Delaying elective procedures was considered critical to save limited resources, including PPE, hospital beds, and ventilators for potential use in the treatment of COVID-19 patients. It was also seen as a way to protect patients scheduled for elective procedures from potential exposure to COVID-19.
Over the subsequent weeks, governors in 35 states issued executive orders related to elective procedures.1 Most of the regulations in these states included language indicating to proceed with urgent or time-sensitive procedures, placing the onus on clinicians and administrators to make these determinations.
Soon, news stories discussed cancellations of procedures that most people didn’t think of as elective, like lumpectomies or mastectomies performed for breast cancer.
This raises a critical point in discussing elective procedures: While the term “elective procedure” seems to imply a procedure that is optional, the common definition of elective procedure in the medical community is a procedure that can be planned in advance.2
Rather than designating certain procedures as always being “elective,” it is more appropriate to differentiate elective procedures from non-elective procedures based on the reason for the procedure. For example, a coronary angioplasty (PCI) may be done non-electively for a patient who just had a heart attack, but performed electively (planned in advance) for an individual with angina due to coronary artery disease. Understanding this wider definition of “elective” helps us understand the enormous impact of delaying these procedures on the healthcare system.
Magnitude of Elective Procedure Postponement
Data from the weeks following the recommendations showed a dramatic decrease in both inpatient and outpatient procedures. For example, data showed significant decreases in three of the most common inpatient procedures performed in the commercial population. (FIGURE 1)
A study of several, common elective outpatient procedures within geographic regions of the US showed varying but significant decreases across the country. (FIGURE 2)3
Downstream Implications of Elective Surgery Postponement
Many employers and health plans are wondering if there will be a surge in the volume of elective procedures in the second half of 2020. The potential for a surge will be impacted by:
- The percent of never rescheduled procedures
- The capacity to perform rescheduled procedures
- The issues related to the “elective procedure pipeline”
Postponement of elective procedures, particularly those that are considered preference sensitive (other treatment options exist), is likely to result in individuals never rescheduling some procedures due to improvements in patient symptoms. Other individuals, particularly those in areas with higher incidence rates of COVID-19 or at higher risk of serious outcomes from COVID-19, may cancel or further postpone these procedures due to fear of contracting COVID-19. In a recent national survey, eleven percent of individuals with delayed procedures said they would not reschedule, and an additional nine percent would wait at least six months.4
How long will it take to accommodate all of the remaining procedures that are not cancelled or further postponed? Several factors influence the answer, including geographic location, provider capacity, and the effects the pandemic has had on the queuing up of new patients.
First, geographic location will influence the volume of procedures that need to be rescheduled. Postponement of elective procedures in some states spanned about four weeks while other states saw cancellations for about 11 weeks, leading to a far more significant backlog.
Provider capacity is another significant factor influencing rescheduling. If a healthcare provider can typically perform “X” procedures per week, the maximum number of procedures that can be accommodated in the best circumstances is probably an additional twenty percent based on adding one additional workday per week. However, even adding an extra workday may not lead to a twenty percent increase in the number of procedures performed. Many organizations report reduced volume of procedures per day due to issues such as bringing human resources back from furlough, supply constraints, and additional time required for new infection control procedures.5
Will all types of elective procedures ramp up at the same rate? Probably not. The American College of Surgeons has provided guidance that considers both medical and logistical factors, including the availability of necessary resources, in determining prioritization.6 In order to keep their doors open, it seems plausible that financially struggling facilities may also consider the profitability of various procedures as they prioritize procedures to reschedule.
Finally, it has been noted that there has also been a dramatic reduction in patients moving through “the pipeline” for procedures – including new patients and existing patients in various stages of treatment and testing required to determine the necessity for a procedure. This effect actually reduces the number of individuals who will be ready to undergo procedures once the backlog is cleared. As shown in Figure 37, there has been a substantial decrease in outpatient visits to a number of specialties, with surgical specialties being particularly affected.
Given likely cancellations of procedures, delays in rescheduling procedures, and reduction of patients ‘in the pipeline’ for elective procedures, it seems likely that the impact will be an overall reduction in elective procedures in 2020.
The impact of COVID-19 on elective surgery is likely to last beyond the pandemic. One expected impact is the increased rate at which procedures traditionally performed on an inpatient basis, like joint replacements, are moving to outpatient settings in an attempt to reduce potential patient exposure to COVID-19. The use of telehealth for pre- and post-operative assessments, as well as remote instruction for post-acute treatment like physical therapy, are likely to continue after the pandemic.
Opportunities will exist to study how procedural delays impacted decisions to undergo surgery by individuals with preference sensitive conditions. Research identifying characteristics that differentiate patients who ultimately cancelled surgery because their symptoms improved during the delay can guide clinicians in making future recommendations related to the need for surgical intervention.
Our Commitment At Springbuk
As discussed in our blog published on 6/18/2020, Springbuk is committed to helping our clients understand the impact of COVID-19 on many facets of healthcare, including elective procedures. In order to help you understand the impact COVID-19 has had on elective procedures for your population, we will supply reports comparing elective procedure trends in the pre- COVID-19 and current time periods. Within our solution, Insights™, users can also find supporting information on elective procedures to mitigate risk in categories such as Steerage: Procedures and Potentially Unnecessary Procedures. Additionally, trends and information related to the place of service for many specific procedures are already available within Answers™.
3https://blog.definitivehc.com/when-do-elective-surgeries-start-at-us-hospitalsBased on year-over-year changes for calendar weeks 12 – 17
4Jarrard, Phillips, Cate & Hancock, National Online Coronavirus Survey, April 2020
7Ateev Mehrotra et al., “The Impact of the COVID-19 Pandemic on Outpatient Visits: A Rebound Emerges,” To the Point (blog), Commonwealth Fund, May 19, 2020. https://doi.org/10.26099/ds9e-jm36