Centralized approaches to surgical referrals are an ethical way to reduce wait times in Canada for common procedures like hip and knee replacements, while also helping to improve the quality of care, according to a recent commentary.

Instead of relying heavily on primary care clinicians to refer their patients to surgeons, provinces and territories could develop more single-entry referral systems, wrote David R. Urbach, MD, head of surgery at Women’s College Hospital, Toronto, and coauthors. This pooled approach to wait times increases the likelihood that patients receive care from surgeons with the skill and knowledge to manage their needs, while relieving primary care clinicians of a significant burden, they wrote.

“Existing referral markets, in contrast, do not protect patients from being referred to inappropriate providers,” they wrote. “Creation of coordinated surgical groups as the receivers of referrals would reduce the risk of patients being treated by unsuitable surgeons, freeing patients and their referring physicians from the obligation of navigating a complex and often confusing referral marketplace on their own.”

The commentary was published on December 8 in CMAJ.

Universal Concierge Service?

Waiting times for surgeries have been a persistent concern in Canada despite many efforts to address these delays. The Canadian Institute for Health Information (CIHI) reported a 26% increase in the annual number of hip replacement surgeries performed in the nation between 2019 and 2024. Yet 32% of patients in need of hip replacement surgery still waited more than 6 months for the procedure last year, CIHI said.

Urbach has led efforts to expand the use of single-entry referral systems for surgery. In addition to publishing analyses of surgical wait times in journals such as PLoS One and CMAJ, Urbach seeks to convey the benefits of this pool approach in simpler terms. In a 2024 interview with the Canadian Journal of Surgery’s Cold Steel podcast, Urbach pointed out that people already are familiar with the premise of single-entry models.

“If you go to most Tim Hortons or banks or whatever, you just join a single line in the beginning, and then at the very end, you just get assigned to the next available person who can provide you a service,” he said.

More public education about the benefits of single-entry referral systems is needed, Urbach told Medscape News Canada. One of the objectives of the CMAJ commentary was to address concerns about the single-entry approach, such as the perceived loss of autonomy for referring physicians and patients.

Few reliable data are available to guide primary care clinicians’ choices of surgeons, Urbach said. A single-entry system would better ensure that patients are treated by surgeons who are more skilled in the relevant procedures than does the current approach of individual referrals, said Urbach.

“These variations in quality of care are not a feature of a system. They’re a bug of the system. And what our job ought to be, to the extent that you can, is to minimize those variations,” he added.

In the CMAJ commentary, the authors proposed greater engagement of specialist groups in directing surgical referrals. The surgeons thus could decide among themselves who would handle which cases, knowing the strengths and weaknesses of their teams. This approach already is used for people with access to meaningful advice in picking surgeons, Urbach noted.

For example, executives at hospitals tend to turn to surgical department heads like Urbach and ask for opinions when their acquaintances need procedures. The leaders of surgery departments then ask their colleagues for advice.

A single-entry approach would make this kind of concierge service more broadly available to the public and ease worries about loss of autonomy, Urbach said. “You can address a lot of these concerns by just changing the way the specialists are organized. They’re not accepting referrals for new consultations independently, but as a group providing the input.”

Interest in single-entry approaches appears to be growing in Canada. Urbach is advising Ontario Health on this issue as part of its Patients Before Paperwork initiative, which includes efforts to expand centralized wait lists for surgical and diagnostic services. One aim is to take “the guesswork out of the referral process” and provide faster access to care for patients.

In 2021, the Canadian Agency for Drugs and Technologies in Health published a review of four examples of centralized approaches in different parts of the country: the Winnipeg Central Intake System, the British Columbia Surgical Strategy, the Nova Scotia Hip and Knee Action Plan, and the Saskatchewan Surgical Initiative.

Preserving Patient Autonomy

Preserving patient autonomy is necessary for building a successful central intake system, Fiona Clement, PhD, head of community health sciences at the Cumming School of Medicine, University of Calgary, Calgary, told Medscape News Canada. Clement has not worked directly with Urbach on this issue.

But she and her coauthors did include Urbach’s research in their systematic review of published papers on central intake systems for managing surgical waiting times. BMJ Open published their review in September.

“It seems like the issues with implementing central triage or single-entry models are really addressable,” said Clement. “Just build in a valve. If we go through a single-entry model, but someone feels very strongly about this patient or not that surgeon, they could go a different way.”

Urbach reported receiving a project grant from the Canadian Institutes of Health Research in support of the present manuscript. Clement reported having no relevant financial relationships.

Kerry Dooley Young is a freelance journalist based in Washington, DC. She has reported on medical research and healthcare policy for more than 20 years.