key: cord-0828324-bdj6quzn authors: Gawron, Andrew J.; Kaltenbach, Tonya; Dominitz, Jason A. title: The impact of the COVID-19 pandemic on access to endoscopy procedures in the VA healthcare system date: 2020-07-22 journal: Gastroenterology DOI: 10.1053/j.gastro.2020.07.033 sha: e8bc229587dbe681ae391f94558c099e901490e7 doc_id: 828324 cord_uid: bdj6quzn nan COVID-19 resulted in rapid and widespread interruption to healthcare, impacting national, regional, and local healthcare systems and practices. Postponement of nonurgent care was recommended at a national level and across all major medical professional societies. 1,2 Decisions to postpone or cancel hundreds of thousands of non-urgent and elective surgeries and procedures were aimed to slow the spread of COVID-19 and preserve resources, including ventilators and personal protective equipment (PPE). In addition, most states implemented stay-at-home orders further prompting patients to defer care. In a matter of days, the COVID-19 pandemic abruptly dismantled one of healthcare's top priorities -access to high quality care, pursuant to competing public health priorities. The Veterans Affairs (VA) healthcare system, the largest integrated health system in the United States, can serve as a powerful model to assess the impact of COVID-19 on access to care. Comprised of 170 medical centers and 1074 outpatient sites, VA serves over 6 million Veterans annually. Hundreds of thousands of procedures and surgeries are performed annually across the VA, providing critical health services for Veterans. Gastrointestinal endoscopy procedures are among the most common ambulatory procedures performed, accounting for approximately 400,000 Veteran visits annually. Herein, we describe the process, timeline, and impact of the COVID-19 pandemic on gastrointestinal endoscopy in the VA and suggest potential opportunities to address access challenges in the COVID-19 era. VA acted swiftly to provide official guidance on elective endoscopy procedures, reflecting the urgency to conserve PPE, protect Veterans and providers, prepare for a possible COVID surge, and "flatten the curve" of incident infections. 3 The rapid response, outlined below, underscores both the pace of the COVID-19 pandemic and the need for communication across the VA healthcare system to ensure staff, physician and patient safety: Guidance for Elective Gastroenterology and Hepatology Procedures. 3 Facilities were directed to cease all non-urgent elective procedures no later than Wednesday, March 18. Primary Care providers were issued guidance to order non-endoscopic colorectal cancer screening (e.g. fecal immunochemical testing [FIT]) rather than refer Veterans for average-risk screening colonoscopy due to postponement of elective procedures. the National Gastroenterology Program Office. 5 The National Gastroenterology Program Office provided guidance on procedure postponement, including clinical indications that are generally non-urgent or elective, and to offer FIT to Veterans who were awaiting screening colonoscopy. 3 The guidance recommended prioritization of procedures based on the indication and time sensitivity (Figure 1) . For example, urgent procedures that should be performed despite the active COVID-19 pandemic (e.g. acute gastrointestinal bleeding) are deemed Priority 1. Routine cases that are not particularly time sensitive, such as an average risk screening colonoscopy due this year should be classified as Priority 4. Toolbox, which is embedded within the electronic health record and assists VA providers with consult management, was modified to facilitate documentation of a clinical priority score on each consult (Supplementary Figure A) . This tool was paired with a secure website application to produce reports for clinical service departments. These reports were designed to facilitate tracking of all patients awaiting clinical care, including sorting by priority and the clinically indicated date for care. This electronic tool was developed by VA informatics leaders and was deployed to over 350,000 VA computers over a period of several days in April 2020. The framework of the toolbox offered individual services the flexibility to define priority levels. Elective Indications. 5 This guidance on when and how to resume elective procedures, including endoscopy, outlined a process for risk stratifying patients and procedures in order to facilitate appropriate use of pre-procedure viral testing, use of PPE and environment of care processes (e.g. room downtime and cleaning). with an option for sites to disable colonoscopy / sigmoidoscopy ordering. Due to the ongoing impact of the COVID-19 pandemic on elective procedures, increased focus on non-endoscopic screening was encouraged. Therefore, VA facilities were allowed to remove the quick order option for ordering a colonoscopy or sigmoidoscopy in the average risk CRC reminder and preferentially use FIT testing in Veterans for CRC screening. Screening colonoscopy could still be ordered outside of the quick order functionality. On June 9, 2020 6 , the VA initiated a phased re-opening process whereby 1-2 facilities that met pre-specified COVID-19 epidemiology criteria in each VA network were authorized to resume limited face-to-face care. This phased process includes careful monitoring of the impact of re-opening upon COVID epidemiology, availability of PPE and other resources. Across the VA healthcare system, gastrointestinal endoscopy procedure volume decreased precipitously in accordance with the policy requirements and guidance described above (Figure 1 The impact of COVID-19 on healthcare systems across the US is unprecedented in modern history. Appropriately, the initial focus was on preparation for the expected surge of patients infected with COVID-19 likely to need care across the US and VA hospitals. These efforts not only focused on securing PPE, staffing and resources (e.g. ventilators), but also required cancellation and deferral of elective procedures and surgeries. Gastroenterology services are performed at a very high volume across the VA healthcare system. In addition to potential exposure of patients and staff to the SARS-CoV-2 virus through the performance of aerosol generating procedures like endoscopy, these procedures also require a large quantity of PPE for admission, procedure and recovery room staff, as well as the staff who are responsible for reprocessing of the endoscopes. For many endoscopy indications (e.g. diagnostic procedures for symptoms), urgency can be difficult to stratify. National guidance was critical in providing the impetus to rapidly implement triage and postponement of nonurgent endoscopy procedures during the COVID-19 pandemic. The VA reacted swiftly but at the same time there are sweeping repercussions, both immediate and delayed, in such a massive postponement of procedures. Unlike ambulatory clinic visits which can be converted to telephone or video telehealth visits, endoscopic procedures require the physical presence of the patient within the healthcare facility. Studies have documented significant COVID-19 related concerns of patients and healthcare staff alike that will have lasting impacts on endoscopy. 8, 9 Contrary to the precipitous drop in procedure volume, the VA saw a 1025% increase in telehealth video appointments since March 1. 10 The endoscopic procedure data presented reveal a massive care de-escalation intervention of historic proportions that would have been previously unthinkable in a national healthcare system serving 6 million people. Based on historic trends and the change from the historical monthly average procedure volume, we can estimate that after 3 months of de-escalation, approximately 64,000 GI procedures have been deferred in VA. The number of Veterans with postponed and deferred endoscopic care will undoubtedly continue to increase for many months to come, despite plans to resume some non-urgent procedural care. The VA Moving Forward Plan 11 and recently issued guidance on resuming non-urgent and elective procedures 5 establish recommendations for pre-procedure screening and testing, PPE, and additional postprocedural environmental cleaning, as well as maintaining surge capacity that will result in decreased endoscopy productivity compared to pre-COVID levels. Adhering to the mantra "Do no harm", VA's priority is ensuring that deferred care does not lead to adverse patient outcomes (e.g. delayed diagnosis of colorectal cancer). The prioritization framework allows sites to quickly track those cases that should be performed as soon as possible (Priority 2). However, prioritization status is not static, as a previously non-urgent procedure may transition to a higher priority over time. For example, updated VA prioritization guidance classifies abnormal FIT results as Priority 2 within 3 months of the test result, but as Priority 1 after 3 months, reflecting published studies of the association between time from FIT positive results to diagnostic colonoscopy with advanced colorectal cancer. 12, 13 Fortunately, sites will be able to monitor the duration of postponement and re-prioritize those with significant wait times. The resumption of procedures will involve balancing risk, resources and the uncertain trajectory of the ongoing pandemic. 14 We have also witnessed multiple opportunities to increase future access to endoscopic care for Veterans. The recently updated colorectal polyp surveillance guidelines In addition to adopting new surveillance recommendations and shifting patients from screening colonoscopy to non-invasive colorectal cancer screening approaches, future capacity for endoscopic procedures can be increased through careful review of referrals to avoid overuse of these high-demand services. Prior research has demonstrated significant overuse both in non-VA and VA settings. [15] [16] [17] Many VA facilities utilize a "direct access" endoscopy, whereby patients are directly scheduled for endoscopy after reviewing the referral and the patient chart. During the lull in face-to-face clinical activity, many VA providers conducted telephone visits with patients awaiting endoscopy to explain the current situation. During some of these telephone visits, the endoscopist uncovered additional information either from the patient or from prior non-VA procedures that resulted in an alternative course of action that did not include endoscopy. Our anecdotal experience highlights the trade-offs inherent in open access or direct access endoscopy, where the determination of the need for endoscopy is primarily based upon the information provided by the referring provider. Given the clear excess in demand for endoscopy relative to supply at this time, it is more important than ever to carefully review each referral for endoscopy to assure that the procedure is indicated. Our hope is that the intense focus on triage and prioritization of consults during COVID-19 will help sites optimize the timing of procedures. This would also help relieve the backlog of procedures needed to be performed more urgently. As shown in Figure 2 , there has been a mild increase in procedure volume during the month of May, suggesting some sites are slowly increasing endoscopic procedure volume based on VA guidance. 5 A review of the VA Colorectal Cancer Screening and Surveillance Report demonstrates that there are approximately 405,000 Veterans that appear to be due for average risk screening and an additional 107,000 patients due for surveillance and/or diagnostic colonoscopy. Over the next 3 months, an additional 168,000 Veterans will become due for average risk screening and 94,000 will be due for surveillance colonoscopy. These numbers do not include those patients who develop signs or symptoms that warrant colonoscopy or who do not have surveillance recommendations currently entered into the reminder system. Thus, it is imperative that the VA optimize its supply of endoscopic resources while continuing to work to shape the demand, as discussed above. As part of that effort to shape the demand, some VA facilities are building infrastructure to support programmatic non-invasive colorectal cancer screening, such as through mailed FIT, [18] [19] [20] which has been shown to be associated with significant benefits in the Kaiser Permanent system. 21 In summary, the COVID 19 pandemic resulted in rapid interruption of access to endoscopic care Veterans receive across the United States. The VA response was strong and swift and provided a standardized approach for rapid implementation of a process to minimize harm and the "collateral damage" of postponed care due to COVID. The impact was almost immediate across the entire health system, reflecting the effectiveness of the process. At the same time, the VA, like all healthcare systems, now has future challenges and potential opportunities to navigate during this historic time for our healthcare system. Addressing these challenges will require a similarly decisive effort to prevent adverse outcomes for patients resulting from postponement of clinical care. Surgeon General Urges Providers To Consider Stopping All Elective Surgeries. Hospitals Push Back. Health Leaders COVID-19 Clinical Insights for Our Community of Gastroenterologists and Gastroenterology Care Providers Deputy Undersecretary for Health for Operations and Management US Department of Veterans Affairs. Guidance for COVID-19 Pandemic response US Department of Veterans Affairs. VHA Guidance for Resumption of Procedures for Non-Urgent and Elective Indications US Department of Veterans Affairs. Veterans Health Administration Moving Forward Guidebook: Safe Care is our Mission Recommendations for Follow-Up After Colonoscopy and Polypectomy: A Consensus Update by the US Multi-Society Task Force on Colorectal Cancer Implementation and Impact of Universal Pre-procedure Testing of Patients for COVID-19 prior to Endoscopy Endoscopy staff are concerned about acquiring COVID-19 infection when resuming elective endoscopy Message from the VHA Executive in charge US Department of Veterans Affairs. Veterans Health Administration Moving Forward Plan Time to Colonoscopy and Risk of Colorectal Cancer in Patients With Positive Results From Fecal Immunochemical Tests Association between time to colonoscopy after a positive fecal test result and risk of colorectal Cancer and Cancer stage at Diagnosis COVID-19: Long-term Planning for Procedurebased Specialties During Extended Mitigation and Suppression Strategies Overuse of Repeat Upper Endoscopy in the Veterans Health Administration: A Retrospective Analysis Repeated Upper Endoscopy in the Medicare Population Physician Non-adherence to Colonoscopy Interval Guidelines in the Veterans Affairs Healthcare System Outreach and inreach strategies for colorectal cancer screening among Latinos at a federally qualified health center: A randomized controlled trial Low-Value Colorectal Cancer Screening: Too Much of a Good Thing Mailed fecal immunochemical test outreach for colorectal cancer screening: Summary of a Centers for Disease Control and Prevention-sponsored summit Effects of Organized Colorectal Cancer Screening on Cancer Incidence and Mortality in a Large Community-Based Population The authors thank Charles Demosthenes, MD (Atlanta VA) and Yiwen Yao, MS (Salt Lake City VA) for their contributions to data collection and review of the manuscript.The contents of this work do not represent the views of the Department of Veterans Affairs or the United States Government.Keywords: Endoscopy, COVID-19, Veterans