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September 23, 2021

Is it time to stop calling surgeries 'elective'?

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    Due to recent surges in Covid-19 cases, many hospitals in the United States have been forced to delay "elective" and "nonessential" procedures again. But those labels sometimes refer to critical surgeries, prompting one medical sociologist to suggest a new way of describing certain procedures.

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

    Hospitals delay 'elective' and 'nonessential' care

    Over the past two months, as the delta variant has spread throughout the United States, hospitals in Covid-19 hot spots have been overwhelmed, forcing some to delay care and turn away patients as they grapple with overflowing EDs and ICUs.

    "We are facing a dire situation," said Marc Harrison, CEO of Intermountain Healthcare. Earlier this month, Intermountain announced it would delay almost all non-urgent surgeries.

    "We do not have the capacity at this point in time to take care of people with very urgent conditions yet are not immediately life threatening," Harrison said.

    In Idaho, state officials enacted "crisis standards of care" at hospitals throughout the state. "We don't have enough resources to adequately treat the patients in our hospitals, whether you are there for Covid-19 or a heart attack or because of a car accident," Dave Jeppesen, director of the Idaho Department of Health and Welfare, said.

    Hospitals in Idaho have not only postponed hip replacements and hernia surgeries, but are now also postponing cancer and heart surgeries, according to Brian Whitlock, CEO of the Idaho Hospital Association.

    In addition, many hospitals are still dealing with the backlog of postponed surgeries created early in the pandemic along with the current surge in Covid-19 patients.

    John Mann, a surgeon who oversees surgical and specialty care services for Novant Health in North Carolina, said, "[C]ompared to March and April, our ED volumes are at all-time highs … It's every illness imaginable. They're all coming in for care."

    Are 'nonessential' procedures really nonessential?

    Because of these delays, many patients have been left waiting for their so-called "elective" or "nonessential" procedures to cure ailments causing them real pain.

    "The term 'elective care' can be misleading," said Joseph Sakran, a trauma surgeon at Johns Hopkins Hospital. When elective procedures are delayed, some patients are forced to "prolong their suffering," Sakran said.

    Robin Strong, who lives in Columbus, Ga., was told that her surgery to repair a vocal cord that had been paralyzed in a previous surgery would be delayed due to the surge in Covid-19 cases. As a result of the condition, Strong chokes easily and has difficulty breathing. "I just cry all the time because of my situation," she said.

    Emily Lipstein was scheduled for excision surgery for endometriosis, but it was delayed indefinitely at the start of the pandemic and deemed nonessential. "It felt like everything I'd been looking forward to with my health just evaporated into thin air," Lipstein said. Since her surgery was delayed, Lipstein has had to pay for an additional MRI scan and experienced mental health issues that are now treated with antidepressants.

    Matthias Merkel, senior associate CMO for capacity management and patient flow at Oregon Health & Science University, said delaying certain elective procedures "might medically make no difference, but emotionally it could have a huge impact."

    Research has found that over 90% of surgeries in the United States are considered to be elective or nonessential. But defining what care is "essential" has been "an ongoing challenge for insurance companies," said Jesse Ehrenfeld, a physician and chair of the American Medical Association's board of trustees, which "leads to a lot of individual decision-making … that is inconsistent."

    Writing for Vox, Andréa Becker, a medical sociologist and teacher at Lehman College, proposed a new way for categorizing procedures. Rather than a binary system of essential and nonessential care, Becker proposed a tiered system, "group[ing] different types of care based on varying degrees of urgency."

    For example, the tiers could be "emergency," "immediate urgency," and "routine." Emergency procedures would "still describe risks of imminent death or severe harm," while routine procedures "would refer to primary care, preventative screenings, and genuinely cosmetic procedures."

    Meanwhile, immediate urgency procedures would include "acute cases that aren't life-threatening but require attention within 24 hours, such as a broken bone or a wound that needs stitches," as well as procedures that could "increase mortality risk, reduce quality of life, or negatively impact mental health."

    "Nonessential does not mean it doesn't need to happen," Virginia Kuulei Berndt, a medical sociologist and professor at Texas A&M University, said. "Elective does not mean superfluous." (Abelson, New York Times, 9/22; Becker, Vox, 9/20)

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