Balancing revenue generation with capacity generation: Case distribution, financial impact and hospital capacity changes from cancelling or resuming elective surgeries in the US during COVID-19

AbstractBackgroundTo increase bed capacity and resources, hospitals have postponed elective surgeries, although the financial impact of this decision is unknown. We sought to report elective surgical case distribution, associated gross hospital earnings and regional hospital and intensive care unit (ICU) bed capacity as elective surgical cases are cancelled and then resumed under simulated trends of COVID-19 incidence.MethodsA retrospective, cohort analysis was performed using insurance claims from 161 million enrollees from the MarketScan database from January 1, 2008 to December 31, 2017. COVID-19 cases were calculated using a generalized Richards model. Centers for Disease Control (CDC) reports on the number of hospitalized and intensive care patients by age were used to estimate the number of cases seen in the ICU, the reduction in elective surgeries and the financial impact of this from historic claims data, using a denominator of all inpatient revenue and outpatient surgeries.ResultsAssuming 5% infection prevalence, cancelling all elective procedures decreases ICU overcapacity from 340% to 270%, but these elective surgical cases contribute 78% (IQR 74, 80) (1.1 trillion (T) US dollars) to inpatient hospital plus outpatient surgical gross earnings per year. Musculoskeletal, circulatory and digestive category elective surgical cases compose 33% ($447B) of total revenue.ConclusionsProcedures involving the musculoskeletal, cardiovascular and digestive system account for the largest loss of hospital gross earnings when elective surgery is postponed. As hospital bed capacity increases following the COVID-19 pandemic, restoring volume of these elective cases will help maintain revenue.DECLARATIONSEthics approval and consent to participateThis study did not meet criteria for IRB review.Consent for publicationNot applicableAvailability of data and materialsTo facilitate research reproducibility, replicability, accuracy and transparency, the associated analytic code is available on the Open Science Foundation [1] (OSF) repository, [DOI 10.17605/OSF.IO/U53M4] at [https://osf.io/u53m4]. The data that support the findings of this study were obtained under license from Truven. Data were received de-identified in accordance with Section 164.514 of the Health Insurance Portability and Accountability Act (HIPAA).Competing interestsJET received modest financial support for speakers fees from LivaNova and from Philips Healthcare, outside of the work. The other authors declare that they have no competing interests.FundingJET is supported by a career development award (K23HL141596) from the National Heart, Lung, And Blood Institute (NHLBI) of the National Institutes of Health (NIH). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. None of the funding sources were involved in the design or conduct of the study, collection, management, analysis or interpretation of the data, or preparation, review or approval of the manuscript.Authors’ contributionsJET, JH had full access to all the data in the study, takes responsibility for the integrity of the data, the accuracy of the data analysis, and the integrity of the submission as a whole, from inception to published article. JET, HH, BSB, JC, MM, JJH, JH conceived study design; JET, HH, BSB, JC, MM, JJH, RD, BK, AJC, JH contributed to data acquisition and analysis; JET, HH, JJH, JH drafted the work; all authors revised the article for important intellectual content, had final approval of the work to be published, and agree to be accountable to for all aspects of the work.AcknowledgementsNot applicable

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Balancing revenue generation with capacity generation: case distribution, financial impact and hospital capacity changes from cancelling or resuming elective surgeries in the US during COVID-19

BMC Health Services Research ◽

10.1186/s12913-020-05975-z ◽

2020 ◽

Vol 20 (1) ◽

Author(s):

Joseph E. Tonna ◽

Heidi A. Hanson ◽

Jessica N. Cohan ◽

Marta L. McCrum ◽

Joshua J. Horns ◽

...

Keyword(s):

Intensive Care ◽

Elective Surgery ◽

Cohort Analysis ◽

Financial Impact ◽

Infection Prevalence ◽

Intensive Care Patients ◽

Retrospective Cohort Analysis ◽

Hospital Revenue ◽

Bed Capacity ◽

Case Distribution

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Cancellation of Elective Surgery and Intensive Care Unit Capacity in New York State: A Retrospective Cohort Analysis

Anesthesia & Analgesia ◽

10.1213/ane.0000000000005083 ◽

2020 ◽

Vol 131 (5) ◽

pp. 1337-1341 ◽

Cited By ~ 2

Author(s):

Jashvant Poeran ◽

Haoyan Zhong ◽

Lauren Wilson ◽

Jiabin Liu ◽

Stavros G. Memtsoudis

Keyword(s):

Intensive Care Unit ◽

New York ◽

Intensive Care ◽

Retrospective Cohort ◽

Elective Surgery ◽

Cohort Analysis ◽

New York State ◽

York State ◽

Retrospective Cohort Analysis ◽

Unit Capacity

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Parameters of bed occupancy of intensive care units in Hungary

Orvosi Hetilap ◽

10.1556/oh.2011.29137 ◽

2011 ◽

Vol 152 (24) ◽

pp. 946-950 ◽

Cited By ~ 1

Author(s):

Miklós Gresz

Keyword(s):

Health Care ◽

Intensive Care Unit ◽

Intensive Care ◽

Health Insurance ◽

Intensive Care Units ◽

Emergency Care ◽

Present Author ◽

Bed Occupancy ◽

National Network ◽

Bed Capacity

According to the Semmelweis Plan for Saving Health Care, ”the capacity of the national network of intensive care units in Hungary is one but not the only bottleneck of emergency care at present”. Author shows on the basis of data reported to the health insurance that not on a single calendar day more than 75% of beds in intensive care units were occupied. There were about 15 to 20 thousand sick days which could be considered unnecessary because patients occupying these beds were discharged to their homes directly from the intensive care unit. The data indicate that on the whole bed capacity is not low, only in some institutions insufficient. Thus, in order to improve emergency care in Hungary, the rearrangement of existing beds, rather than an increase of bed capacity is needed. Orv. Hetil., 2011, 152, 946–950.

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Colonization and Infection With MRSA and CRKP and Its Result in an Increased Mortality Rate Within the Intensive Care and High-Dependency Units in Barbados

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.703 ◽

2020 ◽

Vol 41 (S1) ◽

pp. s173-s174

Author(s):

Keisha Gustave

Keyword(s):

Intensive Care ◽

Length Of Stay ◽

High Mortality ◽

Average Length ◽

Cohort Analysis ◽

Health Concern ◽

Queen Elizabeth Hospital ◽

Surveillance Program ◽

Average Length Of Stay ◽

High Dependency

Background: Methicillin-resistant Staphylococcus aureus(MRSA) and carbapenem-resistant Klebsiella pneumoniae (CRKP) are a growing public health concern in Barbados. Intensive care and critically ill patients are at a higher risk for MRSA and CRKP colonization and infection. MRSA and CRKP colonization and infection are associated with a high mortality and morbidly rate in the intensive care units (ICUs) and high-dependency units (HDUs). There is no concrete evidence in the literature regarding MRSA and CRKP colonization and infection in Barbados or the Caribbean. Objectives: We investigated the prevalence of MRSA and CRKP colonization and infection in the patients of the ICU and HDU units at the Queen Elizabeth Hospital from 2013 to 2017. Methods: We conducted a retrospective cohort analysis of patients admitted to the MICU, SICU, and HDU from January 2013 through December 2017. Data were collected as part of the surveillance program instituted by the IPC department. Admissions and weekly swabs for rectal, nasal, groin, and axilla were performed to screen for colonization with MRSA and CRKP. Follow-up was performed for positive cultures from sterile isolates, indicating infection. Positive MRSA and CRKP colonization or infection were identified, and patient notes were collected. Our exclusion criteria included patients with a of stay of <48 hours and patients with MRSA or CRKP before admission. Results: Of 3,641 of persons admitted 2,801 cases fit the study criteria. Overall, 161 (5.3%) were colonized or infected with MRSA alone, 215 (7.67%) were colonized or infected with CRKP alone, and 15 (0.53%) were colonized or infected with both MRSA and CRKP. In addition, 10 (66.6%) of patients colonized or infected with MRSA and CRKP died. Average length of stay of patients who died was 50 days. Conclusions: The results of this study demonstrate that MRSA and CRKP cocolonization and coinfection is associated with high mortality in patients within the ICU and HDU units. Patients admitted to the ICU and HDU with an average length of stay of 50 days are at a higher risk for cocolonization and coinfection with MRSA and CRKP. Stronger IPC measures must be implemented to reduce the spread and occurrence of MRSA and CRKP.Funding: NoneDisclosures: None

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Changes in the Number of Intensive Care Unit Beds in U.S. Hospitals During the Early Months of the COVID-19 Pandemic, as reported to the National Healthcare Safety Network’s COVID-19 Module

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2021.266 ◽

2021 ◽

pp. 1-12

Author(s):

Lindsey M. Weiner-Lastinger ◽

Margaret A. Dudeck ◽

Katherine Allen-Bridson ◽

Raymund Dantes ◽

Cindy Gross ◽

...

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Hospital Type ◽

National Healthcare ◽

National Healthcare Safety Network ◽

Bed Capacity ◽

Using Data

Abstract Using data from the National Healthcare Safety Network (NHSN), we assessed changes to intensive care unit (ICU) bed capacity during the early months of the COVID-19 pandemic. Changes in capacity varied by hospital type and size. ICU beds increased by 36%, highlighting the pressure placed on hospitals during the pandemic.

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Financial impact of healthcare-associated infections on intensive care units estimated for fifty Brazilian university hospitals affiliated to the unified health system

Journal of Hospital Infection ◽

10.1016/j.jhin.2021.08.012 ◽

2021 ◽

Vol 117 ◽

pp. 96-102

Author(s):

S.F. Osme ◽

J.M. Souza ◽

I.T. Osme ◽

A.P.S. Almeida ◽

A. Arantes ◽

...

Keyword(s):

Intensive Care ◽

Health System ◽

Intensive Care Units ◽

Financial Impact ◽

Healthcare Associated Infections ◽

University Hospitals ◽

Unified Health System ◽

Healthcare Associated

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COVID-19: lessons learnt and priorities in trauma and orthopaedic surgery

Annals of The Royal College of Surgeons of England ◽

10.1308/rcsann.2021.0028 ◽

2021 ◽

Author(s):

S Madanipour ◽

F Iranpour ◽

T Goetz ◽

S Khan

Keyword(s):

Elective Surgery ◽

Risk Mitigation ◽

Mass Casualty ◽

Health Crisis ◽

Lessons Learnt ◽

Mass Casualty Events ◽

Trauma Networks ◽

Major Incidents ◽

Bed Capacity ◽

Orthopaedic Community

The COVID-19 pandemic is the most serious health crisis of our time. Global public measures have been enacted to try to prevent healthcare systems from being overwhelmed. The trauma and orthopaedic (T&O) community has overcome challenges in order to continue to deliver acute trauma care to patients and plan for challenges ahead. This review explores the lessons learnt, the priorities and the controversies that the T&O community has faced during the crisis. Historically, the experience of major incidents in T&O has focused on mass casualty events. The current pandemic requires a different approach to resource management in order to create a long-term, system-sustaining model of care alongside a move towards resource balancing and facilitation. Significant limitations in theatre access, anaesthetists and bed capacity have necessitated adaptation. Strategic changes to trauma networks and risk mitigation allowed for ongoing surgical treatment of trauma. Outpatient care was reformed with the uptake of technology. The return to elective surgery requires careful planning, restructuring of elective pathways and risk management. Despite the hope that mass vaccination will lift the pressure on bed capacity and on bleak economic forecasts, the orthopaedic community must readjust its focus to meet the challenge of huge backlogs in elective caseloads before looking to the future with a robust strategy of integrated resilient pathways. The pandemic will provide the impetus for research that defines essential interventions and facilitates the implementation of strategies to overcome current barriers and to prepare for future crises.

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Severity and prognosis in intensive care: prospective application of the Apache II Index

Sao Paulo Medical Journal ◽

10.1590/s1516-31801999000500005 ◽

1999 ◽

Vol 117 (5) ◽

pp. 205-214 ◽

Cited By ~ 8

Author(s):

Joel Isidoro Costa ◽

José Luiz Gomes do Amaral ◽

Masashi Munechika ◽

Yara Juliano ◽

José Gomes Bezerra Filho

Keyword(s):

Intensive Care ◽

Mortality Rate ◽

Elective Surgery ◽

Tertiary Care ◽

Prognostic Index ◽

Clinical Severity ◽

Apache Ii ◽

Sample Population ◽

Significant Difference ◽

Critical Patients

CONTEXT: The performance of each ICU needs to be assessed within the overall context of medical care, as well as by the institution which the ICU forms part of. Evaluation mechanisms in the field of intensive care have been developed that are recognized worldwide within the scientific literature. OBJECTIVE: To study outcomes from groups of critical patients and to compare their actual and estimated mortality rates. DESIGN: Prospective study of patients' outcomes. SETTING: A tertiary care unit for a period of 13 months (anesthesiology intensive care unit at the Escola Paulista de Medicina). PARTICIPANTS: 520 patients selected according to sex, age and nature of hospitalization. DIAGNOSTIC TEST: The modified APACHE II prognostic index was applied in order to assess clinical severity and anticipation of mortality in three groups who had non-surgical treatment, emergency surgery and elective surgery. MAIN MEASUREMENTS: The APACHE II index. RESULTS: The application of this index allowed patients to be stratified and expected death risks for both subgroups and the entire sample population to be calculated. The observed mortality rate was greater than the expected rate (28.5% versus 23.6%, respectively), with a statistically significant difference. The standardized mortality rate was 1.20. Patients who obtained scores above 25 presented a significant outcome towards death. The most severe and worst evolving cases were, in decreasing order: non-surgical, emergency surgical and scheduled surgical patients; the actual general mortality rate was higher than the expected one. CONCLUSIONS: The use of the APACHE II index made it possible to stratify critical patient groups according to the severity of their condition.

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Fever and Leukocytosis in Critically Ill Trauma Patients: It is Not the Blood

The American Surgeon ◽

10.1177/000313480907500511 ◽

2009 ◽

Vol 75 (5) ◽

pp. 405-410 ◽

Cited By ~ 3

Author(s):

Jeffrey A. Claridge ◽

Joseph F. Golob ◽

Adam M. A. Fadlalla ◽

Mark A. Malangoni ◽

Jeffrey Blatnik ◽

...

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Critically Ill ◽

Injury Severity ◽

Leukocyte Count ◽

Cohort Analysis ◽

Clinical Signs ◽

Blood Cultures ◽

Daily Temperature ◽

Trauma Patients

The diagnosis of bacteremia in critically ill patients is classically based on fever and/or leukocytosis. The objectives of this study were to determine 1) if our intensive care unit obtains blood cultures based on fever and/or leukocytosis over the initial 14 days of hospitalization after trauma; and 2) the efficacy of this diagnostic workup. An 18-month retrospective cohort analysis was performed on consecutively admitted trauma patients. Data collected included demographics, injuries, and the first 14 days maximal daily temperature, leukocyte count, and results of blood and catheter tip cultures. Fever was defined as a maximum daily temperature of 38.5°C or greater and leukocytosis as a leukocyte count 12,000/mm3 or greater of blood. Five hundred ten patients were evaluated for a total of 3,839 patient-days. The mean age and injury severity score were 49 ± 1 years and 19 ± 1, respectively. Four hundred twenty-five blood culture episodes were obtained and 25 (6%) bacteremias were identified in 23 patients (5%). A significant association was found between obtaining blood cultures in patients with fever (relative risk [RR], 7.7), leukocytosis (RR, 1.3), and fever + leukocytosis (RR, 3.2). However, no significant association was found between these clinical signs and the diagnosis of bacteremia. In fact, fever alone was inversely associated with bacteremia. Our intensive care unit follows the common “fever workup” practice and obtains blood cultures based on the presence of fever and leukocytosis. However, fever and leukocytosis were not associated with bacteremia, suggesting inefficiency and that other factors are more important after trauma.

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The good, the bad and the ugly: pandemic priority decisions and triage

Journal of Medical Ethics ◽

10.1136/medethics-2020-106489 ◽

2020 ◽

pp. medethics-2020-106489 ◽

Cited By ~ 4

Author(s):

Hans Flaatten ◽

Vernon Van Heerden ◽

Christian Jung ◽

Michael Beil ◽

Susannah Leaver ◽

...

Keyword(s):

Critical Care ◽

Intensive Care ◽

Point Of View ◽

Just In Time ◽

Time Period ◽

Utilitarian Approach ◽

Bed Capacity ◽

Trained Staff ◽

Short Time

In this analysis we discuss the change in criteria for triage of patients during three different phases of a pandemic like COVID-19, seen from the critical care point of view. Availability of critical care beds has become a hot topic, and in many countries, we have seen a huge increase in the provision of temporary intensive care bed capacity. However, there is a limit where the hospitals may run out of resources to provide critical care, which is heavily dependent on trained staff, just-in-time supply chains for clinical consumables and drugs and advanced equipment. In the first (good) phase, we can still do clinical prioritisation and decision-making as usual, based on the need for intensive care and prognostication: what are the odds for a good result with regard to survival and quality of life. In the next (bad phase), the resources are mostly available, but the system is stressed by many patients arriving over a short time period and auxiliary beds in different places in the hospital being used. We may have to abandon admittance of patients with doubtful prognosis. In the last (ugly) phase, usual medical triage and priority setting may not be sufficient to decrease inflow and there may not be enough intensive care unit beds available. In this phase different criteria must be applied using a utilitarian approach for triage. We argue that this is an important transition where society, and not physicians, must provide guidance to support triage that is no longer based on medical priorities alone.

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