Preparing for an imbalance in orthopedic surgery supply and demand: Insights from Dr. Brian Cole

Laura Dyrda -  

Midwest Orthopaedics at Rush shifted to delivering telemedicine at the practice on March 19 due to the COVID-19 pandemic. Surgeons also postponed non-urgent surgery to make sure caregivers at the front lines had the resources necessary to care for COVID-19 patients and stem the spread of the disease.

More than a month later, the practice is preparing for elective surgeries to resume. Midwest Orthopaedics at Rush has nearly 100 providers who will pivot back to caring for patients in the office when it becomes possible based on federal and state guidelines.

Brian Cole, MD, the managing partner at Midwest Orthopaedics at Rush and associate chairman of the department of orthopedics and chairman of the department of surgery at Rush Oak Park (Ill.) Hospital, said the practice is preparing for an imbalance in the supply and demand for orthopedic care and working overtime to rectify it. Dr. Cole also outlined how the practice will resume surgery and keep patients safe in a YouTube video here.

Question: What is your strategy for ramping surgery back up?

Dr. Brian Cole: Our strategy overall has been guided by several principals, including the federal government's position on essential versus non-essential procedures. We also consider the local orders from Illinois Gov. J.B. Pritzker and the burden of COVID-19 on the health system locally. Being affiliated with Rush, even if we are not providing care in a Rush facility, we are sensitive to the demand for resources at Rush. The decision to resume non-essential elective procedures is made based on the availability of PPE, staff, beds, ICU beds and ventilators as well as the overall ability of Rush to manage the demand and patient surge.

Rush has done an excellent job and we are collaborating on all processes. We are still following guidelines in the state of Illinois since the federal government and executive order is almost exclusively predicated on our ability to flatten the curve so our healthcare system is not overwhelmed. We have a good understanding now of where we are in Illinois and what we need to reduce disease transmission.

The next issue is figuring out how to proceed with the provision of care in a responsible way that continues to maximize patient and staff safety. We are doing that today; we are providing access to essential care and doing it through telemedicine as well as direct face-to-face interactions with all individuals wearing masks while enacting social distancing, proper screening and temperature checks and recording the proper history for patients and staff. If needed, we can conduct a physical examination and MRI, and we are using our office space for urgent and time-sensitive cases.

We are also performing urgent outpatient surgeries in our ambulatory care centers for time-sensitive cases that are deemed emergencies, including when patients have intolerable pain and significant physical dysfunction as long as postoperative care can be predictably provided. We anticipate being able to perform truly elective procedures again on May 11, with all the appropriate social distancing and protective measures in place. We will pay attention to proper hygiene and details in the OR and go above and beyond while following CDC recommendations, including conducting point of care testing for patients undergoing surgery.

Q: What is the biggest challenge for safety of patients and staff?

BC: The challenge is that we will have ongoing processes in place that create extra layers of work to keep patients and employees safe, and ultimately that will reduce throughput and efficiency. We have to be nimble and adapt to that. To address the pent-up demand and ongoing needs, we have many strategies in place, including extended hours, working in shifts, operating and seeing patients on Saturdays. We are going to work harder for longer to manage the pent up demand and existing demand so patients are not inconvenienced and we can maximize procedures that we know to be effective.

Q: What is your current backlog of surgical cases and how do you plan to recover financially?

BC: It depends on the environment. The hospitals where inpatient surgeries are done will have a different ability to ramp up than the ASCs. The first places that will be back online are the ASCs, which are very nimble and we won't be competing with other surgical specialties for operating rooms. At inpatient hospitals where everyone has pent up demand, we will have to take procedure prioritization to panel review. We have to make sure there is ample ICU space for high acuity cases; those that have a low risk of needing the ICU will have a clearer path to surgery. The patients that need an ICU bed will be handled differently than those that are traditional inpatients and don't need those resources.

In some cases, ambulatory surgery that may have been performed in the hospital before can now be safely done in the outpatient setting, and we can accommodate that when it's medically safe at the ASC with our extended hours. The ASC is also an easier place to navigate larger surgical loads than the hospital.

Q: What will your practice look like a year from now?

BC: I think all of us are bracing for an imbalance of the supply of healthcare services and the demand for those services. Because of the processes in place, the practice of medicine will be more expensive to deliver safely. We can make up some of those inefficiencies through telemedicine and hopefully insurance companies will continue to recognize and reimburse for telemedicine. In addition, we will likely see consolidation amongst groups of variable sizes given the implicit overhead to practice medicine today.

On the demand side, there will be some patients who are uninsured or just started new jobs and they won't be able to take time off for surgery. There are also different acuity levels we'll deal with and there will be fewer sports-related injuries. As a result, we expect inefficiencies and increased costs on the delivery side and less demand on the need side from the patient perspective. How long will that last? I don't know; it largely depends on when life looks more like it did pre-COVID. We remain cautiously optimistic in our projections.

If we have an effective vaccine without being faced with new viral challenges, things will begin to look better faster. There is a lot we can't predict, but we are anticipating and building out our infrastructure in a way that anticipates the imbalance between supply and demand. It would be fiscally irresponsible not to do so.

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