three hospital-based MBS programs in Ontario, Canada. Participants (n = 306) were randomized 1:1 to receive either Tele-CBT or standard MBS care. The primary outcome was percentage of total weight loss (%TWL). Secondary outcomes included disordered eating (Binge Eating Scale, Emotional Eating Scale) and psychological distress (Patient Health Questionnaire-9, Generalized Anxiety Disorder-7). Linear mixed models assessed group-by-time interactions across five time points: baseline (1-year post-MBS), post-intervention, and 3-, 12-, and 18-month follow-ups. Results: Tele-CBT resulted in significant post-intervention improvements in binge eating (MD = − 0.46, p < .001), emotional eating (MD = − 0.14, p = 0.01), anxiety (MD = − 0.40, p < .001), and depressive symptoms (MD = − 0.47, p < .001). These improvements were all sustained at 3 months post-intervention (p < .05) whereas only improvements for emotional eating were sustained at 12 months post-intervention (MD = − 0.15, p = 0.01). There were no significant differences in %TWL trajectories between the Tele-CBT and control groups. Conclusions: Tele-CBT provides psychological benefits, particularly in reducing emotional eating. Findings highlight the need for continued psychosocial support to sustain other psychological benefits and mitigate recurrent weight gain post-MBS and further research on optimizing intervention timing and duration. Trial Registration: ClinicalTrials.gov Identifier: NCT03315247.

Long wait times for scheduled surgery are a major problem in Canadian health systems. We sought to determine the extent to which single-entry referral models (next available consultation), team-based care models (next available surgery regardless of consulting surgeon), or both could affect wait times for consultations and surgery. We performed a discrete-event simulation study of wait times for consultations and surgeries for knee and hip joint replacement in Ontario's 5 postal regions using prospectively collected data on surgical wait times. We simulated the effects of coordinated referral models on the wait time for consultation (wait 1) and surgery (wait 2). Coordinated models led to larger reductions in high-outlier wait times (as reflected by the 90th percentile and the percentage of patients exceeding wait-time targets) than on median wait times when compared with the status quo. Single-entry referral models largely influenced wait 1, and team-based models of care affected only wait 2. Fully integrated models incorporating both single-entry referral and team-based care largely prevented patients from exceeding both wait-1 and wait-2 targets; the percentage of patients exceeding wait-1 targets in these models was 0% in all regions, and the percentage exceeding wait-2 targets was 0% except for Ontario West (2.0%, from 35.7% at baseline), East (1.1%, from 22.7% at baseline), and North (1.0%, from 25.1% at baseline). Coordinated referral and practice models improve access to scheduled surgery in Canadian health systems. Implementation of these models could largely eliminate prolonged wait times for joint replacement surgery in Ontario.

Background Little is known about the existing structure and function of referral networks in the prevalent referral system for specialized surgical care in Canada, which is based on direct physician referral to specialists in a largely unmanaged referral marketplace. Our objective was to describe and analyze the referral networks of referring physicians and surgeons for common surgical procedures in Ontario, to better understand potential barriers to single-entry models.Methods We analyzed referral networks for patients between referring physicians and surgeons for 9 common scheduled surgical procedures from 2016 to 2019 using administrative data sources in Ontario. We described the connectedness of referring physician-surgeon pairs using descriptive measures and graphical social network analysis.Results The median number of surgeons connected to a referring physician for patients having a particular surgical procedure ranged from 1 (interquartile range [IQR] 1-3) for spine surgery to 3 (IQR 1-4) for knee arthroplasty and 3 (IQR 2-5) for noncancer uterine procedures. Referral network structure varied according to the procedure studied. Spine surgery was highly clustered with a small number of larger groups; gallbladder, inguinal hernia, and noncancer uterine surgery were highly distributed with many small groups within the referral network. Breast cancer surgery occurred in a largely distributed network, but with a skewed distribution reflecting a few small groups with large numbers of patients.Conclusion Improving surgical wait times by coordinating surgical referrals will require approaches that address the structure of existing referral networks. Most physicians refer their patients to a very small number of surgeons, suggesting that referring physicians largely do not individualize referrals to multiple different surgeons based on specific patient characteristics. Contexte: On en conna & icirc;t peu sur la structure et le fonctionnement actuels des r & eacute;seaux d'aiguillage du pr & eacute;sent syst & egrave;me de r & eacute;partition des demandes de consultations en soins chirurgicaux sp & eacute;cialis & eacute;s au Canada car ce syst & egrave;me repose sur les demandes adress & eacute;es directement aux sp & eacute;cialistes par les m & eacute;decins traitants dans un contexte non g & eacute;r & eacute;. Notre objectif & eacute;tait de d & eacute;crire et d'analyser les r & eacute;seaux d'aiguillage entre m & eacute;decins traitants et sp & eacute;cialistes en chirurgie pour les interventions courantes en Ontario, afin de mieux comprendre les obstacles potentiels aux mod & egrave;les & agrave; acc & egrave;s unique.M & eacute;thodes: Nous avons analys & eacute; les r & eacute;seaux d'aiguillage des patients et patientes entre les m & eacute;decins traitants et les sp & eacute;cialistes en chirurgie pour des interventions courantes planifi & eacute;es de 2016 & agrave; 2019 & agrave; partir de banques de donn & eacute;es administratives ontariennes. Nous avons d & eacute;crit l'appariement m & eacute;decin traitant-sp & eacute;cialiste en chirurgie & agrave; l'aide de mesures descriptives et d'une repr & eacute;sentation graphique des r & eacute;seaux d'aiguillage.R & eacute;sultats: Le nombre m & eacute;dian de chirurgiennes et chirurgiens appari & eacute;s & agrave; un m & eacute;decin traitant pour un type de chirurgie en particulier allait de 1 (& eacute;ventail interquartile [& Eacute;I] 1-3) pour la chirurgie de la colonne vert & eacute;brale & agrave; 3 (& Eacute;I 1-4) pour l'arthroplastie du genou et & agrave; 3 (& Eacute;I 2-5) pour les probl & egrave;mes ut & eacute;rins non canc & eacute;reux. La structure des r & eacute;seaux d'aiguillage variait selon l'intervention & eacute;tudi & eacute;e. La chirurgie de la colonne vert & eacute;brale pr & eacute;sentait plus de grappes, comportant un petit nombre de groupes plus denses; les chirurgies de la v & eacute;sicule biliaire, de la hernie inguinale et des probl & egrave;mes ut & eacute;rins non canc & eacute;reux & eacute;taient largement distribu & eacute;es, comportant plusieurs groupes restreints & agrave; travers tout le r & eacute;seau d'aiguillage. La chirurgie pour cancer du sein & eacute;tait largement r & eacute;partie, mais sa distribution & eacute;tait asym & eacute;trique, t & eacute;moignant d'un nombre restreint de petits groupes plus nombreux de patientes.Conclusion: Pour am & eacute;liorer les temps d'attente en coordonnant les demandes de consultation en chirurgie, il faudra des approches ax & eacute;es sur les r & eacute;seaux d'aiguillage existants. La plupart des m & eacute;decins traitants orientent leur patient & egrave;le vers un tr & egrave;s petit nombre de chirurgiennes et chirurgiens, ce qui laisse entendre que pour une bonne part, ils n'individualisent pas leurs demandes de consultation aupr & egrave;s de multiples chirurgiennes ou chirurgiens en fonction des caract & eacute;ristiques sp & eacute;cifiques des malades.

Purpose: The COVID-19 pandemic has resulted in a significant diagnostic, screening, and procedure backlog in Ontario. Engagement of key stakeholders in healthcare leadership positions is urgently needed to inform a comprehensive provincial recovery strategy. Methods: A list of 20 policy recommendations addressing the diagnostic, screening and procedure backlog in Ontario were transformed into a national online survey. Policy recommendations were rated on a 7-point Likert scale (strongly agree to strongly disagree) and organized into those retained (≥75% strongly agree to somewhat agree), discarded (≥80% somewhat disagree to strongly disagree), and no consensus reached. Survey participants included a diverse sample of healthcare leaders with the potential to impact policy reform. Results: Of 56 healthcare leaders invited to participate, there were 34 unique responses (61% response rate). Participants were from diverse clinical backgrounds, including surgical subspecialties, medicine, nursing, and healthcare administration and held institutional or provincial leadership positions. A total of 11 of 20 policy recommendations reached the threshold for consensus agreement with the remaining 9 having no consensus reached. Conclusion: Consensus agreement was reached among Canadian healthcare leaders on 11 policy recommendations to address the diagnostic, screening, and procedure backlog in Ontario. Recommendations included strategies to address patient information needs on expected wait times, expand health and human resource capacity, and streamline efficiencies to increase operating room output. No consensus was reached on the optimal funding strategy within the public system in Ontario or the appropriateness of implementing private funding models.

Due to the ramping down of cancer surgery in early pandemic, many newly diagnosed patients received other treatments first. We aimed to quantify the pandemic-related shift in rate of surgery following chemotherapy. This is a retrospective population-based cohort study involving adults diagnosed with cancer between 3 January 2016 and 7 November 2020 in Ontario, Canada who received chemotherapy as first treatment within 6-months of diagnosis. Competing-risks regression models with interaction effects were used to quantify the association between COVID-19 period (receiving a cancer diagnosis before or on/after 15 March 2020) and receipt of surgical reSection 9-months after first chemotherapy. Among 51,653 patients, 8.5% (n = 19,558) of them ultimately underwent surgery 9-months after chemotherapy initiation. Receipt of surgery was higher during the pandemic than before (sHR 1.07, 95% CI 1.02–1.13). Material deprivation was independently associated with lower receipt of surgery (least vs. most deprived quintile: sHR 1.11, 95% CI 1.04–1.17), but did not change with the pandemic. The surgical rate increase was most pronounced for breast cancer (sHR 1.13, 95% CI 1.06–1.20). These pandemic-related shifts in cancer treatment requires further evaluations to understand the long-term consequences. Persistent material deprivation-related inequity in cancer surgical access needs to be addressed.

Introduction Transgender and gender diverse (TGD) individuals often identify with a gender different to the one assigned at birth. Transition is a term used to describe the process TGD individuals take to live as their true gender. Surgery can be a very important aspect of care for members of TGD communities. Transition-related surgery (TRS) refers to many different types of surgeries completed to meet a TGD individual’s gender-related goals. While various systematic reviews have attempted to synthesise the existing peer-reviewed literature around aspects of TRS, there are few scoping reviews in this area. Our scoping review aims to address this gap through providing an up-to-date overview of the TRS literature in order to provide an overarching view of the topic. Method and analysis This review will follow the methods outlined by the Joanna Briggs Institute’s methodology for scoping reviews and will be reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews. A search of nine scientific databases resulted in 20 062 potential articles. After removing duplicates, articles will be screened for inclusion using Covidence. Data extraction and synthesis will be carried out using NVivo and reviewed by team members. Ethics and dissemination As this study is a scoping review of the existing literature, no ethics review is required. The findings from this review will be disseminated through multiple pathways including open access publication, submission to conferences, social media and Listservs. The findings of the study will also be readily available to clinicians, organizations, interest groups, and policy-makers.