Abstract
Background
New patient referral models are needed to reduce long wait times for otolaryngology surgical procedures, such as a Single-Entry Model (SEM). However, patient perspectives about SEM in otolaryngology remain unexplored.
Methods
In this mixed methods study, a retrospective chart review was conducted to examine the times from referral to consultation (T1) and from consent to surgery (T2) for all elective otolaryngology surgical procedures at a large community hospital between 2020 and 2023. We then conducted journey mapping interviews with 10 patients and parents of pediatric patients who underwent otolaryngologic surgeries to understand their experiences of waiting for their own or their child’s procedure, and perspectives on how an SEM might impact patient experiences. Data were analyzed using descriptive statistics and thematic analysis.
Results
We identified that average wait times among 2414 elective (oncologic and non-oncologic) otolaryngology procedures often exceeded provincial target wait times. On average, oncology procedures had the shortest wait times (T1: 34 ± 47; T2: 101 ± 161 days), and otologic procedures had the longest (T1: 67 + 72; T2: 355 ± 285 days). While patients often did not wait as long to have a consultation with their surgeon, the time between consenting to and receiving surgery tended to drive wait time duration. Patients who had endured extended wait times experienced poor quality of life, worsening symptoms, and often worried about how long they would need to wait. Systems such as an SEM that could shorten wait times were generally well-perceived. However, patients emphasized the importance of trusting relationships with referring physicians and surgeons, which could be an enabling factor for implementing an SEM.
Conclusion
Long surgical wait times in otolaryngology are negatively impacting patients. A SEM could offer a way to improve patient experiences and outcomes.
Key Messages
• Wait times for head, neck, and throat surgeries from 2020 to 2023 in a large Canadian health system often exceeded quality standard targets.
• Patients who experienced prolonged wait times for non-oncologic procedures reported decreased quality of life, worsening symptoms, and heightened anxiety.
• Implementing a single-entry model, particularly for routine procedures in otolaryngology, could lead to better patient experiences and outcomes.
Introduction
Wait times for Otolaryngology – Head and Neck Surgery (OHNS) procedures have been historically long,1,2 but since the COVID-19 pandemic, they have significantly increased.3,4 The rise in wait times can be attributed to factors such as steep rises in referrals with resumed access to routine care following COVID-19 restrictions, ongoing population growth, a stagnant number of OHNS surgeons, and increases in high-priority surgeries.3,5,6 Prioritization in clinical urgency has been one of the largest driving forces contributing to growing wait lists3,7; while oncologic cases in the Canadian healthcare system are prioritized, 8 non-oncologic surgery wait times grow larger and regularly exceed target time ranges. 1 According to regional quality standards set by Health Quality Ontario (HQO), the lowest priority target wait time for oncologic surgery is 119 days total, and for non-oncologic surgery, the target is 364 days total, with shorter targets for higher priority procedures.2,9 Long wait times can cause patients to experience anxiety, depression, and enduring painful or disruptive symptoms,10-12 which also may exacerbate equity issues by limiting the ability to work or increasing the need for additional care and higher health system costs due to disease progression. 13
When referring a patient to a surgeon, physicians often typically select a surgeon based on their known network, geography, or specific expertise required, but this unsystematic approach does not spread the volume of referrals equally across available resources and can further increase wait times. 14 The Single-Entry Model (SEM) has been proposed as a possible alternative. 15 In SEM, instead of navigating multiple access points or routinely referring to a known surgeon, physicians can refer patients to a single referral touchpoint or be queued for the first available surgeon.16,17 This method has been shown to reduce wait times from referral to consultation, 18 reduce negative effects of waiting for surgery,19,20 and could improve equity among surgeons by reducing preferential or biased referrals. Although SEM shows promise for reducing surgical wait times,18,19 it represents a substantial change from the current queuing process in most Canadian healthcare systems. It also limits a patient’s ability to choose their provider, which may impact satisfaction and could be perceived as a risk to a provider’s usual patient volume. 16
With the current system, the “pain points” patients experience while awaiting otolaryngology surgery have not been described, which are vital to understand as solutions are designed to minimize wait times.3,15,19 Our objectives were to describe OHNS procedure wait times, explore patient experiences of those wait times, and gather patient perspectives about introducing SEM at a large community hospital.
Methods
Setting
Trillium Health Partners (THP) in Mississauga, Ontario, is a large community hospital system, with 3 sites, 1457 inpatient beds, and over 1.7 million annual patient visits. 21 The Division of OHNS at THP performs about 2500 operative cases per year (total; prior to the COVID-19 pandemic) on adults and children. Common surgeries include oncology cases, such as thyroidectomy, as well as non-oncologic procedures like tympanoplasty, septoplasty, endoscopic sinus surgery, pediatric adenotonsillectomy, parotidectomy, and others. Patients are typically referred to individual OHNS surgeons at THP based on preferences or routine practices.
Study Design
We conducted a convergent mixed methods 22 study to describe surgical wait times and explore patient perspectives on introducing SEM to reduce wait times.
In the quantitative phase, we conducted a retrospective chart review of all OHNS procedures by 4 surgeons at THP between November 1, 2020, and November 1, 2023. In the qualitative phase, we conducted journey mapping through semi-structured individual qualitative interviews. Journey mapping is a method to understand patient experiences, barriers and outcomes within the health system and document their interactions and journey through a healthcare service to create a visual or descriptive map. The purpose of journey mapping is to explore patients’ lived experiences by identifying gaps and supporting redesigns where needed to improve care quality. 23
This project was deemed quality improvement by the THP Research Ethics Board.
Data Collection
For the quantitative phase, we extracted wait time data for time from referral to first consultation with the surgeon at THP (T1), and from consent to surgery until the procedure occurred (T2). We used longitudinal datasets from hospital records and surgeon databases. We extracted the timestamps of the patient’s referral, consultation appointments, consent, and surgery, as well as their procedure type, age, birth-assigned sex, and postal code.
For the qualitative phase, we invited 10 patients and/or parents of pediatric patients to participate in one qualitative interview in English. To recruit participants, we employed a combination of convenience and maximum variation sampling. 24 Convenience sampling was used to select patient participants who were undergoing post-surgery follow-up and expressed their interest in an interview. 24 Maximum variation sampling was used to ensure a diverse range of participants were approached by targeting individuals who had undergone different types of procedures and experienced varying wait times. 24 Our selection of individuals was guided by a preliminary analysis of our quantitative data. During follow-up appointments, patients were approached by their surgeons to participate. If they expressed interest, a member of the team then contacted them with further information. If they confirmed interest, a mutually agreeable time was set up for the interview.
Virtual interviews lasted approximately 25 to 45 minutes and were conducted on Zoom between February and May 2024. Prior to each interview, participants received an informational letter about the study. Verbal consent was obtained at the start of each interview. Interviews were audio recorded, de-identified, and transcribed verbatim. Transcripts were not reviewed by participants. To guide the conversation, the interviewer shared a list of key dates corresponding to referral, consultation, surgery, and any other relevant healthcare interactions. This was seen as an initial “map” to orient questions about physical, emotional, and social experiences with, and impacts of waiting for surgery. We used the Miro Board to collaborate and create a visual map for each participant’s journey, 25 as well as an interview guide (Supplementary Appendix) to prompt participants to think about specific aspects of their experience. Virtual “sticky notes” were placed on the board to note emotions and experiences that corresponded to each stage of participants’ surgical journeys. Participants were also introduced to the concept of SEM and asked to imagine how this new system could impact their health or care experience, including exploring trade-offs of shorter wait times with a lack of surgeon choice. A patient partner with lived experience of long wait times for an elective procedure and who was known to the investigator team reviewed and provided feedback to the interview guide to support its relevance and accessibility.
Data Analysis
We used descriptive statistics to analyze the quantitative data. We computed mean wait times in days (with standard deviations) from referral to first consultation (T1) and consent until surgery (T2). For categorical data, we calculated percentages. We classified postal codes using the Ontario Marginalization Index 2021 (ON-Marg) to determine patient’s socio-economic status.26,27 ON-Marg assigns quintiles (5 categories) to postal codes based on relative material deprivation (representing education, low income, unemployment, lone-parent families, and dwellings in need of major repair) and ethnic concentration (representing immigrants within the past 5 years and visible minorities). Surgical wait times were compared across procedure types, surgical priorities, and surgeons. Two-way ANOVA was conducted to evaluate the relationships between surgeon, procedure type, and T1 and T2. Statistical significance was set at 0.05. Statistical analysis was conducted on SAS Software 9.4.
We applied thematic analysis to analyze the interview transcripts and patient journey maps, using NVivo 12. 28 After familiarizing ourselves with the transcripts and patient journey maps, we generated initial codes based on experiences and perspectives. A draft codebook was developed to group similar data together and was applied to a sample of transcripts. After our initial coding, the codebook was further refined by adding new codes, merging existing codes, and deleting codes not relevant to our research question. The refined codebook was applied to the rest of the transcripts.
Results
Quantitative Results
We identified 2414 OHNS procedures that were completed between November 2020 and November 2023. Patient characteristics are summarized in Table 1. Of the 2414 procedures, 29% (n = 710) were adult sinonasal cases, 26% (n = 595) were adult non-oncologic head and neck cases, 21% (n = 509) were pediatric non-oncologic cases, 16% (n = 387) were adult oncology cases, and 9% (n = 213) were adult otologic cases. Based on the ON-MARG index, patients came from a range of socio-economic areas, 20% (n = 490) from low neighborhood material resources and 52% (n = 1236) from neighborhoods with high racial and newcomer populations, which is consistent with the hospital’s catchment population. 29 The 4 surgeons’ years of surgical experience ranged from 4 to 27 years.
Patient Characteristics.
Data only available for postal codes that could be matched with ON-Marg.
For all 2414 otolaryngological procedures, the average (± standard deviation) wait time from referral until consultation (T1) was 85 ± 85 days, and the average wait time from consent for surgery until surgery (T2) was 176 ± 197 days (Table 2). For all non-oncologic surgeries, the average T1 wait time was 95 ± 87 days, and the average T2 wait time was 190 ± 200 days, for an average total of 285 days. Wait times for each type of surgical procedure varied (Figure 1), with adult oncology cases having on average a shorter wait time (T1: 34 ± 47; T2: 101 ± 161 days; average total: 135 days) and adult otologic cases (T1: 67 + 72; T2: 355 ± 285 days; average total: 422 days) having one of the longest. Average wait times for non-oncologic surgeries exceeded the lowest priority targets set by HQO for T2 among the sinonasal, otologic, and oncology procedures in our sample, which are 182 days for non-oncologic and 84 days for oncologic procedures (Figure 1). Statistical significance was found when examining whether the type of surgical procedure and surgeon were related to both T1 (P < .001) and T2 (P < .001) wait times.
Wait Times by Surgeon and Procedure Type.
T1 = time from referral to first consultation with the surgeon; T2 = time from consent to surgery until the procedure occurred.
T1 and T2 wait times by procedure type.
Qualitative Results
We interviewed 8 patients and 2 parents of pediatric patients, whose procedures included 3 oncology, 2 head and neck, 3 sinonasal, and 2 otologic. Participants’ T1 wait times for oncology cases ranged from 7 to 106 days, and T2 ranged from 48 to 356. Non-oncologic T1 wait times ranged from 9 to 70 days and T2 ranged between 4 and 730 days. Appendix Figure 2 shows a consolidated summary of how patients’ experiences were captured, documented, and mapped over time.
Unpredictable Wait Times
Based on their knowledge of surgical wait times in Canada, many participants expected that the wait time would be long, up to a few years. Those who had shorter wait times, typically for oncology procedures, were surprised they were able to receive surgery quickly. Participants’ T1 wait times varied; some reported long wait times, while others felt their wait was reasonable. Patients’ narratives highlighted that their T2 wait time was shaped by various factors, such as their presenting symptoms, the clinical priority of the procedure, the type of surgery required, and any existing life stressors. For those who received surgeries to remove cancer, such as thyroidectomy, wait times were perceived as adequate based on the urgency of the procedure.
She did mention—she said it’ll be 2 months. But living in Canada, we have heard of the waiting times—even my husband, he had some issue and—well, it was small, but it was bothering him, so he went to the doctor. And his waiting time was 1 year. So to be honest, when we went to the doctor, our perception was that the surgery would probably be 5 months, 6 months or maybe later. But I wasn’t expecting it will be that soon. So, surgery in 2 months was pretty good. Patient 03, Adult Oncology
Many patients who received non-oncologic procedures had longer and unpredictable wait times, which caused concern and frustration, often leading to worry and anxiety. A few patients who had additional life stressors, but lacked symptoms, did not perceive a wait time of several months to a year to be particularly significant, even for those with cancer. Others who had symptoms that impacted their quality of life and disrupted their daily activities, work, and social life, such as breathing or sleeping comfortably or hearing well, felt their wait time was too long and should have been prioritized.
I had to wait months to get this—for them to get me into the surgery, to book the surgery. While I was waiting, my complications with my sinuses, issues breathing, couldn’t breathe, it would cause me a lot of headaches, a lot of—I couldn’t function, you know, working on my computer. Breathing. Sleeping at night, very uncomfortable. I had to like, sleep at night. Like, it was just very uncomfortable. Like, I couldn’t breathe. Patient 01, Sinonasal
With poor oversight over how long they might need to wait, patients described seeking and trialing alternative therapies such as medications, nasal rinses, and diets, and participating in clinical trials to alleviate their symptoms while waiting for surgery, sometimes in hopes of avoiding surgery altogether. However, these approaches were not often successful, caused disruption to patients’ sleep or social lives, and may have had unnecessary consequences such as consuming excessive antibiotics or medication side effects.
Trusting Relationships With Referring Physicians and Surgeons
Although participants did not always know the factors their physician considered when referring them to a specific surgeon (such as geography, expertise, or an existing relationship), many expressed a high degree of trust in their physician to select the best surgeon for them. Most were confident that even if they were referred to a surgeon based solely on the shortest wait time, their assigned surgeon would conduct the procedure well regardless.
It was our family doctor that referred, and I trust her with my life. I trust her. And if she had given me a choice of who, I would say, you tell me. So, I always just do what the doctor says, and I don’t want to make the decision on who to see. Whoever my doctor thinks is good, I want to go with whoever my doctor thinks is good. So, she probably knows of Dr. [Name] and thinks that she’s good and that’s why she referred me is what I assume. Patient 07
Participants were generally receptive to an SEM if it shortened wait times, which they associated with alleviating symptoms faster and mitigating potential long-term consequences of their condition worsening while waiting for surgery. However, some expressed concerns when considering their own surgical journey; for example, whether they would feel comfortable with a surgeon selected only based on wait time and not specific expertise if their case was particularly complex, or if there was insufficient opportunity to meet with the surgeon, ask questions, and build a relationship. One participant described seeking a more experienced surgeon than their original referral, as the first lacked experience with the difficulty of the surgery, which heightened their anxiety. Through 1 participant’s repetition of the word comfortable, they highlighted the importance of trust in their relationship with the surgeon:
I think it would depend for me on the type of surgery that I was having. If it was something like—I’ve had my gallbladder taken out. Something that’s a little bit more routine. I think that I would be OK with something like that. But for the particular surgery that I had, considering it was my face and my facial nerves were involved and they were literally opening my face up. And it just—I knew the seriousness of the—I don’t know if I would be as comfortable with that as—especially because of what happened to me where I saw an ENT and he didn’t want to do the surgery. And I get that maybe in a system like that they wouldn’t be, you know, available for those types of surgeries. But I would be less comfortable with something like that particular surgery I had but maybe more comfortable with more of a routine surgery. Patient 9, Head and Neck
Similar to the expressed importance of trust with referring physicians, participants unanimously stressed that establishing a trusting relationship with their surgeon was imperative to feel comfortable.
So, would I just pick just any doctor with the shortest wait time? No. No, I will not. But however, I’m one of the minority, because speaking to Doctor [name], it checked all the boxes that were there. I know who my anesthesiologist is. I’m going to have to potentially ask all the right questions. I had some questions which he answered, and I just felt comfortable having that one-on-one feeling, and I had a feel for who was going to be operating on me. If I didn’t have a feel for who was going to be operating on me, would I want to do? No, but that’s me. Patient 08, Otologic
Some acknowledged that having the best of both scenarios may not be an option, so if it were to improve their symptoms and quality of life and reduce the unpredictability and anxiety associated with long wait times, they would consider another qualified surgeon even if they were selected based on wait time alone.
But I also wouldn’t want to wait because my son’s health is more important than me liking the doctor. So, if I would be putting his health, or if it was even me, like my health, health comes before liking the doctor. If they’re qualified, they know what they’re doing, and I get to see them first, health comes first. So, no, I would not wait to get his tubes done for a year to see Dr. [Name]. I would like to be put in line to the one that has the soonest time because I need him to start talking. Parent of Pediatric Patient 07, Pediatrics
Discussion
In this mixed methods study, we identified that average wait times among 2414 oncologic and non-oncologic OHNS surgical procedures at a large community hospital in Ontario, Canada, often exceeded regional target wait times.2,9 On average, oncologic procedures had the shortest wait times, and otologic procedures had the longest. While patients often did not wait as long to have a consultation with their surgeon, the time between consenting to and receiving surgery tended to drive wait time duration. Particularly for non-oncologic procedures, participants who had endured wait times experienced poor quality of life, worsening symptoms of their condition, and worry or anxiety. Common themes emerged across their narratives including unpredictable wait times and the need for trusting relationships with referring physicians and surgeons. Patients supported the idea of an SEM in otolaryngology, particularly for routine and less specialized procedures, provided they could meet their surgeon in advance.
Several factors may have contributed to the differences between oncologic and non-oncologic surgical wait times, including provincial and institutional priorities that incentivize oncologic and pediatric surgeries, which in turn lead to prolonged wait times for non-oncologic cases. Additionally, oncologic procedures that use the bulk of available resources, high demand for specialized expertise among higher-priority procedures, and variation in surgeon referral patterns and practice priorities could influence wait times. We found that between surgeons, there was a significant difference in wait times for non-oncologic surgeries, with otology surgery exhibiting the longest waits—up to 385 days or more. Implementing an SEM could reduce wait time variability across procedure types and surgeons by assigning patients to surgeons with shorter wait times when possible.
In our study, participants placed a high degree of trust in their primary care physician to choose the most suitable surgeon. Patients often lack awareness of how and why their physician may select a certain surgeon to refer to and lack the autonomy to explore and meet with other qualified surgeons with shorter wait times. However, referring physicians’ selection processes can be sporadic and unsystematic; literature suggests these decisions can be driven by prior experience with particular surgeons, referral habits and routines, and clinical expertise. 14 This may lead to uneven referral distribution, bottlenecks at popular practices, and underutilization of qualified surgeons with shorter wait times. 15
Patients also described how their quality of life declined due to extended wait times for surgery and prolonged disruptive symptoms such as difficulties breathing, sleeping, working, and for 1 patient, their ability to drive safely. These findings align with research in other specialties, which has demonstrated a link between enduring surgical wait times and anxiety, depression, and deterioration of quality of life.11,30,31 These impacts of waiting for surgery can also introduce and deepen inequities; for example, if a patient’s capacity to work or care for their family is diminished for an extended period.11,32
Queuing processes for surgery in Canada need overhauling, especially considering the negative impacts of COVID-19 on already long wait times before the pandemic and improving equitable access to high-quality care.3,33,34 Several health systems have introduced SEMs, 18 of which have effectively shortened wait times for a variety of procedures and reduced waitlist backlogs. 35 Key enablers of SEM include clear communication about its importance and goals, sustained financial investment in change management, and robust data collection mechanisms to support continuous evaluation and improvement. Physician leaders advocating new processes and patient needs is also imperative,3,13 which aligns with our finding that physicians can be champions for change especially when they have trusting relationships with patients. Patients also tend to be satisfied with SEM especially when they have met their surgeon in advance of their procedure, which is consistent with our results 18 ; 1 study even demonstrated that patient-perceived quality of surgeons improved post-SEM implementation. 36 Implementing SEM in Otolaryngology requires careful consideration of factors such as surgeon expertise, case complexity, procedural variability, and patient preferences. Given that SEM in Otolaryngology has not been extensively studied, there is a significant need for further research into implementation techniques, including criteria for case selection, surgeon allocation, and monitoring processes. Adopting SEM should be approached cautiously, within a group of willing participants, to ensure equitable, high-quality care while addressing potential disparities. Additionally, funding an SEM remains unclear, as additional resources such as staff are needed to optimize efficiency. One study reported that funding from the government may hinder the process and suggested that surgeon organizations could be an alternative funding source. 37 Further exploration of funding opportunities is necessary to facilitate SEM implementation.
Strengths and Limitations
Strengths of this study include a convergent mixed methods design, which enabled us to analyze surgical wait times across a diverse patient population and gather detailed insights about patients’ journeys and experiences. We interviewed patients with various procedures, wait times, and levels of urgency, providing a comprehensive understanding of their experiences and outcomes. Patients in this study were referred to surgeons from a variety of providers (family physicians and specialists), which allowed us to capture relationship dynamics between patients and a range of different clinicians, including surgeons as well. Additionally, the use of journey mapping in the qualitative phase offered a visual and interactive method to document and analyze patient experiences, helping to identify specific pain points and areas for improvement in the surgical pathway. This method facilitated a deeper exploration of the emotional and social impacts of waiting for surgery, which are often underrepresented in purely quantitative studies. A patient partner’s involvement ensured the interview guide was patient-centered, relevant, and accessible, improving the quality and depth of the qualitative data.
This study had limitations. First, we were not able to identify the priority of each procedure in our analysis; comparing average wait times among our data to the lowest priority target wait times provided an estimated conservative comparison, but it is likely that many of the procedures in this study were higher priority and therefore deviated more frequently from targets than we demonstrated. Second, beyond patients’ experiences, we did not gather information about specific health outcomes that may have resulted from enduring wait times and therefore were not able to determine causality. Third, recall bias may have influenced participants’ perspectives, as some of the procedures occurred 3 to 4 years ago. Finally, the COVID-19 pandemic disruptions, including pauses in non-oncologic surgeries may have influenced wait time and patient experiences, due to factors like limited care access and clinical restrictions.
Conclusion
Findings of this study are consistent with other literature showing that OHNS surgical wait times in Canada exceed targets and often lead to poor patient experiences and outcomes. A SEM, particularly for routine procedures, could be an effective way to shorten wait times and improve patient quality of life and well-being, reducing the burden on an overstretched healthcare system. Our findings suggest that an SEM in otolaryngology may be best suited to routine surgeries where specialized expertise is less of a requirement. If an SEM is implemented, referring physicians may have a role in assuring patients that their referrals are driven by the shortest possible wait time, but additional factors are considered such as complexity and patient comfort.
Supplemental Material
sj-docx-1-ohn-10.1177_19160216251321456 – Supplemental material for “My Quality of Life is Not There. I’m Dying Here. I Cannot Take This Anymore.” Exploring Patient Experiences With Surgical Wait Times in Otolaryngology: A Mixed Methods Study
Supplemental material, sj-docx-1-ohn-10.1177_19160216251321456 for “My Quality of Life is Not There. I’m Dying Here. I Cannot Take This Anymore.” Exploring Patient Experiences With Surgical Wait Times in Otolaryngology: A Mixed Methods Study by Shelley Vanderhout, Shipra Taneja, Amr Hamour, Eric Monterio and Janet Chung in Journal of Otolaryngology - Head & Neck Surgery
Footnotes
Author Contributions
JC, EM, AH, and SV designed the study and secured funding. SV, JC, and ST led data collection and analysis. SV and ST drafted the manuscript with critical revision and input from JC, AH, and EM. All authors approved the final version.
Data Sharing Statement
Participant consent did not extend to the sharing of transcripts or data beyond the information presented in this article.
Declaration of Conflicting Interestsf
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: We received funding from the Institute for Better Health, Learning Health Systems Accelerator Grant. They had no involvement in the study design, data collection, analysis or preparation for the article.
Supplemental Material
Supplemental material for this article is available online.
References
Supplementary Material
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