It hasn't gone away
“Globally, 3 million new cases and over 23 000 deaths were reported in the last 28 days (13 March to 9 April 2023), a decrease of 28% and 30%, respectively, compared to the previous 28 days (13 February to 12 March 2023). Contrary to the overall trend, important increases in reported cases and deaths were seen in the South-East Asia and Eastern Mediterranean regions and in several individual countries elsewhere. As of 9 April 2023, over 762 million confirmed cases and over 6.8 million deaths have been reported globally.”
This is the summary from the WHO Covid-19 Weekly Epidemiological Update. So, the take home message quite simply is Covid-19 is here to stay for a long time.
The covid-19 pandemic has disrupted many aspects of health care, including elective surgery. Elective surgery refers to planned operations that are not urgent or life-threatening, such as hip replacements, cataract removals, or hernia repairs. These procedures can improve the quality of life and well-being of patients, but they can also be postponed if necessary.
However, postponing elective surgery for too long can have negative consequences, such as increased pain, disability, complications, and even mortality. Elective does not mean optional, as many of these procedures are essential for improving patients' quality of life, preventing complications, and reducing costs.
According to a study published in the British Journal of Surgery, more than 28 million elective surgeries were cancelled or postponed worldwide during the first 12 weeks of the pandemic. The study estimated that it would take 45 weeks to clear this backlog, assuming that countries could increase their normal surgical volume by 20%. One of the main challenges that countries face is to estimate the extent and nature of the surgery backlog, which is not easy due to data limitations and variations in definitions and measurement methods. However, some studies have attempted to quantify the impact of the pandemic on elective surgeries, using modelling or survey data. For example, a study published in The Lancet Rheumatology estimated that nearly ten million people in the UK are now waiting for surgical procedures, up from 4 million before the pandemic hit. Among them are nearly 100 000 patients whose joint replacement surgeries were cancelled during the first COVID-19 wave, many of whom are left struggling with daily activities because of severe pain and limited mobility. Another study published by WHO/Europe, the European Observatory on Health Systems and Policies and the Nuffield Trust found that between February and August 2020, 92% of countries in the Region reported some form of disruption in health services. As the pandemic progressed, countries reported lower rates of disruptions, but an average of 26% of services were still disrupted.
So, how are countries around the world dealing with their elective backlog? Let’s look at some examples:
The U.S.A was facing a backlog of millions of surgeries at the end of 2022, especially in orthopaedic and ophthalmologic specialties. This seriously impacted patients' health outcomes and satisfaction, as well as for health care providers' revenue and capacity. The U.S.A adopted several strategies including.
Educating patients about the benefits and risks of surgery and offering financial assistance or payment to those patients who may be reluctant to undergo elective surgery due to fear of covid 19 or financial hardship.
Prioritising patients based on their urgency and severity of their condition.
Use telemedicine or remote monitoring to follow up patients and free up beds.
The pandemic imposed new constraints on health care operations, such as enhanced sanitation protocols, reduced staff availability, and reserved inpatient capacity. To overcome these barriers, providers are optimising their scheduling and workflow, use standardized checklists and protocols, and leverage digital tools and analytics to monitor demand and capacity in real time.
Providers are also collaborating with other facilities or networks to share resources and best practices.
The pandemic also created an opportunity to rethink how operating rooms function and deliver value. New models of care delivery, such as ambulatory surgery centres, hospital-at-home programmes, or mobile surgical units have been developed. Providers can also invest in new technologies or innovations that can improve efficiency, quality, or safety of surgery, such as robotics, artificial intelligence, or virtual reality.
According to the Australian Institute of Health and Welfare, there were about 1.4 million elective surgery admissions in public and private hospitals in 2020-21, a decrease of 9.2% from 2018-19. The median waiting time for elective surgery in public hospitals increased from 41 days in 2018-19 to 49 days in 2020-21, and the proportion of patients who waited longer than clinically recommended increased from 6.9% to 9.3%.
To reduce the surgery backlog and improve access to elective surgery, the Australian government and state and territory governments have implemented various measures, such as:
Providing additional funding to support elective surgery activity in public and private hospitals. For example, the Australian government announced a $3 billion partnership with states and territories in April 2020 to increase capacity and access to public hospitals, including for elective surgery. The government also extended its agreement with private hospitals until June 2021 to ensure they remain available to support the public health system.
Prioritising urgent and high-need patients for elective surgery, based on clinical criteria and guidelines. For example, the National Elective Surgery Urgency Categorisation Guideline was developed by the Australian Health Ministers' Advisory Council to provide a consistent and transparent approach to categorising and managing elective surgery patients across Australia.
Increasing efficiency and productivity of operating rooms, by optimising scheduling, staffing, equipment, and processes. For example, some hospitals have implemented dedicated emergency surgery theatres, extended operating hours, or introduced new models of care such as day surgery or hospital-in-the-home.
Using data and analytics to forecast demand and manage capacity for elective surgery, by monitoring waiting lists, patient outcomes, and performance indicators. For example, some states and territories have established centralised booking systems or dashboards to track and allocate elective surgery activity across hospitals.
In Germany, the Covid-19 pandemic led to a massive postponement or cancellation of elective surgeries that affected not only the health of patients, but also the financial situation of hospitals. Around 900,000 operations were cancelled or postponed between March and May 2020, a decrease of 39% compared to the previous year.
Coping with this backlog of surgeries represents a major challenge for the German healthcare system, which was already suffering from capacity bottlenecks and a shortage of skilled workers before the pandemic. Strategies adopted included:
The prioritisation of urgent and time-critical surgeries, especially those related to cancer, transplants, or cardiovascular diseases
Many patients have postponed or cancelled their surgeries for fear of contracting Covid-19. To encourage these patients to have their surgery, hospitals adhered to strict hygiene and protective measures, such as regular testing of staff and patients, separating Covid-19 and non-Covid-19 areas and educating patients about the risks and benefits of surgery.
The use of digital tools and data analytics that provide a real-time overview of the demand and supply of surgical services and provide a allow dynamic adaptation to change.
Some centres adopted a holistic approach that involved all stakeholders in the healthcare system: politicians, health insurance companies, hospitals, doctors, and patients. This was the only way to ensure that patients received the necessary surgical care and that the quality and efficiency of the healthcare system was maintained or improved.
During the first year of the pandemic Germany increased its share of day surgeries from 37% in 2019 to 41% in 2020.
In France, according to the Ministry of Health, about 30% of scheduled operations were delayed during the first wave of the epidemic, and up to 50% during the second wave. This created a significant backlog that threatened the quality of life and survival of patients with chronic or serious diseases, such as cancer, cardiovascular disease, or osteoarthritis.
The French government introduced several measures to try to reduce the delay in surgical operations and ensure access to care for all patients including:
The mobilisation of private and public hospital capacities. The government asked private health facilities to participate in the national effort by welcoming covid nineteen patients, but also by performing non-deferrable surgeries to relieve public hospitals. According to the Federation of Private Hospitalization (FHP), private clinics took care of about 20% of hospitalized covid nineteen patients and have maintained 80% of their surgical activity during the crisis.
Prioritisation of interventions according to the degree of urgency and risk of complications. The Ministry of Health has published recommendations to help healthcare professionals triage patients according to their clinical condition and the expected benefit of the operation. For example, oncological, cardiac, or vascular procedures are considered a priority, while aesthetic, bariatric or orthopaedic procedures are postponed if possible.
The implementation of regular monitoring of surgical delays and a catch-up plan. The government asked regional health agencies (RHAs) to identify the number of procedures cancelled or postponed and develop strategies to reduce the backlog as soon as possible. RHAs also had to ensure that patients were informed of their situation and received appropriate medical and psychological support.
The French government announced an investment and upgrading plan for the public hospital of 8.2 billion euros over three years, part of which is intended to increase operating capacity and recruit staff. The plan aims to create four thousand new intensive care beds. The government has also provided an envelope of 150 million euros to support private institutions that have participated in the care of covid nineteen patients.
Denmark has taken some measures to address the surgical backlog and ensure patient safety.
One of these measures is the use of a national prioritisation system, which assigns patients to different categories based on their urgency and clinical need. This system helps to allocate resources and capacity to the most critical cases, while also informing patients about their expected waiting time and alternative options.
Another measure is the use of private hospitals and clinics to increase surgical capacity and reduce waiting lists. The Danish government has allocated funds to cover the costs of outsourcing some elective procedures to private providers, such as cataract surgery, hip and knee replacements, and hernia repairs.
Denmark has implemented a free choice policy that allows patients who have waited more than one month for surgery to choose a private provider at public expense
However, these measures may not be enough to clear the surgical backlog and prevent negative consequences for patients. A study by the Journal of Bone and Joint Surgery estimated that Denmark may need up to 14 months to work through the backlog of orthopaedic care, and that was assuming that surgical activity returns to pre-pandemic levels by July 2021. Moreover, some patients may have delayed seeking care or had their referrals cancelled due to the pandemic, creating a hidden backlog that is not captured by official statistics. The impact of this hidden backlog on patient outcomes and quality of life is unknown but could be substantial.
In the U.K. in January 2023 around 7.21 million people waiting for treatment with 3 million of these patients waiting over 18 weeks. Some of the measures introduced include:
A clinical prioritisation framework that categorizes surgeries into four levels of urgency, from priority 1 (immediate threat to life) to priority 4 (can be delayed for more than three months). The framework also considers factors such as patient vulnerability, risk of deterioration, and potential benefit from surgery.
Increasing surgical capacity by expanding operating hours, using alternative facilities, and redeploying staff. For example, the NHS in England has set up more than 100 community diagnostic centres and 122 surgical hubs across the country to provide more tests and procedures for patients.
Implementing infection prevention and control measures to protect patients and staff from covid-19. These measures include screening patients for covid-19 before surgery, using personal protective equipment (PPE), ensuring adequate ventilation and cleaning of operating rooms, and isolating covid-19 patients from non-covid-19 patients.
Increasing the number of cancer referrals, to ensure we also prioritise those patients who have not yet presented to services.
Improving patient pathways to reduce avoidable delays by ensuring we are making the best use of the latest technology, clinical time, and expertise.
Making effective use of independent sector capacity.
So, there is a snapshot of how some countries around the world are dealing with this challenge?
There is no one-size-fits-all solution, but some common strategies include prioritisation, re-imagining surgical pathways, building new infrastructure, improved data usage, redeployment of staff, improved infection control and better communication with patients to name but a few. And of course, all this comes at a cost when the world economy is in turbulent times.
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Author: Niall Shannon, European Business Manager, Innovgas
This article is based on research and opinion available in the public domain.
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