key: cord-0758121-im07w3lz authors: Madhuripan, Nikhil; Man-Ching Cheung, Helen; Alicia Cheong, Li Hsia; Jawahar, Anugayathri; Willis, Marc; Larson, David B. title: Variables influencing radiology volume recovery during the next phase of the COVID-19 pandemic date: 2020-06-01 journal: J Am Coll Radiol DOI: 10.1016/j.jacr.2020.05.026 sha: 0732b49a59dc59145d944510ebe2b760c0303279 doc_id: 758121 cord_uid: im07w3lz Abstract The COVID-19 pandemic has reduced radiology volumes across the country as providers have decreased elective care in order to minimize the spread of infection and free up health care delivery system capacity. Following the stay-at-home order in our county, imaging volumes at our institution decreased to approximately 46% of baseline volumes, similar to the experience of other radiology practices. Given the substantial differences in severity and timing of the disease in different geographic regions, estimating resumption of radiology volumes will be one of the next major challenges for radiology practices. We hypothesize that there are 6 major variables that will likely predict radiology volumes: (1) severity of disease in the local region, including potential subsequent “waves” of infection, (2) lifting of government social distancing restrictions, (3) patient concern regarding risk of leaving home and entering imaging facilities, (4) management of pent up demand for imaging delayed during the acute phase of the pandemic, including institutional capacity, (5) impact of the economic downturn on health insurance and ability to pay for imaging, and (6) radiology practice profile reflecting amount of elective imaging performed, including type of patients seen by the radiology practice such as emergency/inpatient/outpatient mix and sub-specialty types. We encourage radiology practice leaders to use these and other relevant variables to plan for the coming weeks and to work collaboratively with local health system and governmental leaders to help ensure that needed patient care is restored as quickly as the environment will safely permit. The authors declare that they had full access to all of the data in this study and the authors take complete responsibility for the integrity of the data and the accuracy of the data analysis. There is no financial or any other form of real or apparent conflict of interest in the context of the subject of this article. The Coronavirus Disease 2019 (COVID- 19) pandemic has reduced radiology volumes across the country as providers have decreased elective care in order to minimize the spread of infection and free up health care delivery system capacity [1, 2] . Healthcare institutions have rapidly implemented infection control and social distancing protocols [3, 4] and are now better prepared to safely accommodate greater numbers of patients. Radiology practices are now beginning to resume routine imaging. The impact and the severity of the pandemic have varied markedly in different localities across the United States. For example, Figure 1 shows a graph of new cases per 100,000 population every 5 days since mid-March 2020 in an illustrative sample of states, with the peak in the most-affected state, New York (253.4), 23 times that of the peak in the least-affected state included in the illustration, Montana (9.3) . Even within states, there is wide variance in case numbers; for example, there have been 2,298 cases per 100,000 population in New York City, NY compared to 219 cases per 100,000 population in Monroe County, NY, which includes the city of Rochester [5] . Given the substantial differences in severity and timing of the disease in different geographic regions, it appears unlikely that radiology volumes will recover at the same rate across the country. Therefore, estimating resumption of radiology volumes will be one of the next major challenges for radiology practices. In order to help radiology practices plan for likely imaging volumes in the next phase, we briefly describe the impact of COVID-19 on imaging volumes in our practice to date and identify six variables that we hypothesize will influence the rate and degree to which imaging volumes will recover in the coming weeks. Stanford Health Care is a tertiary care medical center based in Santa Clara County in the state of California and is the largest hospital system within the Stanford University academic medical center. The acute care facility has a 600-bed capacity and is a Level 1 trauma center and a National Cancer Institutedesignated comprehensive cancer center. Santa Clara County experienced early onset of COVID-19 relative to the rest of the United States [6, 7] and was one of the first four counties to issue stay-at-home orders in the US on March 17, 2020 [6] . for outpatient exams on April 16, 2020. We observed a slight decline in outpatient imaging volumes in the week prior to the implementation of the stay-at-home order on March 17, 2020 (Figure 2) . A gradual increase in outpatient imaging volumes began to occur the last week of April 2020, primarily reflecting an increase in outpatient imaging volumes (Figure 2 ). Daily average imaging volumes varied substantially by radiology subspecialty (Figure 3 ). Musculoskeletal imaging was most impacted, with a decrease to 27% of baseline imaging volumes during the four-week period of lowest volumes ( Interventional radiology and neuroimaging also experienced substantial but relatively smaller declines, with decreases to 57% and 52% of baseline volumes, respectively. In the absence of a validated prediction model for imaging volumes in the near future, our practice is closely observing the following six variables as part of our planning efforts. For each variable, we describe a "low-impact" scenario, which would lead less severe decreases in imaging volumes, and a "high-impact" scenario, which would lead to lower imaging volumes, recognizing that actual outcomes will likely fall somewhere in between ( Table 2) . In Table 2 , we have listed assumptions, including values that may represent high-impact and low-impact scenarios based on national data, as available, or based on our local experience. We expect the severity and duration of the acute phase of the COVID-19 pandemic in the local region to be the primary driver of radiology volumes in the acute phase, with continued impact in the recovery phase and in the intermediate term. In the low-impact scenario, lower regional severity of disease will likely result in lower decreases in imaging volume for a shorter amount of time and with a more rapid recovery period (Fig. 4a) . In the high-impact scenario, higher regional severity of COVID-19 infection will likely result in greater decreases in imaging volumes for a more sustained period of time and with a longer recovery period. Public health officials anticipate potential subsequent "waves" of infection, referring to renewal of growth in numbers of infections in the community [9] . The impacts on radiology volumes would likely mirror those of the original wave of infection, though they may be less pronounced, since health care institutions would have had more time to prepare and implement COVID-19 protocols. In response to the pandemic, most states have mandated some version of social distancing restrictions (including a stay-at-home order) for the population beginning mid-March, 2020. Governments are now starting to lift those restrictions, though in a non-uniform manner across the country [1,10]. Lifting of these restrictions will clearly impact imaging volumes. In the low-impact scenario, prompt lifting of restrictions will likely lead to more rapid return of imaging volumes (Fig. 4b) . In the high-impact scenario, gradual or delayed lifting of restrictions will likely lead to more delayed return to normal imaging volumes (Fig. 4b) . In regions in which social distancing restrictions are being lifted in a staged fashion, as long as routine medical care is included in essential services, such staged lifting of restrictions should not directly result in prolonged imaging volume decreases, though it will likely have an impact on patient concern, discussed in the next section. Public perception of the risk of leaving home or entering healthcare facilities to undergo medical imaging likely will influence the rate of restoration of radiology volumes. Even if government stay-athome restrictions are lifted, patients may still choose to forgo or delay care during the pandemic. Disparities in the share of people leaving home again by county, which do not directly correlate with severity of disease of lifting of restrictions, have been published, suggesting variation in patient concern by region [11, 12] . In the low-impact scenario, a lower level of patient concern will likely lead to more rapid return to normal imaging volumes (Fig 4c) . In the high-impact scenario, a higher level of patient concern will likely lead to more gradual return to normal volumes. Achieving pre-pandemic levels of patient confidence in safety may take time and repeated interactions with the public and with patients. Our medical center's strategy is to combine a public information campaign with general messages to patients and specific scripting when scheduling exams. As radiology practices have postponed less urgent examinations and referring clinicians have deferred elective care, a backlog of unordered and ordered-but-not-yet-performed imaging exams has accumulated [13] . The size of this backlog depends on the severity and duration of the decrease of imaging in the acute phase [14] . Institutions may respond to this pent-up demand in two ways. In the low-impact scenario, delayed examinations would be quickly scheduled and performed, leading to an initial 'bump' in imaging volumes above those that would otherwise be expected, potentially even above normal operating capacity (Fig. 4d) . In the high-impact scenario, delayed examinations would take time to schedule and perform, causing a delayed return to normal radiology volumes. Limiting factors may include limited resources to reschedule exams, decreased efficiency due to enhanced cleaning protocols, limited availability of personal protective equipment (PPE), and requirements for greater social distancing in waiting rooms. These likely will vary by practice type; practices with fewer available resources to absorb inefficiencies will likely experience greater impact. It is important to note that this is the only variable that has a potential positive impact on volumes, which could help offset losses from delayed resumption of volumes from other causes. This is also the variable that is presumably most under control of radiology practices and healthcare systems. Since the onset of the pandemic, the real unemployment rate has been reported to be close to 25% [15] . The economic downturn will likely affect radiology volumes, primarily through loss of insurance coverage or inability to pay deductibles or co-pays for medical imaging due to unemployment or underemployment [16] . Economic consequences will likely be widespread, although regional socioeconomic factors such as types of dominant employers, ethnic diversity, and strength of social safety nets, will likely vary by locale. In the low-impact scenario, a small number of individuals would lose access to healthcare coverage, leading to a return to the pre-pandemic baseline of imaging volumes (Fig. 4e) . In the high-impact scenario, a large number of individuals would lose access to full healthcare coverage, leading to a resumption of imaging volumes to a level lower than the pre-pandemic level, potentially extending into the long term. The Center for Medicare and Medicaid Services (CMS) recently issued guidelines for Medicare Advantage Organizations giving them the discretion to waive or relax prior authorization requirements to improve access [17] . Physician organizations including the American College of Radiology have urged private insures to implement similar policies [18, 19] . These steps may improve the rate of recovery to baseline volumes. Examinations that are considered to be more elective in nature likely will be more susceptible to be deferred than those that are considered more urgent. The elective nature of an exam is difficult to define and is context-dependent, but will likely become more apparent in the coming weeks. While it may not be clear exactly how it will be manifested, it is likely that radiology practices with that perform different types of examinations, with different referral patterns, and with different ratios of emergency/inpatient/outpatient imaging settings, will likely be impacted differently, even within the same geographic region. Practices with a lower proportion of elective exams will likely experience less of a decrease in imaging volumes and a faster return to baseline levels than those with a higher proportion of elective exams In applying the model to our local practice, we find the following: The severity and duration of disease in our region has been relatively low, with the peak never reaching 10 cases per day per 100,000 population. We were allowed to resume imaging relatively early, before new cases reached peak in the state, though patient concern appears to remain relatively high in our region, with approximately 50% of people staying at home as of May 20, 2020 [19] . Our ability to manage pent-up demand for imaging is relatively favorable; recent opening of new facilities have added capacity to our system that may offset inefficiencies due to infection control and social distancing, and medical center operations were restored to near normal within 5 weeks following lifting of social distancing orders. We believe that our region will be substantially impacted by the economic downturn, though perhaps to a lesser degree than other regions. Our health system and radiology practice care for a relatively high number of patients with cancer and other non-elective types of conditions, which we consider to constitute >80% of our cases. In aggregate, our model has been reasonably predictive, with volumes reaching as high as 85% within 4 weeks of restoration of normal scheduling (Fig. 2) . Assuming local disease prevalence remains low, the question of whether volumes will now level off or continue to rise to pre-pandemic levels will likely depend primarily on continued patient concern and the effects of the economic downturn. The abrupt decrease in imaging volumes to approximately 30%-60% of baseline volumes from March 30-April 26, 2020 corresponds to findings reported by other authors [16, 20] . Imaging volumes began to increase in late April 2020, with progressive restoration of elective procedures and normalization of volumes. It has been three and a half weeks since we resumed normal scheduling; increases in volumes have been relatively prompt, as our model would predict. At our institution, it was widely recognized that radiology needed to resume services before other clinical specialties since many of those specialties critically depend on imaging support. We started performing these exams approximately three weeks prior to resumption of full clinical services in order to reduce the significant backlog of pending orders, though some clinical programs had been gradually increasing services during this time. An understanding of likely imaging volumes in coming weeks and months is important for radiology practices' planning efforts since, as Cavallo and Forman recently discussed, sustained volume decreases could lead to delay in care for patients and substantial financial losses for practices [16] . Snow and Taylor recently outlined a four-step approach to managing fluctuating radiology volumes during the COVID-19 pandemic [21] and Davenport et al outlined 7 categories of recommendations to help radiology practices resume non-urgent radiology care [22] . Practices that are likely to experience low volumes may need to reduce staffing to preserve financial viability; however, excessive reductions in staffing could have the potential side effect of limiting imaging capacity to accommodate a possible subsequent surge in imaging volumes, further exacerbating financial losses. This is especially critical during the recovery phase; practices that do not invest additional resources in quickly scheduling and performing additional exams may find it difficult to perform those examinations later, especially if another wave of infection in the local region requires resumption of stay-at-home restrictions. Prediction of imaging volumes may also help practices make accommodations for inefficiencies of practices, including infection control and social distancing efforts [22, 23] . These inefficiencies will likely become increasingly important as volumes increase. We recognize a number of limitations of our analysis. The dynamic nature of the COVID-19 pandemic makes accurate predictions of future radiology volumes difficult. Although this article attempts to address some of the variables that we believe may affect radiology volumes in the future, they are admittedly hypothetical and are likely neither exhaustive nor mutually exclusive. We have expressed the impact in quantitative terms. Additionally, our simplified model illustrates predictions based on a single wave of infection and recovery, which is unlikely to be the case and would need to be adapted for additional waves of infection. The data presented in this paper represent the experience of a single academic institution in one US region, primarily for the purpose of providing context to the discussion of estimating imaging volumes. Given the wide variability of radiology practices and the impact of COVID-19 across the country, the experiences of others may differ from ours, though we believe they are likely to be directionally similar. As has been true broadly for radiology practices in the US, we have observed substantial decreases in imaging volumes associated with the acute phase of the COVID-19 pandemic. Our early experience has shown a gradual but steady restoration of imaging volumes, consistent with our predictive model. Because of the highly variable impact of the disease in different regions in the US, we believe that the impact on radiology practices' volumes will also likely vary. By focusing on key variables specific to local regions and institutions that will likely impact imaging volumes, radiology practices can better prepare to provide safe and effective care in subsequent phases of the pandemic. We emphasize that reduction in imaging volumes represents delayed medical care. When considered for all regions across the country, the impact on the lives of patients and families is likely to be substantial, adding to already heavy impacts from the virus and from economic losses [24] , and even greater for regions most heavily impacted by the disease. We encourage radiology practice leaders to work collaboratively with local health system and governmental leaders to help ensure that needed patient care is restored as quickly as the environment will safely permit. For each variable, two scenarios are presented: a "low-impact" scenario (associated with higher imaging volumes, in blue) and a "high-impact" scenario (associated with lower imaging volumes, in red). (See Table 2 for further explanation.) (A) depicts the effect of severity of disease in the local region, (B) depicts the effect of lifting of government social distancing restrictions, (C) depicts the effect of patient concern, (D) depicts the management of pent-up demand for imaging, (E) depicts the impact of the economic downturn, and (F) depicts the effect of the radiology practice profile. Public perception of leaving home or entering a healthcare facility High concern with patients deciding to postpone/forgo care, leading to delayed return to normal imaging volumes (>50% of people staying at home [19] ) Low concern with rapid return to normal imaging volumes (<35% of people staying at home [19] Radiology practices with smaller proportion of elective imaging, leading to less initial loss of and more rapid return to normal imaging volumes (<20% elective exams) While this is not an environmental variable, this factor will likely substantially affect radiology practices Take-home Points: • At our institution, total daily imaging volumes decreased to 46% of baseline, with a greater decrease observed in outpatient examinations compared to emergency and inpatient examinations. • Severity of disease, lifting of social distancing restrictions, patient concern, management of pent-up demand, impact of the economic downturn, and radiology practice profile are likely key determinants of how radiology volumes will recover immediately following the acute phase of the pandemic. • Imaging volumes have increased relatively promptly at our institution following resumption of normal scheduling 3½ weeks ago, consistent with our qualitative model. • Rates of recovery of imaging volumes will likely vary by geography and time; local conditions should be closely monitored at the local level by individual practices and institutions. with elective medical procedures guidance in effect elective medical services, and treatment recommendations. 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