Discussion
This retrospective population-based study highlighted the demographic trends of ophthalmic surgical wait times from 2010 to 2021 in Ontario, Canada. Consistent with previous reports and epidemiological data, more women undergo ophthalmic surgery (56%).30 While men represent a higher proportion of high-priority cases in our data set, it is important to note that women experienced longer wait times across all priority levels when compared with their male counterparts within the same priority category. The proportion of women undergoing ophthalmic surgery is slightly higher than the general Ontario population, which has 50% women overall and 54% women in the 65-or-older age group.31 Our study also shows that the average age at the time of ophthalmic surgery has been rising slowly over the last decade, and women are slightly older than men. The most striking finding of this study is that there are sex-based differences in surgical wait times, where men have shorter wait times compared with women across ophthalmic subspecialties, geographic regions and levels of priority. Although the difference in wait time might seem modest in terms of absolute difference when compared with the mean wait times, it is important to consider the cumulative impact of these differences on patients and the healthcare system as a whole.
It is important to note that our study included data from the COVID-19 pandemic period (2020–2021), which has had a significant impact on healthcare systems and patient care. The disparities in wait times between sexes observed in our study existed prior to the pandemic, and recent work highlights that these disparities have been gradually worsening with time, especially during the pandemic.32 In fact, the COVID-19 pandemic exacerbated pre-existing wait time disparities between sexes, with women waiting 4.1 days longer than men overall to receive surgery in 2010–2019 compared with waiting 8.8 days longer in 2020–2021 (117% increase) in Ontario, Canada.32 This suggests that the pandemic has further intensified the systemic sex-based biases that may be affecting the care of women.
Overall, men waited 5 days less for surgery than women in our study, with oculoplastic and corneal procedures having the greatest difference. Women experienced longer wait times across all priority levels and geographic regions, with medium-to-high priority levels and Toronto Central, North West and North Simcoe Muskoka LHINs having the greatest disparities from 2010 to 2021. Previous studies have also investigated sex-based differences in surgical wait times with varying results depending on the medical specialty, region and data availability. A study based in the USA found that women had a 2.95-day delay in receiving retinal detachment repair surgery compared with men along with 34% reduced odds of receiving surgery.33 Similarly, a study based in Japan found that men had 83% higher odds of early (within 1 week) retinal detachment surgery compared with women.34 In our study, women waited 4.6 days longer than men on average for retinal surgeries.
Aligned with our study findings, an analysis of data from the Swedish National Cataract Register found longer waiting times for women that persisted across priority levels. Women waited 6 days longer than men, and this difference increased proportionally with increasing overall waiting times.35 Another study in Sweden found that longer waiting times were associated with good visual acuity, older age, low income, low level of education and being women.36 They found that even when adjusting for factors unrelated to wait time in addition to month of operation and surgical centre, women persistently waited 3.7 days longer than men for cataract surgery.36 When intersecting multiple inequalities together, such as a low-income female patient with no education, the authors found that wait times additively increased.36 Similarly, in our study, women waited 3.6 days longer than men for cataract surgery and this difference persisted across all priority levels and geographic regions.
Beyond ophthalmology, the differences in wait time between men and women are more variable. For example, a longitudinal analysis of bariatric surgery wait times in Ontario found that men had significantly increased odds of longer wait times, with an effect size of 34 additional days compared with women.37 Conversely, another Ontario-based study that used the full WTIS database found that women waited 3.1 days longer than men across all surgical specialties.38 Other studies outside of Ontario have also demonstrated significant sex-based differences in wait times, such as in female Medicare beneficiaries waiting 13% longer to undergo pancreatectomy,39 female trauma patients experiencing longer delays in trauma care40 or women with shoulder injury waiting 18 days longer than men to receive surgery.41 Some reports have also shown differences in specialist referral wait times, such as one in Southwestern Ontario that found female patients waiting 4 days longer than men to see a specialist.42
The wait time differences discovered in this study may be suggestive of systemic sex-based biases. These biases may be affecting the care of women or other groups in other meaningful ways that are not currently measured. Previous studies have suggested that a complex interplay of sociopolitical and cultural factors, such as taking on the role of a caregiver and postponing appointments for the sake of other family members, has contributed to women having longer wait times.41 43 While this may be true and contribute to the wait time disparity along with other patient factors, it will be equally as important to further investigate the practice patterns and surgical referrals of ophthalmologists or other physicians in Ontario and beyond. It should also be noted that currently less than a third of all Canadian and Ontario ophthalmologists are women, and despite this being the largest proportion of women in Canadian history, ophthalmology is still severely lagging behind most other medical specialties.17 44
The average patient age at the time of eye surgery has been gradually increasing at a rate of +0.02 years/year over the past decade across all ophthalmic specialties, though this is at a much lower rate compared with the general Ontario population over the same time period (+0.18 years/year; 95% CI (0.15 to 0.20)).31 However, patient groups in the cornea, glaucoma, strabismus and oculoplastic subspecialties have been outpacing general population growth over the last 10 years, and have been doing so primarily in the Toronto Central region. This may be due to a variety of reasons, including greater accessibility to resources and availability of doctors and social supports, improvements in practice standards and enhanced screening which results in elderly patients having higher chances of receiving eye surgery. We also found that Ontario women on the wait list for eye surgery were slightly older than men across all ophthalmic subspecialties with the exception to oculoplastic surgery, and that this difference increased with increasing priority level. The general female population in Ontario is noted to be 1.8 years older than men on average.31 As such, the difference in our study is likely attributable to the fact that women represent the majority of patients receiving ophthalmic surgery and are older than men due to their higher life expectancy.31 45
Each of the 14 LHINs of Ontario had longer surgical wait times for women compared with men. The Toronto Central LHIN, which has the highest ratio of ophthalmologists per 100 000 in Ontario (8.87), also had the greatest overall difference in wait times at 9.3 days.46 This pattern did not persist for most other LHINs. For example, the North Simcoe Muskoka region had the third highest wait-time disparity at 6.7 days, yet it has one of the lowest ratios of ophthalmologists per 100 000 at 2.05.
Limitations and future directions
The authors would like to acknowledge limitations to this study. First, this was a retrospective study using aggregated data limited to the province of Ontario. Due to the limitations of our retrospective study design and the aggregate data available in the WTIS database, we were unable to adjust for patient-level and hospital-level covariates in our analysis. We also did not have data on the time from primary care referral to diagnostic work-up, nor did we have data on the time between surgical consultation and the day of operation. Furthermore, the WTIS database only collects patient sex, not gender or other self-reported identities. Thus, the findings of this study may not represent the true wait-time differences between self-identifying men and women, and they also do not incorporate potential disparities that may be experienced by non-binary individuals.47 Additionally, there may be some variability with respect to patient priority-level assignments in the WTIS database (eg, one high priority case being worse than another, or a high priority case which should have been classified as medium priority) that may have affected results. Finally, as we only have access to aggregated data, we cannot verify or account for any potential repeated measures. However, it is important to note that the waiting times reported in this study are not self-reported by patients, but rather are collected automatically through administrative information technology systems, which minimises the likelihood of reporting errors or biases. Future studies may explore the associations in the observed trends with important patient and provider characteristics.
