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September 26, 2025
7 min read
Key takeaways:
- In Canada, orthopedic surgery had the longest wait time between referral to receipt of treatment.
- Implementation of team-based care may reduce wait time for patients.
In Canada, the recommended wait time between referral to receipt of treatment for an elective procedure is about 6 months. However, a 2024 report showed patients experienced an actual wait time of about 30 weeks.
Among the specialties included in the report, orthopedic surgery had the longest wait time at 57.5 weeks, as well as the largest increase in wait time between 2023 and 2024.
“There are more people who need procedures like hip replacement or knee replacement than there are orthopedic surgeons and OR time to perform them,” David R. Urbach, MD, MSc, head of the department of surgery at College Hospital in Toronto and professor of surgery and health policy management and evaluation at the University of Toronto, told Healio. “We often have this problem where people have to wait longer for elective surgery than they would want because the demand exceeds the supply.”
In addition, Urbach said a lack of coordination between general practitioners and specialists contributes to increased wait times.
“There is no mechanism to say, ‘Here is a pool of surgeons and we will make sure you get to see the next available appointment,’” Urbach said. “One doctor refers you to another doctor but not with a lot of other information. Because of that context, wait times are a problem in most things in Canada because of variation in wait time. It is not that everybody waits a year and a half for a knee replacement. Some people wait a year and a half but other people in the same place wait 3 or 6 weeks. There is not a lot of rhyme or reason to it.”
One way wait times may be mitigated is through the type of referral model implemented in a health system. In a discrete-event simulation study, Urbach and colleagues aimed to identify whether certain referral models could reduce wait times for consultation and surgery without increasing funding to hospitals or investment in private for-profit surgical facilities.
Healio spoke with Urbach about the referral models included in the study and how implementation of these models may impact health care.
Healio: What were the referral and practice models included in the study? Why were these models chosen?
Urbach: The predominant model in Canada is direct physician-to-physician referrals. You see your primary care doctor and they send you to an orthopedic surgeon. We looked at other types of models, but the one we were most interested in is a single-entry model, which is a type of central intake. In that model, instead of your doctor having to figure out who is the orthopedic surgeon you should see, they send you into a central queue and you are directed to the next available surgeon who can assess you.
One of the other problems in Canada is once you have been seen by a surgeon there is a wait for the surgery. One way to address the wait for surgery is to put patients in a common pool again and have them see the next available surgeon. If a surgeon has decided you need a total knee replacement but they cannot do it for 1 year, there might be another surgeon in the group who does the same surgery but can do it within 1 month. Allowing patients to have surgery by the next available surgeon is called team-based care or shared care.
We chose these models because they have been proposed as being potentially helpful to address the various wait time problems that exist. For example, single entry has been advocated for many years by health system reform advocates in Canada as being able to reduce wait times for consultations and shared-care models do exist in small numbers.
Healio: What is the overall take home message of the study and what are the key findings?
Urbach: We found a couple of major things. No. 1 is that single-entry models could reduce the wait times for consultation, but it did not reduce it by much — partially because the wait times for consultations were not that long. In Ontario, most patients are able to see a specialist within 30 or 50 days or within 1 or 2 months. It is not like people have to wait 1 year to see an orthopedic surgeon. Typically, you get to see a specialist quickly. It is once patients have seen the orthopedic surgeon that some patients wait a long time for surgery.
The other problem with single-entry models is that it sometimes worsened the problem of the time people would wait for surgery. We were not sure at first why that happened, but it might have to do with the fact that because surgeons operate their own independent practices they can modulate and they can buffer seeing patients. If they have a huge influx of demand, they can hold off new consultations for a while or redirect and focus on operating and clearing out patients. But the computer simulations did not think through all of these scenarios. If you are told the next available consultant no matter what, then even if a surgeon sees tons of patients very quickly, they will just keep seeing more and more patients even if, in reality, they do not have the capacity to operate on all of them. We had these bizarre results in the model that made the wait times for surgery much worse.
Having said that, when you combine single-entry models with team-based care, what this looks like is that orthopedic surgeons would not necessarily work independently in their own practice but in an associate practice of five or 10 orthopedic surgeons. All the referrals would get pooled and directed to the next available associate and the associate practice. Once one of the surgeons decided that a patient needed surgery, they would get directed to the next available associate in the practice for surgery. That could virtually eliminate prolonged wait times.
Healio: In what ways have the results of this study impacted your practice?
Urbach: We are very interested in tackling the problem of wait times. It is a huge issue of public concern in Canada, and it is a big source of dissatisfaction with health care here. One thing that has become clear is that, for something like surgery and orthopedic surgery, single-entry models are not the answer by themselves. They probably are going to be helpful for specialist consultations or diagnostic imaging or something where the first point of contact is the actual service. But the problem with surgical care is the first point of contact with the provider is not the service itself generally. The first point of contact is usually a consultation.
We realized moving toward team-based models of care where it is possible is probably the most helpful thing to reduce wait times for surgery. It is challenging because, historically, most of our surgeons are highly independent and not used to working in group practices or associate practices. We are very independent, we are very autonomous and we have a lot of control of our practices. That is a huge behavior change and social change in Canadian medical practice that is going to be a challenge, but that has been a significant impact from our research.
Healio: How could these results be translated across health care worldwide?
Urbach: There is a lot of applicability to health systems around the world because virtually every Western country has some form of public payment for health services for at least portions of the population.
The reason that is so much of a concern in Canada is because it is a universal single-payer system. There is no private sector that can address unmet needs. A lot of people think that these are just uniquely Canadian problems because of the structure of our health system, but there is no other country in the developed world that does not have a mix of a private sector and public delivery, and almost always the access in terms of wait times are more of a problem in the public sector than in the private sector. This is not just an issue in Canada where we do not have a private funding stream for health service that can ensure faster access, but even in other countries it is incumbent to figure out what you can do within the publicly funded health sector to be able to improve access to care in that sector because that is typically where these problems occur.
Healio: Could this research be translated to other specialties?
Urbach: Absolutely. We looked at orthopedic surgery because it is big, important and always in the news in Canada because there is always someone who has waited 2 years for a hip or a knee replacement. But we are trying to do the same thing for cataract surgery, which is by far the most common surgery that is done in just about anywhere in the world. In Ontario, one out of every five operations is cataract surgery, and we have the same problem with variation in wait times.
In just about anything else, research for these models would be helpful and movement toward more coordinated or organized approaches to ensure patients are receiving care in the shortest time possible by the most appropriate provider is the desirable end goal of how we organize health systems. By no means should this be limited to joint replacement or orthopedic surgery.
Healio: What advice would you give to orthopedic surgeons when it comes to reducing wait times for scheduled surgery?
Urbach: My personal opinion is team-based care is the best model of care for surgeons. It allows us to share the care of patients, it allows equilibration of resources so you can make sure people are able to access care in the most efficient way possible, and it is also the best model of care for a professional work environment as a surgeon.
My own experience is working as part of a team is a much more supportive environment. If you have to manage a patient who is complicated or difficult, it is easier to manage them as part of a group with others than when you are on your own. For other issues, like physician burnout and dissatisfaction with our professional work life, a team-based model of care tends to be a more highly supportive and acceptable way of working than always working on your own.
For more information:
David R. Urbach, MD, MSc, can be contacted at david.urbach@wchospital.ca.
Sources/Disclosures
Source:
Healio Interviews
References:
Disclosures:
Urbach reports no relevant financial disclosures.
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