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Characterizing the impact of procedure funding on the Covid-19 generated procedure gap in Ontario: a population-based analysis

Gomez D, de Mestral C, Stukel TA, Irish J, Simpson AN, Wilton AS, Rotstein OD, Campbell RJ, Eskander A, Urbach DR, Baxter NN. Ann Surg. 2022; Dec 20 [Epub ahead of print]. DOI:

Background — Surgical procedures in Canada were historically funded through global hospital budgets. Activity-based funding models were developed to improve access, equity, timeliness and value of care for priority areas. COVID-19 upended health priorities and resulted in unprecedented disruptions to surgical care which created a significant procedure gap. We hypothesized that activity-based funding models influenced the magnitude and trajectory of this procedure gap.

Methods — Population-based analysis of procedure rates comparing pandemic (March 1, 2020 to December 31, 2021) to a pre-pandemic baseline (January 1, 2017 to February 29, 2020) in Ontario, Canada. Poisson generalized estimating equation models were used to predict expected rates in the pandemic based on the pre-pandemic baseline. Analyses were stratified by procedure type (out-patient, in-patient), body region, and funding category (activity-based funding programs vs. global budget).

Results — 281,328 fewer scheduled procedures were performed during the COVID-19 period compared to the pre-pandemic baseline (Rate Ratio 0.78; 95%CI 0.77–0.80). In-patient procedures saw a larger reduction (24.8%) in volume compared to out-patient procedures (20.5%). An increase in the proportion of procedures funded through activity-based programs was seen during the pandemic (52%) relative to the pre-pandemic baseline (50%). Body systems funded predominantly through global hospital budgets (e.g. gynecology, otologic surgery) saw the least months at or above baseline volumes whereas those with multiple activity-based funding options (e.g. musculoskeletal, abdominal) saw the most months at or above baseline volumes.

Conclusions — Those needing procedures funded though global hospital budgets may have been disproportionately disadvantaged by pandemic-related health care disruptions.