August 18, 2021

Hospitals are delaying elective surgeries again. But this time, they're doing it differently.

Daily Briefing

    As Covid-19 cases surge, some hospitals are once again delaying elective surgeries. But based on their experiences postponing surgeries last year, they're now being more selective about what procedures they're deeming "elective," Claudia López Lloreda reports for STAT News.

    3 scenarios for Covid-19—which will shape the volume outlook for providers in 2021?

    The dangers of delaying "elective" surgeries

    The term "elective" is used to describe a surgery that doesn't need to be done immediately "to maintain life or limb," Brian Cole, chair of surgery at Rush Oak Park Hospital, said. "But it's a very nebulous term to call something elective."

    At the start of the pandemic last year, virtually all scheduled operations were deemed "elective." But studies of the affected patients reveal that those delays may have led to significant health consequences.

    For example, one study from Mount Sinai Hospital found that, following delays in transcatheter aortic valve replacement surgeries, 10% of affected patients experienced a cardiac event within the first month, and 35% experienced such an event within the next three months.

    Another study from the University of Bern in Switzerland similarly found that delaying aortic valve replacements increased patients' risk of experiencing hospitalization and worsening heart failure.

    And a report from the British Heart Foundation estimated that there were 5,800 excess deaths from heart and circulatory conditions in the United Kingdom in 2020 due to delays in cardiology care related to Covid-19.

    Some providers also say that, as a result of care disruptions over the last year, some patients now have more serious needs. For instance, surgeons at Covenant High Plains Surgery Center in Texas noted about a 10% increase in the severity of conditions among patients entering the hospital. "Patients who had delayed their procedures may have had more complex procedures or may have come in sicker as a result," Alfonso del Granado, administrator and CEO of the center, said.

    How some hospitals are choosing which surgeries to delay

    Now, as Covid-19 cases surge in many states, hospitals are being forced to decide once again which surgeries they will delay. In Texas, for instance, Gov. Greg Abbott (R) asked providers to delay some elective surgeries to free up hospital beds.

    "It's just agonizing to have to go through this with our patients again," said Avital O'Glasser, medical director of the preoperative medicine clinic at Oregon Health and Science University Hospital. She added that, while her hospital has yet to delay any surgeries, "it's mentally and emotionally tough to be staring down this possibility again."

    Some hospitals are being very deliberate about which procedures they deem to be "elective." At Vanderbilt University Medical Center, for example, doctors evaluate cases every morning to determine which procedures can be rescheduled based on the specifics of each case.

    In Oklahoma, Tulsa Bone and Joint Associates has been delaying some—but not all—elective orthopedic procedures for lack of hospital beds. "[T]otal joint replacement, we could delay that," Wesley Stotler, an orthopedic surgeon, said. "But a fracture has a healing time and could heal in the wrong position if we do not fix it appropriately and in a timely fashion. Those are more urgent cases."

    In other instances, the coronavirus more directly forces delays in procedures. "Just the other day, I had to cancel an elective surgery because the patient walked into the building and she was Covid-positive and sick," David L. Holden, an orthopedic surgeon and president-elect of the Oklahoma State Medical Association, said. "So we had to send her home."

    Some providers argue that even patients whose conditions may not seem critical could still face cascading consequences if their procedures are delayed.

    Seth Trueger, an emergency physician at Northwestern Medicine, gave the example of a patient with a scheduled knee surgery. He said that if that procedure is delayed, the patient could suffer chronic pain that could prevent them from exercising, which could in turn lead to other conditions.

    "There are clearly conditions that, if neglected and go without surgery, will end up in a different place later on if that surgery does not occur," Cole said.

    To avoid canceling surgeries, hospitals that are part of larger systems could consider transferring patients to affiliated hospitals in areas where Covid-19 case counts are lower, Lloreda reports. However, that strategy won't work in places like Florida or Texas, where cases are surging throughout the state.

    Ultimately, experts told Lloreda that the problem won't be resolved until Covid-19 case counts decline. Then, hospitals will be able to reliably schedule elective surgeries again. (Lloreda, STAT News, 8/13; Keefover, KTUL, 8/13; Svitek, The Texas Tribune,  8/9)

     

    Advisory Board's take

    3 reasons why elective surgery planning will be different this year

    By Lauren Lawton and Colin Gelbaugh

    As we navigate the current delta surge in the United States, some hospitals and health systems are again postponing elective surgeries. The decision to pause cases is a necessary one for many organizations dealing with an influx of Covid-19 cases and staffing shortages. But, as this STAT article highlights, this year is different even during the moments of déjà vu.

    Why will we not see the same degree of elective surgery postponements compared to prior surges? We've highlighted three reasons.

    1. The context of Covid-19 is different than before.

      Don't get me wrong—what we are seeing in the current delta surge is scary and frustrating, but we should acknowledge the difference in context. In 2020, providers were attempting to navigate through uncharted territory with supply shortages, evolving care standards, and a concerned public. Now, we are in a much better position to provide adequate PPE to health care workers and patients. We also have experience with necessary changes to hospital operations such as screening patients and separating infected from non-infected patients. And, of course, we now have vaccines that reduce the risk of severe Covid-19 cases and a better understanding of how to treat those that do require hospitalization.

       

    2. There are negative effects of postponing elective cases.

      Postponing elective cases can cause serious detriment to patient health and wellbeing, which should prompt some serious deliberation. The STAT article exemplifies the seriousness of delayed procedures on preventative measures like cancer screenings and cardiac operations. Numerous studies have recorded excess mortalities across 2020 that are likely due to these disruptions in care for those with non-Covid-19 health needs.

      Additionally, hospitals now understand the degree to which elective surgeries support their bottom line and ability to sustainably operate. We recognize that each health system operates differently, so we developed a tool can help estimate the revenue an organization may lose from postponing or cancelling elective surgeries during Covid-19. This allows you to see not only total volumes and revenue lost, but also the number of weeks required to clear backlogged volumes.

       

    3. Hospitals can (and should) be more selective about which cases to postpone
    4. As the STAT article highlights, rather than a full, generalized pause in electives, many hospitals and health systems are now reviewing elective on a case-by-case basis to determine what can be safely postponed. And they are doing the right thing—many health systems have the experience and tools to narrow in on which cases truly need to be postponed. For example, health systems have experience with which types of care can be shifted to alternate sites during times of surge. We've seen health systems utilize ASCs, home care, and partnering hospitals to treat patients when surge scenarios occur.

    In order to be selective, hospitals will need to prioritize their elective services. We've written about how to do this in depth, and the following are the main steps to follow in the prioritization process:

    • Tier elective procedures based on clinical urgency and position in care pathway. There are several options for grouping based on clinical urgency, including published guidance by the American College of Surgeons (Elective Surgery Acuity Scale and Medically Necessary Time-Sensitive (MeNTS) Prioritization) and CMS. 
    • Compare strategic and financial importance of elective procedures. Look at average margin per case to identify the most profitable cases. Consider pre-crisis market share to identify services where you have a competitive edge. Systems should prioritize services with existing high market share to ensure they can maintain market position.
    • Assess feasibility of providing elective procedures. Determine how feasibly your organization can safely offer elective procedures, based on capacity, labor, and supply constraints, as well as testing availability.

    It is worth noting that staffing shortages and burnout are variables that many hospitals are still confronting. Some organizations may have to operate at reduced capacity, by postponing electives, due to these factors. But the state of the pandemic has changed compared to 2020, and your approach to elective procedures should be different as well. If you are unsure where to start, these considerations may help guide your strategy.

    Andrew Mohama contributed to this piece

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