Coronavirus disease 2019 (COVID-19) has significantly affected gastrointestinal (GI) endoscopy, with jurisdictions reporting up to a 95% reduction in procedure volumes compared to 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, a large volume of colonoscopies not performed during the first wave of the pandemic (the backlog) must now be managed (Supplementary Table 1). Ontario Health (Cancer Care Ontario) oversees colonoscopies performed in hospitals (70% of those performed in the province). Ontario Health's "COVID-19 Tip Sheet for Facilities Performing Gastrointestinal Endoscopy" (June 2020) recommended that individuals originally scheduled for low-yield colonoscopies (ie, average-risk screening colonoscopy or surveillance colonoscopy in those with a history of low-risk adenoma [LRA]) should instead receive the 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. et al.Colorectal cancer screening in average risk populations: evidence summary. Program in evidence-based care evidence summary no. 15-14. Cancer Care Ontario, Toronto, Canada2015Google Scholar, 4Dubé C. et al.Am J Gastroenterol. 2017; 112: 1790-1801Crossref PubMed Scopus (78) Google Scholar and be referred for colonoscopy only if the FIT result is abnormal. Ontario Health's surveillance guidelines recommend FIT as the follow-up test in those with a history of LRA based on recent evidence that the risk of colorectal cancer in these individuals is less than in the general population.5Dubé C et al. https://www.cancercareontario.ca/en/guidelines-advice/types-of-cancer/38506.Google Scholar, 6Loberg M. et al.N Engl J Med. 2014; 371: 799-807Crossref PubMed Scopus (226) Google Scholar, 7Wieszczy P. et al.Gastroenterology. 2020; 158: 875-883Abstract Full Text Full Text PDF PubMed Scopus (128) Google Scholar, 8Cross A.J. et al.Long-term colorectal cancer incidence after adenoma removal and the effects of surveillance on incidence: a multicentre, retrospective, cohort study.Gut. 2020; 69: 1645-1658Crossref PubMed Scopus (58) Google Scholar Our aims were to (1) estimate the volume of hospital-based outpatient colonoscopies not performed because of the pandemic and (2) compare the effect of 2 strategies, redirecting individuals from low-yield colonoscopy to FIT and increasing hospital colonoscopy capacity, on backlog recovery time. We used the GI Endoscopy Data Submission Portal, which receives monthly hospital colonoscopy data (including colonoscopy date and indication) to identify all outpatient hospital colonoscopies performed from January 2019 to August 2020. We estimated hospital-based outpatient colonoscopy volumes from March 2020 to February 2024 by calculating the difference between expected monthly colonoscopy volumes (derived from monthly 2019 volumes inflated by 1%/year) in the absence of the pandemic and observed or projected volumes during the pandemic. Volumes from March to August 2020 were obtained from the Gastrointestinal Endoscopy Data Sharing Portal ("observed") and projected for subsequent months by multiplying the expected volumes by assumptions of system capacity during the pandemic. We assumed that (1) colonoscopy volume in September 2020 would be 85% of that expected; (2) capacity would increase by 5%/month, reaching 100% in December 2020; and (3) the maximum capacity of 115% would be reached in March 2021, remaining stable thereafter. In any given year, 100% capacity was defined as the mean of expected monthly volumes for that year. Maximum system capacity was set at 115% based on the relative difference between the highest and average monthly volumes in 2019. Recovery time was defined as the number of months until the colonoscopy backlog was eliminated. Colonoscopies were added to the backlog after August 2020 in months where capacity was anticipated to be below 100%. We counted low-yield colonoscopies that would have been performed in the absence of the pandemic. All average-risk screening colonoscopies and 50% of surveillance colonoscopies were considered low yield. The latter assumption was required because we do not have data on pathology from the prior colonoscopy. A proportion of people redirected to FIT (OC-Sensor DIANA, Eiken Chemical Co) will have an abnormal result (Ontario target positivity range: 5%–6.5%) and require a colonoscopy (Ontario's prepandemic colonoscopy follow-up rate: 90%). Beginning in September 2020, redirected low-yield colonoscopies were subtracted, and abnormal FIT result colonoscopies resulting from redirection were added to expected hospital colonoscopy volumes. Corresponding recovery times, varying the proportion of low-yield colonoscopies redirected to FIT (25%, 50%, and 75%), were calculated. An alternative strategy for managing the backlog is to increase hospital endoscopy capacity. Again, we assumed (1) 85% capacity in September 2020 and (2) that capacity would increase by a constant rate each month until March 2021, when the maximum capacity would be reached and maintained thereafter. We then calculated the maximum expected increase in system capacity required to match the recovery times achieved by redirecting 25%, 50%, and 75% of low-yield colonoscopies to FIT. Before the pandemic, 18% and an estimated 13% of all colonoscopies were performed for average-risk screening and LRA surveillance, respectively (Supplementary Table 1). Estimated recovery times vary depending on the proportion of persons scheduled for low-yield colonoscopies who are redirected to FIT. The backlog is projected to take 41 months to recover without redirection, but redirecting 25%, 50%, and 75% low-yield colonoscopies to FIT will reduce recovery times to 28, 22, and 19 months, respectively (Figure 1A). If there was no redirection to FIT, hospitals would need to increase colonoscopy capacity to 124%, 134%, and 145% to recover the backlog in 28, 22, and 19 months, respectively (Figure 1B). As in other jurisdictions,1Rutter MD et al. Gut [published online July 20, 2020]. https://doi.org/10.1136/gutjnl-2020-322179.Google Scholar GI endoscopy services in Ontario have been profoundly affected by the COVID-19 pandemic, leading to a colonoscopy backlog that, absent any intervention, is estimated to take 41 months to recover. The impact to patients is consequential, particularly in terms of delays in diagnosis. The UK estimated 2828 fewer colorectal cancers diagnosed using lower endoscopy during the pandemic compared to the months leading up to COVID-19, representing a 72% absolute decrease.1Rutter MD et al. Gut [published online July 20, 2020]. https://doi.org/10.1136/gutjnl-2020-322179.Google Scholar We have presented 2 strategies to address the colonoscopy backlog and shown that redirecting persons originally scheduled for low-yield colonoscopy to FIT can substantially reduce the colonoscopy backlog and recovery time. To achieve a similar effect, colonoscopy capacity would need to exceed mean historical volumes by as much as 45%, which would be costly and challenging to achieve due to the constraints in the delivery of care introduced by COVID-19 (eg, physical distancing in recovery rooms). Limitations to this work include that we did not account for subsequent pandemic waves or for reduction in demand for colonoscopy during the study period because of patients' reluctance to undergo a colonoscopy, including follow-up procedures after an abnormal FIT result. Furthermore, although the FIT cutoff used to define a positive test can be adjusted to local colonoscopy capacity, we did not vary this cutoff in our analyses. Other jurisdictions facing a similar backlog in colonoscopy should consider redirecting individuals waiting for low-yield colonoscopy to FIT to mitigate the impact of the pandemic on access to colonoscopy. Other members of the ColonCancerCheck/Gastrointestinal Endoscopy COVID Working Group: Melissa Coulson, Julia Gao, Dan He, Nathaniel Jembere, Bronwen R. McCurdy, and Justine Wallace, all of Prevention and Cancer Control, Ontario Health (Cancer Care Ontario), Toronto, Ontario. Jill Tinmouth, MD, PhD (Conceptualization: Equal; Formal analysis: Supporting; Methodology: Lead; Supervision: Lead; Writing – original draft: Lead); Steven Dong, MA (Conceptualization: Supporting; Formal analysis: Lead; Writing – original draft: Equal); Christine Stogios, MSc (Project administration: Lead; Writing – original draft: Equal); Linda Rabeneck, MD, MPH (Conceptualization: Equal; Methodology: Equal; Writing – review & editing: Equal); Michelle Rey, MSc, PhD (Methodology: Supporting; Supervision: Supporting; Writing – review & editing: Equal); Catherine Dubé, MD, MSc (Conceptualization: Equal; Methodology: Equal; Writing – review & editing: Equal). Supplementary Table 1Impact of the COVID-19 Pandemic on Hospital Outpatient Colonoscopy Volumes in OntarioColonoscopy indicationHospital outpatient colonoscopy volumesBefore Pandemic, March–June 2019 n (%)Pandemic, March–June 2020 n (%)% change, 2020 vs 2019gFOBT+/FIT+4390 (4)4758 (13)8Symptomatic44,651 (42)19,501 (54)–56Family historyaIndividuals at increased risk due to a family history in 1 or more first degree relative(s) with colorectal cancer.10,855 (10)2134 (6)–80SurveillancebIndividuals with a prior polypectomy or colorectal cancer. Prior histology (ie, low- or high-risk adenoma) is not known.28,107 (26)6033 (17)–79Average-risk screeningcIndividuals at average risk for colorectal cancer (ie, no first degree relatives with colorectal cancer).19,031 (18)3603 (10)–81All colonoscopies107,034 (100)36,029 (100)–66FIT, fecal immunochemical test; gFOBT, guaiac fecal occult blood test.a Individuals at increased risk due to a family history in 1 or more first degree relative(s) with colorectal cancer.b Individuals with a prior polypectomy or colorectal cancer. Prior histology (ie, low- or high-risk adenoma) is not known.c Individuals at average risk for colorectal cancer (ie, no first degree relatives with colorectal cancer). Open table in a new tab FIT, fecal immunochemical test; gFOBT, guaiac fecal occult blood test.
Ministry of Health and Long-Term Care and the Ontario Lung Association.The primary purpose of the meeting was to solicit input and advice from a panel of experts (n=27) knowledgeable and experienced in quality of care and/or asthma
The COVID-19 pandemic has impacted cancer systems worldwide. Quantifying the changes is critical to informing the delivery of care while the pandemic continues, as well as for system recovery and future pandemic planning.
Objective
To quantify change in the delivery of cancer services across the continuum of care during the COVID-19 pandemic.
Design, Setting, and Participants
This population-based cohort study assessed cancer screening, imaging, diagnostic, treatment, and psychosocial oncological care services delivered in pediatric and adult populations in Ontario, Canada (population 14.7 million), from April 1, 2019, to March 1, 2021. Data were analyzed from May 1 to July 31, 2021.
Exposures
COVID-19 pandemic.
Main Outcomes and Measures
Cancer service volumes from the first year of the COVID-19 pandemic, defined as April 1, 2020, to March 31, 2021, were compared with volumes during a prepandemic period of April 1, 2019, to March 31, 2020.
Results
During the first year of the pandemic, there were a total of 4 476 693 cancer care services, compared with 5 644 105 services in the year prior, a difference of 20.7% fewer services of cancer care, representing a potential backlog of 1 167 412 cancer services. While there were less pronounced changes in systemic treatments, emergency and urgent imaging examinations (eg, 1.9% more parenteral systemic treatments) and surgical procedures (eg, 65% more urgent surgical procedures), major reductions were observed for most services beginning in March 2020. Compared with the year prior, during the first pandemic year, cancer screenings were reduced by 42.4% (−1 016 181 screening tests), cancer treatment surgical procedures by 14.1% (−8020 procedures), and radiation treatment visits by 21.0% (−141 629 visits). Biopsies to confirm cancer decreased by up to 41.2% and surgical cancer resections by up to 27.8% during the first pandemic wave. New consultation volumes also decreased, such as for systemic treatment (−8.2%) and radiation treatment (−9.3%). The use of virtual cancer care increased for systemic treatment and radiation treatment and psychosocial oncological care visits, increasing from 0% to 20% of total new or follow-up visits prior to the pandemic up to 78% of total visits in the first pandemic year.
Conclusions and Relevance
In this population-based cohort study in Ontario, Canada, large reductions in cancer service volumes were observed. While most services recovered to prepandemic levels at the end of the first pandemic year, a substantial care deficit likely accrued. The anticipated downstream morbidity and mortality associated with this deficit underscore the urgent need to address the backlog and recover cancer care and warrant further study.
Limb girdle muscular dystrophy type 2A is linked to a skeletal muscle‐specific calpain isoform known as p94. Isolation of the intact 94‐kDa enzyme has been difficult to achieve due to its rapid autolysis, and uncertainty has arisen over its Ca 2+ ‐dependence for activity. We have expressed a C‐terminally truncated form of the enzyme that comprises the protease core (domains I and II) along with its insertion sequence, IS1, and N‐terminal leader sequence, NS. This 47‐kDa p94I‐II mini‐calpain was stable during purification. In the presence of Ca 2+ , p94I‐II cleaved itself within the NS and IS1 sequences. Mapping of the autolysis sites showed that NS and IS1 have the potential to be removed without damage to the protease core. Ca 2+ ‐dependent autolysis must be an intramolecular event because the inactive p94I‐II C129S mutant was not cleaved by incubation with wild‐type p94I‐II. In addition, the rate of autolysis of p94I‐II was independent of the concentration of the enzyme.
ABSTRACT Background The appropriate nursing staff mix is imperative to the provision of quality care. Nurse staffing levels and staff mix vary from country to country, as well as between care settings. Understanding how staffing skill mix impacts patient, organizational, and financial outcomes is critical in order to allow policymakers and clinicians to make evidence‐informed staffing decisions. Aims This paper reports on the methodology for creation of an electronic database of studies exploring the effectiveness of Registered Nurses (RNs) on clinical and patient outcomes, organizational and nurse outcomes, and financial outcomes. Methods Comprehensive literature searches were conducted in four electronic databases. Inclusion criteria for the database included studies published from 1946 to 2016, peer‐reviewed international literature, and studies focused on RNs in all health‐care disciplines, settings, and sectors. Masters‐prepared nurse researchers conducted title and abstract screening and relevance review to determine eligibility of studies for the database. High‐level analysis was conducted to determine key outcomes and the frequency at which they appeared within the database. Results Of the initial 90,352 records, a total of 626 abstracts were included within the database. Studies were organized into three groups corresponding to clinical and patient outcomes, organizational and nurse‐related outcomes, and financial outcomes. Organizational and nurse‐related outcomes represented the largest category in the database with 282 studies, followed by clinical and patient outcomes with 244 studies, and lastly financial outcomes, which included 124 studies. Linking Evidence to Action The comprehensive database of evidence for RN effectiveness is freely available at https://rnao.ca/bpg/initiatives/RNEffectiveness . The database will serve as a resource for the Registered Nurses’ Association of Ontario, as well as a tool for researchers, clinicians, and policymakers for making evidence‐informed staffing decisions.
