key: cord-0942191-gzhgc5mg authors: Mirchia, Kanish; Khurana, Kamal title: Financial and Educational Impact of the COVID-19 Pandemic in an Academic Hospital-Based Tertiary Cytopathology Practice date: 2021-09-02 journal: J Am Soc Cytopathol DOI: 10.1016/j.jasc.2021.08.006 sha: 25589ccdc9cabc1cf7c1c34f2be53d4374b1cd5c doc_id: 942191 cord_uid: gzhgc5mg Background The ongoing COVID-19 pandemic has led to a dramatic shift in volumes and practice patterns for hospitals around the globe. We analyzed its effect on the cytopathology subspecialty practice and resident education at our institution. Design Specimen volumes were analyzed for the cytology practice for 2019 and 2020. Patient registration and elective and scheduled surgery volumes were also included in the analysis for 2020. The impact of innovative concepts, such as virtual teaching, on resident teaching was evaluated using a survey consisting of five multiple choice questions with four possible responses each. Results The total number of specimens decreased by 28% in March 2020 (p<0.00001), with a continuing decline in April (66% decrease YoY, p<0.00001), followed by recovery in May and return to baseline within June 2020. Specimen volumes continued to show an upward trend thereafter. Improved specimen volumes correlated with patient registration and surgical volumes. The majority of residents considered virtual teaching conferences (75%) and self-study sets (58%) as beneficial and did not view absence of one-on-one microscope learning (58%) as significantly affecting their education. Conclusion The recovery curve for our cytopathology service was V-shaped, essentially the most ideal response to an economic downturn. The majority of residents viewed virtual teaching conferences and self-study sets favorably and did not regard absence of one-on-one microscope learning as adversely affecting their education. The novel coronavirus SARS-CoV-2 is responsible for the COVID-19 pandemic: A respiratory borne illness, which began in Wuhan, China in 2019 and has since spread throughout the globe (1) . Easy transmission via respiratory droplets led to a dangerous and deadly spread of the virus, causing countries and institutions around the world to scramble for mitigation measures. Rapidly escalating cases worldwide and in the United States impacted the varied measures taken by governments, health care systems, and academic institutions to deal with unprecedented circumstances. Since the inception of the COVID-19 predicament, an average of 55% decrease in revenue and 60% decrease in patient volume has been reported by medical practices (2). The dramatic shift in pathology specimen volumes as a result of the pandemic, has affected pathology practices and training of pathology residents and fellows (3-6). The primary measures in addition to hand sanitization and mask wearing was the institution of "social-distancing" guidelines. The exact social distancing guidelines varied from state to state and country to country, but in essence led to cancellation of any large gatherings affecting travel, restaurants, sporting events, etc. Healthcare institutions had to make drastic changes as well, including cancellation of all elective procedures, restrictions on visitors, travel restrictions for staff, and daily temperature checks. This also included cancelling all indoor gatherings including conferences, multidisciplinary tumor boards, lectures, one-on-one sign-out at the microscope etc. Overnight most residency and fellowship programs had to figure out alternatives that would keep everyone safe but also allow education and patient care to proceed in the best possible J o u r n a l P r e -p r o o f way. Continuing conferences in our cytopathology division evolved with using teleconferencing tools such as Zoom (Zoom Video Communications, Inc, San Jose, CA), WebEx (Cisco WebEx, Milpitas, CA), and Microsoft Teams (Microsoft Corporation, Redmond, WA). To limit one-on-one teaching at the scope, we moved to sequential preview of slides, as well as microscope cameras and projecting to another screen during sign-out. Overall case volumes also decreased and to compensate for that, we introduced mini teaching-sets, which could be reviewed by trainees at their own pace followed by informal feedback later. To the best of our knowledge, there has been no published literature exclusively focusing on the educational and financial Impact of the COVID-19 pandemic in an academic hospital-based tertiary cytopathology practice. The aim of our study was to summarize our experience at a hospital based academic cytopathology practice that was affected by the COVID-19 pandemic. J o u r n a l P r e -p r o o f An institutional review board (IRB) exempt status was obtained from the hospital's IRB. To assess the financial impact of the pandemic, overall specimen volume and revenue generated was analyzed for the cytology practice for financial year 2019 and 2020. Variables such as patient population, intake area, and financial accounts were included in the analysis when comparing years 2019 and 2020. The data was divided into monthly segments further subdivided into gynecologic cytology specimens, non-gynecological cytology, and fine-needle aspirate (FNA) specimens. Institutional, state, and national guidelines were incorporated into the study as well as stimulus strategies to ease the effect of the pandemic. We also collected data on patient registrations, elective, and non-elective surgical procedure scheduling at our institution and affiliated hospitals to better understand the correlation of hospital policies with our tertiary cytopathology specimen volume. This data was obtained from an institutional request to the cost manager and the chief financial officer of the hospital. This data was a part of their routine data-gathering efforts and did not involve access to any protected health information (PHI). To assess the impact of novel concepts affecting resident and fellow education, such as virtual teaching, compliance with social distancing and institutional/state/national guidelines on resident teaching, a voluntary anonymous survey questionnaire was sent to all the ACGME-pathology residents and fellows at our institution via Google Forms The overall cytopathology specimen volume (Figure 2A Security (CARES) Act 2020 helped to offset an additional 2% of economic loss, bringing the net revenue decrease for year 2020 to 15%. Based on the specimen volume in June 2020, the projected annual volume deficit for the practice was -22.33%; however, the actual YoY volume deficit for financial year 2020 was -5.22%. The subdivided specimen populations showed a similar pattern with a few notable differences. The gynecologic specimens ( Figure 2B ) showed a decline in March through April, with recovery by June 2020. However, the YoY specimen volume actually increased by 10.02% (projected increase of 4.97%) despite the effect of the COVID-19 pandemic. The non-gynecologic specimens ( Figure 2C ) showed a similar downward trend, and recovery trend, however, the volume was consistently lower from June (point of maximum recovery) through December 2020, compared to similar duration in 2019. The YoY specimen volume decrease was 21.46%. FNA specimens ( Figure 2D ) showed a decline similar to the other specimen subdivisions, however differed in recovery. FNA specimens showed a delayed recovery with return to baseline in July 2020 compared to June 2020 for the remaining services; and lower specimen volumes for the remainder of financial year 2020 compared to the same period in 2019. The final YoY volume decrease was the most of all services at 23.56%. To study the impact of operating within a tertiary hospital, we analyzed total monthly patient registrations, scheduled and elective surgery volumes for adults, The FNA specimen volumes however, most closely approximate the cumulative monthly surgical volume (both scheduled as well as elective procedures; Figure 3B ). Both show a protracted recovery curve with return to baseline volume in July 2020. The volume curves from July through December 2020 also closely approximate each other. Sixteen ACGME-residents and fellows were polled to assess the impact of COVID pandemic protocols on education. Twelve responses (75%) were recorded. A category of not-applicable (N/A) was added for certain questions to allow those trainees to participate in the survey who did not specifically work in the department of cytopathology during lockdown but attended didactics and other cytopathology educational activities. One of the earliest changes to prevent large gatherings in closed indoor spaces was to transition didactic sessions, multidisciplinary conferences, and meetings to an online teleconference platform such as WebEx/Zoom/Teams. 67% (n=8) of trainees reported a beneficial impact on their education due to transition to Zoom/WebEx based didactic session, 25% (n=3) reported no change, and 8.3% (n=1) reported preference for inperson didactics ( Figure 4A ). We also increased the number of slide-based self-study sets to compensate for the decrease in specimen volume in the cytopathology practice. 58% (n=7) reported a beneficial effect of these additional slide sets ( Figure 4B ) and 17% (n=2) reported no change. Interestingly, 33% (n=4) of the trainees found the decreased volume of cases J o u r n a l P r e -p r o o f helpful towards learning the subject matter while 25% (n=3) found it detrimental and 33% (n=4) reported no change due to the change in case-volume. (Figure 4C) There was also a need to decrease one-on-one resident/fellow teaching at the microscope, which was found to be harmful by 8% (n=1), helpful by 33% (n=4) and not a significant change to educational objectives by 58% (n=7) of the respondents ( Figure 4D ). To be compliant with institutional gathering policy, trainees were also not allowed to attend FNA procedures, which was reported as a detriment by 17% (n=2), helpful by 8% (n=1), no change by 33% (n=4), and was not applicable for 43% (n=5) respondents ( Figure 4E ). Aside from single-answer poll questions, trainees were also asked to grade 5 factors on a scale from 1 (poor) to 5 (excellent) and the contribution of these factors towards their education ( Figure 4F ). Impact of these factors reported as excellent in order of magnitude is case sign-out with attending cytopathologist on service, case preview with ACGME-fellow on service, use of self-assessment modules, participation in on-site assessment of specimens, and knowledge of anatomic pathology from general surgical pathology rotations. In compliance with state-mandated and our own institutional policies, there was a significant reduction in monthly patient registrations, scheduled and elective surgery volumes for adults, pediatric visits, outpatient procedures, and interventional radiologybased procedures during early phase of pandemic (March to April 2020). This resulted in a significant drop of cytopathology specimen volumes during the same period (28% to 66%). Based on the overall cytopathology volume in the month of June the projected reduction for 2020 was volume 22.33%. However, the annual cytopathology practice volumes for financial year 2020 decreased by 5.22% with FNA subspecialty volumes decreasing by as high as 23.56% compared to 2019. This overall annual decrease, however, was much lower than the projected deficit, and the strongest effect on FNAs was due to restrictions in OR scheduling, time-delay for the required COVID rule-out testing and triage process for most efficient allocation of hospital resources. Our data also shows an abrupt and significant decrease in patient volume, mostly due to stringent initial guidelines and restrictions instituted by our hospital and the state government in response to the pandemic. Our financial recovery was a V-shaped curve, which is essentially the most ideal economic response to a downturn. Monroig-Bosque et al. showed similar recovery in their gynecologic cytology, non-gynecologic cytology, surgical pathology, and neuropathology volumes for the time period of January through May 2020 during the coronavirus pandemic (4) . Moving from the most ideal to least ideal scenario, financial recovery can take many shapes that can be described as a V-shaped curve, U-shaped curve, W-shaped curve, L-shaped curve, and the newly hypothesized K-shaped curve J o u r n a l P r e -p r o o f (14, 15) . The curves are an informal shorthand to plot gross domestic product (GDP). A V-shaped curve is the most ideal response to a recession; where the economy suffers a sharp but brief period of economic decline with a clearly defined trough, followed by a strong and sustained recovery. A U-shaped curve is a longer lasting recession with a widened trough, and a slower return to growth. In a W-shaped recession, the economy falls into recession, recovers with a short period of growth, then falls back into recession before finally recovering. An L-shaped depression occurs after a severe recession with a lack of return to baseline growth. The K-shaped/two-stage recession is a recovery hypothesized for the coronavirus 2020 pandemic where the recovery is divergent with parts of society experiencing more of a V-shaped recession, while other parts of society experiencing a slower more protracted L-shaped recession. Based on the specimen volume in June 2020 the projected annual volume would have resulted in a volume deficit for the cytopathology practice of 22.33% and contributed to greater than 50% loss of revenue, which is similar to that reported in most practices since the beginning of the pandemic (2). However, V-shaped recovery of cytopathology specimen volumes resulted in 17% gross revenue loss for year 2020 compared to 2019 and the stimulus measure: CARES Act helped to offset an additional 2% of economic loss bringing the net decrease in gross revenue to 15%. Our study shows a V-shaped recovery that was aided by implementation of guidelines at the hospital, state, and national levels. The presence of excellent laboratory policies prior to the pandemic, such as universal precautions, use of N95 masks, use of biosafety cabinets for aerosolizing procedures, allowed the staff to rapidly adapt to the changing needs of the pandemic and avoid further hardship. We were also able to avoid staffing problems or furloughing employees. This was aided by the stimulus measures such as the issuance of a PPP loan under the HHS CARES act and billing assistance by our institutional governing board, which further allowed full retention of technical and administrative staff during the pandemic. Of the categories of non-gynecologic, gynecologic and FNA specimen, the most significant decline was noted in FNA specimen volumed. We believe that the reason for slower recovery and more significant decline in FNA specimens was connected to the complexity of acquiring most FNA specimens. This included dependence on availability of procedure room, availability of ultrasound or computed tomography equipment and skilled staff, as well as competing triage demands for the same equipment/rooms/staff by other surgical procedure, which was further compounded by COVID-19 restrictions imposed in the hospital setting. A similar requirement may also explain the higher YoY decline in non-gynecologic cytology specimens compared with gynecologic cytologymost of which can be collected quickly, in an outpatient non-invasive setting; and do not compete with the same hospital resources as the other specimen types. (4) . The experience of other non-pathology programs has also been alike (7) (8) (9) (10) (11) (12) (13) . The majority of residents did not view the loss of one-on-one scope training as adverse when offset by the use of real-time video displays and supplemented by self-study sets. Reduced volumes during pandemic allowed residents to spend more time on study sets, to learn the morphologic skills and diagnostic criteria at their own pace. Under normal circumstances the caseload in cytology service may preclude residents to go over study sets in detail. Mini quizzes were administered during their rotation to ensure that the residents were developing the right skill sets. Although residents were not able to attend FNA procedures, they were able to give an input on rapid on-site assessment by reviewing real time images via telecytopathology. While not being able to attend or perform superficial FNA was a concern for some residents, we hoped that the 3-month resident rotations in cytopathology, distributed over different years of training would provide ample opportunities when they returned for their second or third rotations at a time when the pandemic was better controlled. Review of our program's cumulative score for the cytopathology section of RISE (2021) following the introduction of novel concepts for resident education revealed no change when compared to RISE score for the year 2020. Although RISE performance does not provide a wholesome overview of resident training, we believe that review of the cumulative program scores reveals that the implementation of changes in resident training in cytopathology during pandemic did not adversely affect the resident education. While this study-set is limited by responses from 12 AP/CP residents, the trainees studied are evenly distributed from PGY-1 through PGY-4. However, given the smaller number of trainees surveyed, this may not accurately reflect the experience across all training programs, or across residents pursuing AP-only residency track. Overall, our study informs policymaking. Our data shows a sharp and significant decrease in patient volume, mostly due to stringent guidelines set by the state and national governments and our institution in response to the pandemic. The recovery curve was V-shaped, essentially the most ideal economic response to a downturn. The recovery efforts were also helped by stimulus measures such as the HSS provider relief CARES act, avoiding any potential loss of employees and a quick return to full workload and workforce. Most surveyed residents welcomed the innovative practices introduced for their training and education. An overwhelming majority of residents considered virtual teaching and self-study sets review as beneficial and did not view absence of one-onone scope learning as adversely affecting their education. While we are still working under some pandemic regulations, we foresee long-term incorporation of most of the novel concepts introduced during this pandemic. 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The many shapes of recessions and recoveries". The Conversation. Retrieved Powell's Ready to Play the Fresh Prince of Bubbles The authors declare no conflict of interest.J o u r n a l P r e -p r o o f The financial and educational impact of COVID-19 pandemic in our academic hospitalbased tertiary cytopathology practice are examined.The financial recovery curve for our cytopathology was V-shaped, essentially the most ideal economic response to a downturn.Our residents and fellows welcomed utilization of innovative educational tools including virtual teaching and did not regard absence of one-on-one scope learning as adversely affecting their education.