As we enter a second year of the COVID-19 pandemic, important lessons on the role of effective healthcare systems have emerged. The pandemic has resulted in unprecedented stress on care systems around the world, revealing our Achille’s heel. In the U.S., while the focus of delivery system reform has been on delivering value-based care, the pandemic has illustrated an urgent need to redefine value by prioritising resilient healthcare systems.
Central to health systems resiliency is the role that surgical care provides in hospitals and health systems. For example, in March 2020, with the uncertainty of an alarming escalation of COVID-19 cases in major U.S. cities, one of the primary non-pharmacological interventions to preserve hospital capacity and critical shortages of personal protective equipment (PPE) was the cancellation of non-emergent surgical cases, an enormously expensive choice for hospitals with unknown potential impacts on the patients whose operations and procedures were delayed. This strategy, while initially necessary, has sparked conversations about the need to transition to a more robust, resilient post-pandemic healthcare system. Additionally, in many hospitals across the U.S., there was a realisation of the importance of generalism in an increasingly specialised world. As medical units became filled with COVID-19 patients and with increasing burnout among front-line clinicians, surgeons and surgical trainees were often cross-tasked with providing care to medical patients with COVID-19. Many intensive care units with intubated COVID-19 patients were staffed with general surgeons, who had undergone extensive critical care training during their graduate medical education.
A silver lining to the pandemic is the opportunity to reimagine and redesign surgical healthcare delivery. There will likely be a continuing accelerated transition to telehealth, a shift from inpatient to outpatient surgery, and a renewed focus on home-based care. During the COVID-19 pandemic, 30.1 per cent of all visits across medical specialties were provided via telemedicine. Especially for surgical care at academic tertiary referral centers, telemedicine visits create the opportunity for expanded patient access while minimising direct and indirect costs to patients. For elective operations, such as bariatric and metabolic surgery, with multiple preoperative multidisciplinary visits and life-long follow up, the flexibility of virtual visits may actually decrease patient attrition and loss to follow up. However, emerging data suggest that rates of telemedicine use were lower in communities with higher rates of poverty, and a rapid shift to telehealth could exacerbate existing structural inequalities in health care access. Expansion of telehealth, therefore, needs to ensure that care is expanded equitably across patient populations. This requires universal access to reliable, high-speed internet connections, which communities with high rates of poverty do not currently have.
Second, post-pandemic, there will be a rapid evolution of inpatient surgical procedures to the outpatient setting. In the U.S., the lifting of Medicare reimbursement restrictions on “inpatient only” procedures will have a profound effect on the trend of outpatient procedures. For example, after removal of total knee arthroplasty from the inpatient surgical list in 2018, the proportion of these operations performed as an outpatient went from 0.2 per cent in 2017 to over 35 per cent in 2018. On top of existing clinical innovations such as enhanced recovery after surgery protocols, the large-scale experimentation with postoperative care pathways caused by COVID-19 disruptions to elective surgical cases will likely continue to decrease inpatient lengths of stay and increase the transition towards outpatient procedures.
Lastly, there will likely be a trend towards home-based care, in what Medicare has called the “hospital without walls.” These will entail the adoption of home hospital models of care which provide inpatient-level care in the patient’s own home, avoiding the use of a hospital bed. While these programmes have mostly been utilised for medical patients within the United States, in November 2020 the Centers for Medicare and Medicaid Services announced the Acute Hospital Care at Home waiver, creating a path for more hospitals to establish home hospital programmes to create more capacity for acute hospital care. Home hospital care includes nursing/paramedic support, daily provider and therapist visits, point-of-care lab and imaging tests, and administration of IV medications, providing an opportunity for this modality to be used for pre-operative optimisation and post-operative care of surgical patients. Home hospital is the next frontier in patient-centered care that focuses on the patient and not around the physical infrastructure of the healthcare system.
While the COVID-19 pandemic has caused unprecedented stress to healthcare systems, it has also highlighted the need for flexible thinking around payment and delivery models that incentivise creative solutions for capacity building. Re-engineering health systems will necessarily involve re-engineering surgical care delivery to focus on patients, and this focus will accelerate the trends of increased telehealth, outpatient procedures, and home hospital adoption. Redefining healthcare value around resiliency will create the foundations of a stronger, more nimble system capable of responding to future pandemics, climate disasters, and other healthcare surges that we will undoubtedly face.
Dr Stanley W. Ashley Dr Ava Ferguson Bryan Dr Thomas C. Tsai
This article appears in the latest issue of Omnia Health Magazine. Read the full issue online today.