key: cord-0737679-glrgm2le
authors: Gupta, Ryan; Mouawad, Nicolas J.; Yi, Jeniann A.
title: The Impact of the COVID-19 Pandemic on Vascular Surgery:Healthcare Systems, Economic, and Clinical Implications
date: 2021-07-17
journal: Semin Vasc Surg
DOI: 10.1053/j.semvascsurg.2021.06.003
sha: 77875e41e05e43b10ac3389dcbf47e6eafe9869c
doc_id: 737679
cord_uid: glrgm2le

The novel coronavirus SARS-CoV-2 (COVID-19) pandemic is responsible for over 500,000 deaths in the United States and nearly 3 million worldwide profoundly altering the landscape of healthcare delivery. Aggressive public health measures were instituted and hospital efforts became directed at COVID-19 related concerns. Consequently, routine surgical practice practically halted resulting in billions of dollars in hospital losses while pandemic costs escalated. Navigating an uncertain new landscape of scarce resource allocation, exposure risk, role redeployment and significant practice pattern changes has been challenging. Furthermore, the overall effect on the financial viability of the healthcare system and vascular surgical practices is yet to be elucidated. This review explores the economic and clinical implications of COVID-19 on the practice of vascular surgery in addition to the healthcare system as a whole.

The novel coronavirus SARS-CoV-2 (COVID-19) was first identified in December 2019 in Wuhan, China, before spreading to the United States (US) and starting a rapid national breakout by March 2020 1 . To date, this has resulted in nearly 3 million global deaths and over 500,000 deaths in the US 1 . In the wake of patients deferring hospital exposure and the diversion of healthcare resources to emergent care, demand for non-COVID care plummeted resulting in US hospitals collectively losing approximately $50 billion per month during the peak months of the pandemic 2 . Furthermore, the deferral of usual care in addition to COVID-19 related sequelae has significantly impacted the health of vascular surgery patients. Herein, we describe the effects of COVID-19 on healthcare and specifically vascular surgery from a systems, economic, and clinical care perspective as well as offer insights into the ongoing recovery phase of the pandemic.

Common resource databases were utilized and searched to identify current literature on the subject of financial sequelae from the COVID-19 pandemic. Search terms included economic, financial, health systems, and clinical impact from COVID-19.

Identified articles were reviewed by the authors and the most representative of these works were included in order to provide a thorough review for the purpose of this article.

This review was intended to be a contemporary perspective of the known economic, health systems, and clinical implications of the COVID-19 pandemic encompassing the most up to date information, with known limitations due to the available data and the ongoing nature of this health crisis.

The global pandemic of COVID-19 has led to unprecedented public health challenges due to the severity of the disease, the breadth of its impact, and the rapidity of its infectious spread. Within a few weeks, the COVID-19 public health emergency (PHE) overwhelmed current healthcare resources, especially in densely populated cities, forcing clinicians to make very difficult triage decisions about the types of care and interventions offered to patients during a time of resource scarcity. Not surprisingly, these effects transcend national borders onto the global scalea recent report by the CovidSurg Collaborative projected that 28.4 million surgeries worldwide would be canceled or postponed in 2020 3 . In order to stratify the urgency of procedures and surgical care, tier classifications were designed to focus on preserving scarce resources and human capital, maintaining optimal patient outcomes, reducing exposure risk, and upholding the necessary public health measures of physical distancing [4] [5] [6] [7] .

Vascular surgery procedures can require a significant amount of equipment and resource allocation, not only in the operating suite but also postoperatively in critical care unitsa particularly scarce resource during the COVID-19 PHE. Therefore, there was early recognition of the need to limit operative capacity to only emergent and/or urgent procedures. In some geographic regions affected disproportionately worse like Michigan, guidelines were developed by independent health systems that were ultimately shared with national programs 8 . Rapidly, however, guidelines were set forth by national surgical and specialty societies such as the American College of Surgeons (ACS) and the Society for Vascular Surgery (SVS) to triage vascular surgical care during the time of resource scarcity 4,6,7 . These tier systems created a graduated hierarchy of treatment urgency where life-and limb-threatening procedures take precedence for intervention and were assigned a high priority; this served as an effective method to decrease vascular surgical volumes during the pandemic with minimal increase in patient morbidity. Attaching this system to a SURGCON (Surgical Activity Condition) and VASCCON (Vascular Activity Condition) framework has been further suggested to provide more granular specialty-specific and relevant clinical guidance for vascular surgery triage although the combination has not been currently validated 7,9 . Mouawad et al. conducted a cross-sectional survey of over 530 practicing vascular surgeons in the US during the height of the pandemic 10 . The overwhelming majority of respondents (>91%) noted elective surgery cancellation despite no regional variation in the presence of COVID-19 operating room protocols, availability of personal protective equipment and adherence to national surgical standards 10 . In the in-hospital setting, only 8.3% of respondents were still performing elective cases focused primarily on dialysis access, followed by aortic repair and lower extremity revascularization The COVID-19 PHE also caused a dramatic shift in most vascular surgeons' practices. Aziz et al found that 82% of vascular surgeons were operating at VASCCON 3 ("severe limitations of non-emergency surgery") or lower during the early pandemic, indicating higher acuity with greater limitations in surgical care 24 . Many reported decreases in clinic referrals, inpatient consultations, and emergency department consultations as well 24 . While the majority noted that these limitations lasted 4 weeks or less, survey respondents in lower VASCCON levels reported longer durations of practice changes as well 24 . Thus, providers in COVID surge areas seemed disproportionately affected by these disruptions. decreased by 51% and professional claims reimbursement decreased by 54%, while hospital claims reimbursement decreased by only 47% 27 . Clearly, the overall impact on vascular surgery has been profound.

The severity of the COVID-19 PHE required an unprecedented mobilization of national healthcare resources and workforce in response. However, this also resulted in a dramatic shift in the allocation of such resources within medicine. The need to minimize exposures and limit valuable items such as personal protective equipment (PPE) necessitated an extensive triage of common medical problems on a national and global scale. As such, many medical practices shut down, both temporarily and permanently, and most hospitals limited non-COVID care to emergencies only. Though these measures in response to the COVID-19 PHE were appropriate, it has caused a tremendous and historic negative economic impact on the healthcare industry.

Early in the COVID-19 PHE, estimated losses in US hospitals were $50.7 billion per month 2 . The most recent estimate of total losses sustained by the US healthcare system is over $320 billiona staggering amount 28 . In March 2020, an unprecedented 42,500 jobs were lost in the healthcare sector 29 . A report by the Medical Group Management Association found that 97% of medical group practices experienced a negative financial impact during the COVID-19 pandemic. In US hospitals, inpatient admissions decreased by 30%, emergency room visits decreased by 40%, and observation services decreased by 47% 30 . Practices reported on average a 60% reduction in patient volume 31 . Providers experienced pay cuts, furloughs, layoffs, or early retirement due to the financial pressures of the pandemic, and many remain at risk of losing their practices given the lack of revenue 32 . In addition to lost revenue, the need for PPE, screening and testing of patients and staff, and capital costs related to the expansion of telehealth technology are all novel expenses now essential to practicing medicine in the COVID-19 era 33 . Furthermore, caring for COVID-19 patients has come at significant expense; the cost for treating a COVID-19 patient begins at around $20,000 and can increase to more than $80,000 if requiring ventilator support 2 .

However, reimbursement for their care often does not match their complexity and the loss from COVID-19 care alone was $36.6 billion from March -June 2020 in US hospitals 2 .

On March 14, 2020 the US Surgeon General recommended ceasing all elective surgeries 34 . This was in line with several societal recommendations as well as local governmental mandates to limit exposures and concentrate valuable healthcare resources towards the care of COVID-19 patients 6, 35 . While a necessary intervention, the cessation of nearly all elective operations had a major financial impact on the US healthcare system. During the first four months for the COVID-19 PHE, US hospitals lost an estimated $161.4 billion in revenue from the cancellation of elective services including surgeries 2 . Generally, elective operations involve the highest margin of reimbursement and surgical volume often accounts for nearly half of a hospital's revenue 33 . Additionally, overhead related to operating room facilities and equipment persisted despite the lack of surgical revenue. Considering the median operating margin of 2% for US hospitals, this has resulted in a precarious financial situation; ambulatory surgery centers, whose profitability similarly rely on operative volumes, remain even more vulnerable due to their smaller budgetary margins 30, 36 .

The Coronavirus Aid, Relief, and Economic Security (CARES) Act included several measures intended to lessen the financial burden on the healthcare system. It allocated $100 billion in emergency funds distributed to providers with lost revenue due to COVID-19, of which $10 billion will go directly to hospitals in high COVID areas and $10 billion to rural health clinics and hospitals 36 

The greatest financial losses sustained were in the first four months of the COVID-19 PHE 28 . Encouragingly, many markers of healthcare productivity have returned to pre-pandemic levels. One major hospital's vascular surgery division found that their margins returned to within 1% of pre-COVID levels by month 4 of the PHE 28 .

However, to regain financial equipoise will still require ongoing efforts to counter those losses. Increased productivity to recover these losses has been encouraged. One group estimated that a 10% increase in productivity would require 15-16 months to recover the financial losses from the first three months of the pandemic 28 . With a more realistic increased productivity of 5%, this would still require 31-32 months 28 . A separate financial modeling study of an academic university vascular surgery practice determined that increasing revenue by 10%, 5%, or 3% above pre-pandemic levels would lead to recovery of pandemic-associated losses by 9 months, 19 months, or 31 months Added to this is the mounting pressure to address the surgical backlog created by the COVID-19 PHE 48 . As surgical services recover and expand in an attempt to address this backlog and recover financial losses, consideration must be given to creating transparent algorithms for patient prioritization, increased surgical capacity through utilization of outpatient care, and increased perioperative efficiency while maintaining safe COVID-19 operating protocols 49 . Thus, ongoing advocacy efforts for continued aid for the healthcare workforce remain critical as the path to financial recovery is clearly a long and arduous one.

At the peak of the pandemic, demand for healthcare beyond COVID-19 fell as patients [54] [55] [56] . Numerous studies have demonstrated the increased incidence of ALI during the pandemic and the devastating associated outcomes [56] [57] [58] [59] [60] . Multiple studies reported an increased ALI incidence during the pandemic in Lombardy, Italy, one of the hardest COVID-19 struck regions in the world; 305 referred vascular surgery patients at the peak of the pandemic were analyzed, and although only 21% were found to have COVID-19, two-thirds of ALI cases occurred in COVID-19 positive patients 56, 59 . COVID-19 ALI patients were more likely to die or incur major adverse event including amputation than ALI patients without COVID-19 56 . In another epicenter of COVID-19, New York City, 12,630 patients were treated at Northwell Health System and 49 patients were diagnosed with ALI; 45% of the patients had ALI as their presenting symptom prior to COVID-19 diagnosis. A staggering 46% of ALI patients died in the hospital and limb loss occurred in 18% of patients 57 . Chronic limb threatening ischemia (CLTI) patients also fared worse during the pandemic with increased limb loss during the pandemic 61 . Reports of other sequelae from COVID-19 associated hypercoagulability and endothelial damage have also been reported such as increased aortic thrombus and aortitis 55, 62 .

Typical standards of care were not always achievable during the pandemic, and alteration of normal protocols was necessary. To assist in appropriately triaging care during the pandemic, surgical societies such as the ACS and the SVS provided guidelines that were implemented in many institutions nationwide as previously noted 9 .

During this period, alterations were also made to treatment algorithms such as This unique clinical situation has led to the inception of the Vascular Surgery COVID-19 Collaborative (VASCC), a combined international effort to help obtain prospective data on the impact of widespread vascular surgical care delays due to the COVID-19 pandemic that is currently ongoing 67 .

As we look forward to recovery with increasing vaccination rates in the U.S. on track to be available to all Americans by the summer 2021, we also must contend with the enormous financial losses and multifaceted negative effects on patient health that occurred during the pandemic. A 35 hospital analysis of vascular surgery groups found a 90% backlog averaging 700 cases that could take up to 8 months from which to rebound 68 . At the same time, dropping reimbursements, which have been criticized by the SVS and ACS, could result in significant revenue decreases and place additional financial strain on surgical operations 69-70 . However, certain lessons from the pandemic stand to improve vascular surgery care including using space and staff flexibility to care more efficiently for more patients, implementing previously underutilized technology such as telemedicine to reach more patients, and internalizing the need to make extra efforts to extend our medical care to the most disadvantaged individuals in our communities 71 . As hospital systems' financial recovery is underway, it is likely that process improvement and value-based healthcare will be foundational in addressing the need for increased efficiency and revenue generation. In this coming period it is essential that the field of vascular surgery continues to advocate the valuable care that vascular surgeons provide to hospitals. As outlined by Powell 

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. 

An interactive web-based dashboard to track COVID-19 in real time

Elective surgery cancellations due to the COVID-19 pandemic: global predictive modelling to inform surgical recovery plans

American College of Surgeons COVID-19 guidelines for triage of vascular surgery patients

How to risk-stratify elective surgery during the COVID-19 pandemic?

American College of Surgeons COVID-19: Recommendations for Management of Elective Surgical Procedures

Vascular surgery activity condition is a common language for uncommon times

The initial experience and response of vascular surgeons in Michigan during the COVID-19 pandemic

Vascular surgery triage during the coronavirus disease 2019 pandemic

The impact of the COVID-19 pandemic on vascular surgery practice in the United States

Strategy for the practice of digestive and oncological surgery during the Covid-19 epidemic

Neurosurgical Practice During the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Pandemic: A Worldwide Survey

Academic Ophthalmology during and after the COVID-19

Reply To The Article "Bariatric Surgical Practice During the Initial Phase of COVID-19 Outbreak

Published in Obesity Surgery

Managing central venous access during a health care crisis

The COVID-19 Pandemic and Acute Aortic Dissections in New York: A Matter of Public Health

Implications of the severe acute respiratory syndrome associated with the novel coronavirus-2 on vascular surgery practices

Emerging practice patterns in vascular surgery during the COVID-19 pandemic

Financial implications of covid-19 on a tertiary academic vascular surgery practice

Surgery and COVID-19

COVID-19 and the Upcoming Financial Crisis in Health Care. NEJM Catalyst

Covid-19 and the financial health of us hospitals

Emergency management of the COVID-19 pandemic in a vascular surgery department of a large metropolitan hospital in Italy. Preparation, escalation, de-escalation, and normal activity

The financial and employment effects of coronavirus disease 2019 on physicians in the United States

Accessed 3/15/21

Immediate and long-term impact of the COVID-19 pandemic on delivery of surgical services

The covid-19 pandemic and the incidence of acute myocardial infarction

Impact of coronavirus disease 2019 pandemic on the incidence and management of out-of-hospital cardiac arrest in patients presenting with acute myocardial infarction in england

Excess deaths from covid-19 and other causes

Immunity, endothelial injury and complement-induced coagulopathy in COVID-19

Acute limb ischemia in COVID-19 patients: Could aortic floating thrombus be the source of embolic complications?

Vascular surgery during covid-19 emergency in hub hospitals of lombardy: experience on 305 patients

Acute arterial thromboembolism in patients with covid-19 in the new york city area

Acute limb ischemia in a peruvian cohort infected by covid-19

Acute limb ischemia in patients with COVID-19 pneumonia

Covid-19 presenting as acute limb ischemia

Vascular surgery practice guidelines during covid-19 pandemic in a setting of high work volume against limited resources: perspective of a developing country

Vasculitis and aortitis: COVID-19 challenging complications

Acute complicated type B aortic dissection during the New York City COVID-19 surge

Doing the right thing for the right reason when treating ruptured abdominal aortic aneurysms in the COVID-19 era

Accessed 3/15/21

The Vascular Surgery COVID-19

Collaborative (VASCC)

Modeling the elective vascular surgery recovery after coronavirus disease 2019: Implications for moving forward

Delivering high-quality vascular care by telehealth during the COVID-19 pandemic

The value of the modern vascular surgeon to the health care system: A report from the Society for Vascular Surgery Valuation Work Group