This article was first published on Linkedin on 17th March, 2020
It’s now an ominous rule of thumb that we can predict the future of #Coronavirus by looking to Italy: currently, the number of United States infections is tracking some 10-15 days behind, and this imperfect crystal ball has at least allowed us to grasp the general contours of the coming crisis. We can see that the next phase is health care capacity as hospitals and Intensive Care Units (ICUs) gird themselves for this unprecedented challenge.
While Italy’s infection rate can give us a general sense of what the United States will face next on a societal level, elective surgery data may help us fill in some of the specifics as to where and when hospitals might be most challenged by a surge of new #COVID19 patients.
Because Covid-19 is a respiratory disorder, a minority of patients who require hospitalization will require ventilator support due to pneumonia-related complications. Such complications are typically treated in Medical/Surgical ICUs. ICU capacity is limited and can be quickly overwhelmed. This requires hospitals to use every lever at their disposal to reallocate short-term capacity and qualified personnel from all core activities to emergency response.
A drop in elective surgeries is a powerful indicator of looming capacity challenges. My company, caresyntax, provides data solutions to help caregivers more efficiently manage surgical and perioperative care-- so we track this data closely. Our research shows that in the middle of the Wuhan outbreak, Chinese elective surgery volume went down to zero. The current situation in Italy follows the pattern. Elective surgery constitutes 90% of all surgeries in the United States. As of last Friday, the Surgeon General of the United States advised canceling elective surgeries:
And we see the first evidence that capacity may be shifting from elective and non-emergency acute care to Covid-19 response:
- Through the end of last week, March surgical volume in our U.S sample looked largely intact, even slightly increasing by 2% relative to the prior month
- Nevertheless, we see the first evidence of reductions in the larger metropolitan areas with populations of 1 million or more; March volume has dropped by more than 11%
- Knee and Hip are the most common elective surgeries, especially among senior citizens; unsurprisingly, they experienced the biggest drop, decreasing over 20% in total in March
- More alarming, we’ve observed a palpable drop of up to 15% in the more acute oncology treatments such as cervical cancer hysterectomies
Elective surgeries won’t go to zero uniformly around the country, nor do they represent the entirety of added capacity that hospitals will need. In New York, for example, Governor Cuomo estimates that cancelling elective surgeries would increase hospital capacity by 25-30%. Healthcare systems will do everything they can to add capacity wherever else is possible too. And patients themselves may choose to cancel elective surgeries rather than risk exposure in a hospital setting— and the degree to which they do so will vary from one state to another. But in general, closely analyzing and modeling the variation in scheduling and cancellations of elective or even more acute surgeries across different markets may give hospitals an earlier indication of a surge in COVID-19 patient volume and a better assessment of overflow risk in Intensive Care Units.
Our preliminary analysis shows that the highest cancellation rates for elective surgeries have been seen in the New York, New Jersey and Pennsylvania area, consistent with the recent jump in Coronavirus cases. We also see the South Atlantic area, including Florida and South Carolina, reporting less dramatic, but increasing procedure drops in more acute oncology cases. This could be related to the specifics of the hospital emergency response, a higher risk patient population, or an earlier stage outbreak cluster.
* Original date of first reported case of COVID-19
How hospitals go about this shift will have a huge impact on outcomes. It’s paramount for hospitals to be extremely data-driven in the decisions they are making as they scale down surgery volume as safely as possible and accurately assess patient demand and supply utilization of scarce ICU assets and staff. Anything they can do to more efficiently reallocate resources to higher acuity areas is crucial.
I’ll be monitoring this surgery data and keeping you updated, as it can be a powerful leading indicator for the most significant capacity shifts around the country—and it can help us equip hospitals with the best possible information to overcome this unique challenge.
As we look further ahead, we anticipate a profound ‘rebound effect’--a second wave of capacity issues as the backlog of postponed non-critical surgeries overflows—that will represent another set of challenges for hospitals for the rest of this year and beyond. It will impact the entire healthcare industry as hospitals’ forward-planning is set aside to handle the immediate Coronavirus response, insurers work to determine appropriate risk models, medical device reps temporarily lose access to hospitals, and normal course training opportunities for residents, med students and staff become more limited. I’ll discuss more of these medium-term trends in the days to come.