Estimating the Backlog of Colonoscopy due to Coronavirus Disease 2019 and Comparing Strategies to Recover in Ontario, Canada

Coronavirus disease 2019 (COVID-19) has significantly affected gastrointestinal (GI) endoscopy, with jurisdictions reporting up to a 95% reduction in procedure volumes compared before the pandemic.1Rutter MD et al. Gut [published online July 20, 2020]. https://doi.org/10.1136/gutjnl-2020-322179.Google Scholar In Ontario, Canada, large volume of colonoscopies not performed during first wave pandemic (the backlog) must now be managed (Supplementary Table 1). Ontario Health (Cancer Care Ontario) oversees hospitals (70% those province). Health’s “COVID-19 Tip Sheet for Facilities Performing Gastrointestinal Endoscopy” (June 2020) recommended that individuals originally scheduled low-yield (ie, average-risk screening colonoscopy or surveillance history low-risk adenoma [LRA]) should instead receive fecal immunochemical test (FIT)2Ontario Health. https://www.ontariohealth.ca/sites/ontariohealth/files/2020-05/A%20Measured%20Approach%20to%20Planning%20for%20Surgeries%20and%20Procedures%20During%20the%20COVID-19%20Pandemic.pdf.Google Scholar, 3Tinmouth J. al.Colorectal cancer average risk populations: evidence summary. Program evidence-based care summary no. 15-14. Cancer Toronto, Canada2015Google 4Dubé C. al.Am J Gastroenterol. 2017; 112: 1790-1801Crossref PubMed Scopus (66) Google and referred only if FIT result is abnormal. guidelines recommend as follow-up LRA based on recent colorectal these less than general population.5Dubé C https://www.cancercareontario.ca/en/guidelines-advice/types-of-cancer/38506.Google 6Loberg M. al.N Engl Med. 2014; 371: 799-807Crossref (191) 7Wieszczy P. al.Gastroenterology. 2020; 158: 875-883Abstract Full Text PDF (85) 8Cross A.J. al.Long-term incidence after removal effects incidence: multicentre, retrospective, cohort study.Gut. 69: 1645-1658Crossref (45) Our aims were (1) estimate hospital-based outpatient because (2) compare effect 2 strategies, redirecting from increasing hospital capacity, backlog recovery time. We used GI Endoscopy Data Submission Portal, which receives monthly data (including date indication) identify all January August 2020. estimated March 2020 February 2024 by calculating difference between expected (derived inflated 1%/year) absence observed projected pandemic. Volumes obtained Sharing Portal (“observed”) subsequent months multiplying assumptions system capacity assumed September would 85% expected; increase 5%/month, reaching 100% December (3) maximum 115% reached 2021, remaining stable thereafter. any given year, was defined mean year. Maximum set at relative highest 2019. Recovery time number until eliminated. Colonoscopies added where anticipated below 100%. counted have been All 50% considered low yield. The latter assumption required we do pathology prior colonoscopy. A proportion people redirected (OC-Sensor DIANA, Eiken Chemical Co) will an abnormal (Ontario target positivity range: 5%–6.5%) require (Ontario’s prepandemic rate: 90%). Beginning 2020, subtracted, resulting redirection volumes. Corresponding times, varying (25%, 50%, 75%), calculated. An alternative strategy managing endoscopy capacity. Again, constant rate each month when maintained then calculated match times achieved 25%, 75% FIT. Before pandemic, 18% 13% surveillance, respectively Estimated vary depending persons who are take 41 recover without redirection, but reduce 28, 22, 19 months, (Figure 1A). If there no FIT, need 124%, 134%, 145% 1B). As other jurisdictions,1Rutter services profoundly COVID-19 leading that, absent intervention, recover. impact patients consequential, particularly terms delays diagnosis. UK 2828 fewer cancers diagnosed using lower COVID-19, representing 72% absolute decrease.1Rutter presented strategies address shown can substantially To achieve similar effect, exceed historical much 45%, costly challenging due constraints delivery introduced (eg, physical distancing rooms). Limitations this work include did account waves demand study period patients’ reluctance undergo colonoscopy, including procedures result. Furthermore, although cutoff define positive adjusted local our analyses. Other facing consider waiting mitigate access members ColonCancerCheck/Gastrointestinal COVID Working Group: Melissa Coulson, Julia Gao, Dan He, Nathaniel Jembere, Bronwen R. McCurdy, Justine Wallace, Prevention Control, Ontario), Ontario. Jill Tinmouth, MD, PhD (Conceptualization: Equal; Formal analysis: Supporting; Methodology: Lead; Supervision: Writing – original draft: Lead); Steven Dong, MA Equal); Christine Stogios, MSc (Project administration: Linda Rabeneck, MPH review & editing: Michelle Rey, MSc, (Methodology: Catherine Dubé, Equal). Supplementary 1Impact Pandemic Hospital Outpatient Colonoscopy OntarioColonoscopy indicationHospital volumesBefore Pandemic, March–June n (%)Pandemic, (%)% change, vs 2019gFOBT+/FIT+4390 (4)4758 (13)8Symptomatic44,651 (42)19,501 (54)–56Family historyaIndividuals increased family 1 more degree relative(s) cancer.10,855 (10)2134 (6)–80SurveillancebIndividuals polypectomy cancer. Prior histology low- high-risk adenoma) known.28,107 (26)6033 (17)–79Average-risk screeningcIndividuals relatives cancer).19,031 (18)3603 (10)–81All colonoscopies107,034 (100)36,029 (100)–66FIT, test; gFOBT, guaiac occult blood test.a Individuals cancer.b known.c cancer). Open table new tab test.