Cardiovascular Rounds

11 ways Covid-19 could affect the CV service line

by Julie Bass

The past few weeks have brought about unprecedented changes to health care providers as the Covid-19 epidemic continues to escalate across the country. While my colleagues are providing up-to-the-minute guidance on the broader implications on hospitals and the health care system as a whole, I wanted to unpack the specific implications this crisis could have on CV service lines across the country.

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Short-term

  1. Covid-19 and CV disease are inextricably linked, requiring closely coordinated care delivery.

    Initial evidence shows that individuals with CV conditions are at higher risk of complications from Covid-19. Furthermore, many patients who contract the virus are developing CV conditions as a result: Early reports show that up to one-in-five Covid-19 patients develop heart damage, increasing the need for CV consults not only while a patient is in the hospital, but also for longer-term care management. Due to the nature of the disease and the impacted patient population, CV providers and care teams may be at a higher risk of exposure to the virus themselves.

  2. Elective procedures are being rescheduled (or canceled).

    As cases of Covid-19 expand across the country, CDC is recommending that hospitals in counties that are experiencing a high volume of Covid-19 cases—such as counties in California and New York—cancel and reschedule all non-urgent procedures as needed. Hospitals in many other states have followed the recommendation, despite the financial ramifications. While "elective" procedures typically constitute non-emergent cases, many elective CV procedures are still time-sensitive; they prevent potential life-threatening cardiac events. Programs will need to reschedule those as soon as it is appropriate.

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  4. Specialty telehealth services are no longer a 'nice to have,' but now a 'must have.'

    To reduce the need for direct patient contact and to enable patients to stay home, many programs are evaluating opportunities to leverage telehealth during the outbreak. CV service lines are evaluating telehealth for both direct-to-patient virtual visits as well as provider-to-provider consults.

    First, virtual services for patients can minimize the need for in-person contact and enable patient to maintain social distancing. Since CV patients are at higher-risk of developing Covid-19, maintaining social distancing is critical, yet so is receiving ongoing support for their conditions. Additionally, direct-to-patient virtual visits can alleviate capacity constraints and free up provider capacity to treat more emergent patients. Some CV telehealth services, such as virtual cardiac rehab and remote patient monitoring technology, can provide necessary treatment and supervision with remote part-time oversight by a provider.

    Second, CV specialists are extending their reach by leveraging provider-to-provider virtual visits to consult at other sites in their health network. This can help alleviate the need for unnecessary transfers from spoke hospitals to tertiary facilities, which may be experiencing capacity issues due to Covid-19. This also preserve EMT capacity to transfer patients who require more advanced medically necessary services at hub facilities.

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  6. Existing CV patients in your network still need ongoing support.

    CV patients require support now more than ever before, including emergent patients coming through the ED as well as patients with preexisting CV diseases.

    • Emergent patients: For emergent care, CV providers are attempting to efficiently identify and triage CV patients. This task is becoming more complicated as reports have shown that patients presenting to the ED with symptoms similar to heart attack are in some cases in fact due to Covid-19 rather than heart disease. Additionally, there are reports of patients delaying seeking treatment for heart attack symptoms out of fear of contracting the virus at the hospital. This could cause an increase in the level of acuity of heart attack patients in the ED. Both trends are complicating existing care pathways, further amplifying the need for efficient diagnosis and effective triage to maintain ED capacity.

    • Stable CV patients: In addition to navigating CV patients with emergent needs, programs still need to actively manage non-emergent CV patients in their networks. This includes ensuring CV patients have access to medications, reassessing care delivery for patients requiring regular touch-points not easily transitioned to telehealth (e.g., anticoagulation services), and reserving provider time to consult patients.

Mid-term

  1. Managing care team burnout and post-traumatic stress should be a top priority.

    The needs and asks of providers during this pandemic are piling on top of existing stressors for the CV workforce. In addition to exacerbating existing sources of burnout, Covid-19 has introduced additional considerations that may impact the psychological and physical well-being of CV providers for years to come. CV leaders will need to develop strategies to support and help recover from traumatic experiences.

  2. Labs, ORs, and care teams need to accommodate delayed elective procedures and regularly scheduled procedures.

    Operational efficiency will become increasingly important as programs navigate providing care for procedural cases delayed by Covid-19, as well as the standard demand of scheduled CV procedures. At this stage, providers will be evaluating ways to improve efficiency of all elective procedures, such as increasing radial access adoption to improve same-day discharge rates for percutaneous coronary intervention (PCI) patients.

    CV leaders may also consider leveraging local ambulatory surgery centers (ASCs) and office-based labs to reallocate lower-acuity procedures (e.g., loop recorder implants, peripheral vascular interventions) to maximize hospital capacity for higher-acuity cases. There are also underlying questions as to whether evidence from recent trials like ISCHEMIA may be used to determine the necessity and utility of rescheduling some CV procedures that may not be necessary.

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  4. Quality, operational, and financial outcomes will look different than in years past.

    2020 outcomes across the board will likely look different for the CV service line than in previous years. The most obvious may be the variation in volumes and types of services delivered. While volumes of some CV services contribute to the bottom line, others are necessary to achieve credentials and satisfy national requirements. It's unclear at this point how, or if, national coverage determination (NCD) volume requirements for procedures like transcatheter aortic valve replacement (TAVR) may change in light of the Covid-19 pandemic as programs may struggle to meet the PCI thresholds.

    Other industries are flexing threshold policies in response to the pandemic—for example, some airlines have announced lower mile thresholds to achieve preferred status or an extension of existing status through 2021—but volume requirements for health care services are set to maintain quality standards and CMS may uphold by the current annual NCD requirements.

  5. Already long wait times to see a specialist may get longer.

    When in-person patient contact starts to ramp back up, CV providers will be faced with a backlog of delayed appointments with the potential addition of new CV patients recovering from the virus. The national average wait time for a new cardiology patient appointment was 21.1 days in 2017, which could increase over the next few months as a result of the pandemic.

    In response, CV service lines will need to implement strategies to improve outpatient access—whether through continued use of virtual visits and telehealth technology, leveraging advanced practice providers (APPs) and the broader CV care team where appropriate, or other creative solutions, such asexpanded clinic hours.

Long-term

  1. Expect hospitals to look to CV service lines to help improve margins.

    As CV service lines have historically been a growth engine for hospitals, many executive teams will be looking to the service line to help support revenue lost during the pandemic. Health system finances are already feeling the effects of the costs of Covid-19 care, combined with significant reductions in traditional sources of revenue across all service lines.

    For many facilities, the lost revenue from cancelled elective procedures is likely to outweigh Covid-19 revenue. In some dire situations, CV programs may be looking at service closure and hospitals may need to evaluate facility closure.

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  3. The post-pandemic response could accelerate the outpatient shift.

    The pandemic may prompt programs to strategically allocate lower acuity services across the system. In some markets, this may also accelerate competition from ASCs as a more convenient and accessible location to seek treatment for delayed elective procedures.

    This may be a catalyst for programs to think more strategically about how to allocate services across their network to reduce the need for patients to come to the main campus to receive lower-acuity services. In some markets, this may also accelerate competition from ASCs as a more convenient and accessible location to seek treatment for delayed elective procedures.

    The pandemic may prompt programs to strategically allocate lower acuity services across the system. In some markets, this may also accelerate competition from ASCs as a more convenient and accessible location to seek treatment for delayed elective procedures.

  4. We could be treating a different-in-kind CV patient population in the future.

    Researchers and CV providers still do not know the long-term implications of Covid-19 on patients with and without preexisting CV conditions

    Understanding the short- and long-term impacts of Covid-19 on cardiovascular function is paramount, and there are research studies and support services underway to monitors the trends over time. For example, the American Heart Association just launched a new, free Covid-19 patient data registry to provide insight on CV outcomes. CV leaders should monitor for any changes in their patient demographics, and follow the latest society guidance on treating patients in the future.

What else is on your mind?

The Cardiovascular Roundtable team is investigating CV-specific implications to help your short- and long-term response. Let us know how we can be supporting your team during this evolving and trying time by emailing cardiovascular@advisory.com

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