Long-haul COVID: Healthcare Utilization and Medical Expenditures 6 Months Post-diagnosis

Background Despite evidence that long-term COVID-19 symptoms may persist for up to a year, their implications for healthcare utilization and costs 6 months post-diagnosis remain unexplored. Methods Our objective is to determine for how many months post-diagnosis healthcare utilization and costs of COVID-19 patients persist above pre-diagnosis levels and explore response heterogeneity across age groups. This population-based retrospective cohort study followed COVID-19 patients’ healthcare utilization and costs from January 2019 through March 2021 using claims data provided by the COVID-19 Research Database. The patient population includes 328,777 individuals infected with COVID-19 during March-September 2020 and whose last recorded claim was not hospitalization with severe symptoms. We measure the monthly number and costs of total visits and by telemedicine, preventive, urgent care, emergency, immunization, cardiology, inpatient or surgical services and established patient or new patient visits. Results The mean (SD) total number of monthly visits and costs pre-diagnosis were .4805 (4.2035) and 130.67 (1,216.66) dollars compared with 1.1998 (8.5184) visits and 341.7576 (2,439.5581) dollars post-diagnosis. COVID-19 diagnosis associated with .7338 (95% CI, 0.7175 to 0.7500 visits; P < .001) more total healthcare visits and an additional $215.40 (95% CI, 210.76 to 220.00; P<.001) in monthly costs. Excess monthly utilization and costs for individuals under 19 years old subside after 5 months to .021 visits and $3.7, persist at substantial levels for all other groups and most pronounced among individuals 50-59 (.236 visits and $78.60) and 60-69 (.196 visits and $73.10) years old. Conclusions This study found that COVID-19 diagnosis was associated with increased healthcare utilization and costs 6 months post-diagnosis. These findings imply a prolonged burden to the US healthcare system from medical encounters of COVID-19 patients and increased spending.

Theatre Performance Dashboard: Development and Challenges

Manual theatre performance measurement is resource yearning and inaccurate. To automate the process, we built a dashboard which provides interactive visualisation of key performance metrics related to operating theatres. The aim is to assist in the efficient management of surgical services and provide visibility on metrics trending over time for health service facilities.

P-O17 The Royal Stoke Green Pathway: a method to undertake safe UGI surgery during the COVID pandemic

Background During the first wave of the COVID pandemic surgical services we paralysed globally, with cancellation of an estimated 28-million operations during the first 12 weeks. Worryingly, surgical patient with COVID were reported to have unacceptably high peri-operative mortality, approaching 25%. However, there was an urgent clinical need to progress with category 1 and 2 operations, to prevent disease progression and avoidable morbidity and mortality from non-COVID pathologies. During the second and subsequent waves of the pandemic it was vital to protect patients from peri-operative COVID whilst undertaking urgent surgery safely. Methods Our centre developed a ring-fenced 'Green Pathway' for category 1 and 2 patients requiring surgery. Patients were treated in physically separate area of the hospital, with no interaction between COVID and non-COVID patients, healthcare staff or facilities. Patients self-isolated for 14-days prior to admission, and had pre- and peri-operative COVID RT-PCR tests. We assessed outcomes for patients immediately prior to the introduction of the Green Pathway (1/10/2020) and following implementation (31/12/2020) to assess safety. Textbook outcomes for pancreatoduodenectomy were compared to assess safety and quality. Other data suggests that UGI surgery couldn't continue in other hospitals from December 2020. Results There were 47 admissions to surgical HDU following category 1 and 2 upper GI operations during the study; 31 pre-pathway (PP) implementation, and 16 green pathway (GP) patients. Median age 66-years (43-78 range) PP vs 65-years (range 42-74) GP, median ASA 3 vs 2. Median HDU length of stay (LOS) 5-days vs 7-days, and median hospital LOS 11.5-days vs 9-days for PP vs GP respectively. There were 6 cases of peri-operative COVID in PP cohort, and 1 in GP (contract following discharge). There was no mortality within either cohort. For the subgroup of patients undergoing PD: 10 patients PP, 6 patients GP, textbook outcomes were achieved in 90% vs 67% PP vs GP. Conclusions The implementation of the Green Pathway at our institution enabled continuation of surgery for patients with category 1 and 2 operations during the COVID pandemic with a significant reduction in peri-operative COVID infection, no mortality and no increase in length of stay. The TO rate was lower with the GP (not statistically significant), but our 4-year institution TO rate is 70.3%, comparing favourably to other studies. This pathway has enabled safe continuation of urgent surgery during the pandemic and could be a model for adoption in other centres especially if there is resurgence of COVID cases during the coming winter.

P-BN45 The Impact of Covid-19 on Benign Upper GI Operations in England During 2020

Background Since the cancellation of elective surgery in early 2020 due to the threat of Covid-19, surgical provisions in England have continued to be affected by the Covid-19 pandemic. Elective surgery makes up the majority of surgical procedures performed in England and therefore cancelled operation lists and increased demand for ITU beds has had a significant impact upon the surgical services delivered to patients through out 2020. The following research looks at the impact of Covid-19 on benign upper GI surgery in England and reviews the relationship between Covid-19 deaths and operations performed throughout England and analyses the data at a regional level. Methods Data relating to operation numbers was taken from The Surgical Workload Outcomes Audit (SWORD) database. The SWORD database was interrogated for the years 2017 – 2020. A mean number of operations was calculated using the 2017-2019 data and compared to data from 2020. Operations performed and other demographic data was analysed regionally and compared to Covid-19 deaths throughout England. Covid-19 data was obtained from the national government dashboards. Results The results show that there is a correlation with increasing Covid deaths and lower rates of elective surgery. Furthermore, elective surgery was worse hit than emergency surgery with a slower recovery overall. Cholecystectomies were reduced by a total of 20817 (31.4%) for the year 2020 with a greater reduction seen in elective operations (35.6%). However, similar reductions were seen in both laparoscopic (31.4%) and open (37.5%) Similarly, bile duct explorations and elective splenectomy were reduced by 34.4% and 23.4% respectively. Comparatively, both paraumbilical and inguinal hernias also saw reductions of greater than 40% in 2020 when compared to the mean of the previous 3 years. Regional variances were seen between operation numbers performed and Covid-19 rates, however the overall trend remained the same for national level data. Conclusions Overall, the Covid-19 pandemic has had a significant impact on operations, particularly on those deemed as benign and ‘less urgent’. Whilst a global impact across all benign operations was seen, greater reductions were seen in elective operations compared to emergency operations. Hernia operations and bile duct exploration saw greater overall reductions compared to cholecystectomies and splenectomies, which suggests that whilst operation numbers were reduced, efforts were made to prioritise operations with greater clinical need throughout the pandemic. On analysis of the data in relation to Covid-19 rates and deaths, variation was seen across the regions in the UK, however overall the trend remained the same. Centres and regions worse hit by Covid-19 performed less operations during 2020. However, further qualitative research to investigate why certain centres maintained higher levels of performance during the pandemic would be beneficial for planning for future waves and future pandemics.

Emergency Surgery Admissions and The COVID-19 Pandemic: Did The First Wave Really Change Our Practice? Results of An ACOI/WSES International Audit On 6263 Patients.

IntroductionThe COVID-19 pandemic is having a deep impact on emergency surgical services, with a significant reduction of patients admitted into emergency surgical units world widely. Reliable figures of this reduction have not been produced yet. Our international audit aimed at giving a precise snapshot of the absolute and relative changes of emergency surgical admissions at the outbreak of the pandemic. Materials and methodsDatasets of patients admitted as general surgical emergencies into 45 internationally distributed emergency surgical units during the months of March and April 2020 (Covid-19 pandemic outbreak) were collected and compared with those of patients admitted into the same units during the months of March and April 2019 (pre-Covid-19). Primary endpoint was to evaluate the relative variation of the presentation symptoms and discharge diagnoses between the two study periods. Secondary endpoint was to identify the possible change of therapeutic strategy during the same two periods. ResultsForty-four centres participated sent their anonymised data to the study hub, for a total of 6263 patients. Of these, 3810 were admitted in the pre-Covid period and 2453 in the Covid period, for a 35.6% absolute reduction. The most common presentation was abdominal pain, whose incidence did not change between the two periods, but in the Covid period patients presented less frequently with anal pain, hernias, anaemia and weight loss. ASA 1 and low frailty patients were admitted less frequently, while ASA>1 and frail patients showed a relative increase. The type of surgical access did not change significantly, but lap-to-open conversion rate halved between the two study periods. Discharge diagnoses of appendicitis and diverticulitis reduced significantly, while bowel ischaemia and perianal ailments had a significant relative increase.ConclusionsOur audit demonstrates a significant overall reduction of emergency surgery admissions at the outbreak of the Covid-19 pandemic with a minimal change of the proportions of single presentations, diagnoses and treatments. These findings may open the door to new ways of managing surgical emergencies without engulfing the already busy hospitals.

Humanitarian surgical service utilization by a host country population: comparing surgery patterns between refugees and Tanzanians using an interrupted time-series analysis

Background While current estimates suggest that up to three million additional surgical procedures are needed to meet the needs of forcibly displaced populations, literature on surgical care for refugee or forced migrant populations has often focused on acute phase and war-related trauma or violence with insufficient attention to non-war related pathologies. To our knowledge, no study has compared refugee versus host population utilization of surgical services in a refugee camp-based hospital over such an extended period of twenty years. The aim of this paper is to first describe the patterns of surgical care by comparing refugee and host population utilization of surgical services in Nyarugusu refugee camp between 2000 and 2020, then evaluate the impact of a large influx of refugees in 2015 on refugee and host population utilization. Methods The study was based on a retrospective review of surgical logbooks in Nyarugusu refugee camp (Kigoma, Tanzania) between 2000 and 2020. We utilized descriptive statistics and multiple group, interrupted time series methodology to assess baseline utilization of surgical services by a host population (Tanzanians) compared to refugees and trends in utilization before and after a large influx of Burundian refugees in 2015. Results A total of 10,489 operations were performed in Nyarugusu refugee camp between 2000 and 2020. Refugees underwent the majority of procedures in this dataset (n = 7,767, 74.0%) versus Tanzanians (n = 2,722, 26.0%). The number of surgeries increased over time for both groups. The top five procedures for both groups included caesarean section, bilateral tubal ligation, herniorrhaphy, exploratory laparotomy and hysterectomy. In our time series model, refugees had 3.21 times the number of surgeries per quarter at baseline when compared to Tanzanians. The large influx of Burundian refugees in 2015 impacted surgical output significantly with a 38% decrease (IRR = 0.62, 95% CI 0.46–0.84) in surgeries in the Tanzanian group and a non-significant 20% increase in the refugee group (IRR = 1.20, 95% CI 0.99–1.46). The IRR for the difference-in-difference (ratio of ratios of post versus pre-intervention slopes between refugees and Tanzanians) was 1.04 (95% CI 1.00–1.07), and this result was significant (p=0.028). Conclusions Surgical care in conflict and post-conflict settings is not limited to war or violence related trauma but instead includes a large burden of obstetrical and general surgical pathology. Host population utilization of surgical services in Nyarugusu camp accounted for over 25% of all surgeries performed, suggesting some host population benefit of the protracted refugee situation in western Tanzania. Host population utilization of surgical services was apparently different after a large influx of refugees from Burundi in 2015.

Admitting Service and Outcome for Small Bowel Obstruction

Introduction Small bowel obstruction (SBO) is a common admission diagnosis. Prior research has shown improved length of stay and time to operation for SBO patients on surgical services (SS) compared to medical services (MS). This study evaluates the impact of admitting service on readmission and mortality. Methods A 12-year retrospective cohort study of patients ≥18 years old, admitted with SBO to either a MS or SS within one health care system was performed. Clinicodemographic characteristics and admission details were extracted and reviewed. Statistical analyses performed included the Student’s t-test, chi-square, and multivariable regression. Results The study included 7921 patients, of which 3862 (48.8%) were admitted to a SS. No significant clinicodemographic differences existed between the groups except SS patients were more likely to have cancer (23.3% vs 15.2%, P < .0001) and to be within a 30-day post-operative period (9.4% vs 1.8%, P < .0001). On multivariable analysis, admission to a SS was associated with a decreased admission mortality (OR .70), 30-day mortality (OR .42), and 180-day mortality (OR .42). 30-day readmissions (OR .54) and 180-day readmission (OR .43) were also significantly decreased for SS patients. In patients requiring a procedure during admission, there was significantly decreased admission mortality (OR .684), 30-day mortality (OR .470), 180-day mortality (OR .431), 30-day readmission (OR .63), and 180-day readmission (OR .50). Conclusion In patients with SBO, admission to a SS confers decreased odds of readmission and mortality compared to MS. Future studies are needed to understand the management decisions potentially underlying these differences. These findings may help better define admission pathways and improve outcomes.

A systematic review of the accessibility, acceptability, safety, efficiency, clinical effectiveness and cost-effectiveness of private providers of elective surgical services compared with public providers

Many publicly funded health systems use a mix of privately and publicly operated providers of care to deliver elective surgical services. We review the role of private elective surgical provision within publicly funded health systems in high-income countries. The outcomes evaluated include accessibility, acceptability, safety, clinical effectiveness, efficiency, and cost/cost-effectiveness. Twenty-seven articles met the review inclusion criteria. We found mixed results across each of our reported outcomes. Wait times were shorter for patients treated in private facilities in most studies, and inequalities by age and socioeconomic deprivation were found to increase with private provision in some studies. Acceptability results were mixed, with most studies finding no differences between public and private provision and others finding higher satisfaction at public facilities. The results for safety outcomes were divided, but most studies that found improved safety outcomes in private facilities, noting that private patients had a lower preoperative risk of complications. Clinical effectiveness was similar in most studies, with differences in outcomes mainly attributed to patient selection or prosthesis choice. Very few studies reported cost and cost-effectiveness outcomes, and just two included studies concluded that private facilities are economically viable.