key: cord-0950393-hjdfeh6e
authors: VERALDI, Gian F.; MEZZETTO, Luca; PERILLI, Valeria; MASTRORILLI, Davide; MORATELLO, Ilaria; MACRÌ, Marco; D’ORIA, Mario; CARLUCCI, Matilde; POLI, Ranieri
title: Clinical and economic impact of COVID in Vascular Surgery at a Tertiary University ‘Hub’ Hospital of Italy.
date: 2022-03-02
journal: Ann Vasc Surg
DOI: 10.1016/j.avsg.2022.02.004
sha: 5c8bf020f9206a04c4f37af84ea44f6518a352e9
doc_id: 950393
cord_uid: hjdfeh6e

OBJECTIVE: To analyse the clinical and economic impact of Coronavirus Disease (COVID) Emergency State (Cov-ES) in the Department of Vascular Surgery at a Tertiary University ‘Hub’ Hospital. MATERIALS/METHODS: Differences in clinical practice according to Diagnostic Related Group (DRG) and International Statistical Classification of Diseases (ICD) and related Health Problems and the financial impact of Cov-ES were considered. Vascular procedures performed between March 2019 to December 2019 (Pre-pandemic) were compared to those performed in the period March 2020 – December 2020 (Pandemic). Pre-pandemic and Pandemic reimbursements of all vascular activities and the top three vascular diagnoses were evaluated. RESULTS: Pre-pandemic vs Pandemic era documented a decrease of vascular consultations performed (2,882 vs 2,270, -21.2%). The number of total vascular procedures decreased from 997 to 797 (-20.1%) with a higher reduction observed in outpatient surgical activities (247 to 136, -45.0%, p=.0005) rather than inpatient surgical activities (750 vs 661, -11.9%, p=.02). Length of hospital stay (LOS) increased from 3.3± 2.7 days in Pre-pandemic to 5.3 ± 3.9 in the Pandemic era (p=.004). Among patients with limb-threatening ischemia, the rate of major limb amputation was higher in the Pandemic (3.3% vs 5.4% respectively, p=.02) and a higher rate of elective hospitalization procedures were performed as urgent/emerging setting after clinical deterioration (2.8 % vs 6.4%, p=.0002). According to DRG classification, an increase of ‘complicated’ limb-threatening ischemia (DRG 554) and aortic aneurysm (DRG 110) was observed pre-pandemic to pandemic (+84.2% and +25.0%, respectively). Total reimbursement for vascular activities between Pandemic vs Pre-pandemic was 4,646,108 € vs 5,054,398 €, respectively (-8.0%). Management of ‘complicated’ limb-threatening ischemia (DRG 554) and aortic aneurysm (DRG 110) required a higher clinical and financial support that was translated into higher economical reimbursement during the pandemic (273,035€ vs 150,005€, +82.0% and 749,250€ vs 603,680€, +24.1%, respectively). CONCLUSIONS: During the Pandemic, the main resources were employed for treatment of limb-threatening ischemia, aortic aneurysm, and carotid stenosis. Inpatient activities documented an increase of major limb amputation and LOS. An increased reimbursement for each vascular procedure and for all ‘complicated’ diagnoses revealed the more serious and resource-demanding pathology occurred in this period.

pandemic to 5.3 ± 3.9 in the Pandemic era (p=.004). Among patients with limb-threatening ischemia, the rate 48 of major limb amputation was higher in the Pandemic (3.3% vs 5.4% respectively, p=.02) and a higher rate of 49 elective hospitalization procedures were performed as urgent/emerging setting after clinical deterioration (2.8 50 % vs 6.4%, p=.0002). According to DRG classification, an increase of 'complicated' limb-threatening 51 ischemia (DRG 554) and aortic aneurysm (DRG 110) was observed pre-pandemic to pandemic (+84.2% and 52 +25.0%, respectively). Total reimbursement for vascular activities between Pandemic vs Pre-pandemic was 53 4,646,108 € vs 5,054,398 €, respectively (-8.0%). Management of 'complicated' limb-threatening ischemia 54 (DRG 554) and aortic aneurysm (DRG 110) required a higher clinical and financial support that was translated 55 into higher economical reimbursement during the pandemic (273,035€ vs 150,005€, +82.0% and 749,250€ vs 56 INTRODUCTION treatment in a Covid-dedicated operating room. Only one patient was found positive after admission in the 101 'Green Zone' and he was transferred to the Covid ward for further medical therapy. 102

Availability of beds in the ward decreased from 12 to 8 and specific personnel (nurses and care givers) were 103 redeployed to perform critical activities in Covid-wards. To guarantee the availability of vascular surgeons 104

during the pandemic at all times, all vascular surgeons received at least one NPS per week and avoided 105 precautionary quarantine in case of direct contact with a Covid-patient. Vascular consultations were mainly 106 reserved to urgent or not deferrable clinical questions and telehealth was never used for clinical consultation. Since the beginning of Pandemic, the priority of treatment was given to patients with urgent/emergent or non-117 deferrable pathologies, as follows: 118 -Abdominal aortic aneurysm: any symptomatic or diameter ≥ 60 mm, rapid growth (≥ 0.5cm in 6 119 months or ≥ 1cm in 12 months, lesion instability on CT scan (blister, fissuring thrombus). 120 -Thoracic and thoraco-abdominal aneurysm: any symptomatic or diameter ≥ 65 mm, rapid growth 121 (≥ 0.5cm in 6 months or ≥ 1cm in 12 months, lesion instability on CT scan (blister, fissuring thrombus). 122 -Iliac aneurysm: any symptomatic or diameter ≥40mm, rapid growth (≥ 0.5cm in 6 months or ≥ 1cm 123 in 12 months, lesion instability on CT scan (blister, fissuring thrombus). 124 -Peripheral aneurysm: any symptomatic or diameter ≥30mm, rapid growth (≥ 0.5cm in 6 months or 125 ≥ 1cm in 12 months, lesion instability on CT scan (blister, fissuring thrombus Similarly, the volume of vascular consultations (ambulatory visits, advanced medications, and ultrasound 141 duplex examinations) during the Pandemic were observed and compared to the Pre-pandemic volume. 142

The study was performed in accordance with the Institutional Ethics Committee rules. Individual consent for 143 this retrospective analysis was waived. All patients signed consent to the processing of personal and clinical 144 data to be collected prospectively in the integrated institution database. For this specific type of study, consent 145 for publication is not required by the local Institutional Review Board, in accordance to the Italian National 146

Policy in the matter of Privacy Act on retrospective analysis of anonymized data. Guidelines from the Italian ministry of health about rate system of health care and the methodological 155 definition of DRG system has been well described elsewhere 7-8 . In brief, the ministerial rates are fixed for all 156 types of hospitals and each region has the opportunity to modulate its own rates as a function of various types 157 of patients. To allocate each patient to a specific DRG, some information contained in the Hospital Discharge 158

Records (HDR) was evaluated, including data about ordinary and outpatient admission. Diagnoses were 159 divided into 17 sectors. The principal diagnosis at discharge is the main condition treated during the hospital 160 stay and it requires the greatest resources. The presence of several secondary diagnoses, such as diabetes or 161 was considered significant. Analysis was performed with SPSS software (IBM, Chicago, USA). 174

Clinical characteristics of patients were similar between the two periods, and outcomes of procedures are listed 178

in Table I . Length of hospital stay (LOS) increased from 3.3 ± 2.7 days in Pre-pandemic to 5.3 3.9 in the 179 Pandemic era (p=.004), even when the need of early reintervention and early mortality did not statistically 180 differ. Among patients with limb-threatening ischemia, the rate of major limb amputation was higher in the 181

Pandemic vs Pre-pandemic (5.4% vs 3.3% respectively, p=.02) and a higher rate of procedures scheduled for 182 elective hospitalization were performed as urgent/emerging setting after clinical deterioration in the Pandemic 183 era (6.4% vs 2.8%, p=.0002) ( Table I) (Table II ). An endovascular approach was used 194 in 299 vs 264 (-11.7%), an open surgical approach was used in 220 vs 191 (-13.2%) and a hybrid technique 195 was performed in 58 vs 37 (-36.2%). Only in the subgroup of patients with aortic aneurysm, a higher rate of 196 5,054,398 €, respectively (-8.0%). The greatest loss of reimbursement was observed in the total outpatient 210 activity, which decreased by 59.4% (153,952 € vs 378,898 €). Inpatient procedure loss of reimbursement was 211 less evident (-3.9%, 4,492,156 € vs 4,675,500) and, on the contrary, the average reimbursement for procedure 212 increased by 9.0% (6,796 € vs 6,234 €) (Table V) . 213

The top three vascular diagnoses in 2020 were 'limb-threatening ischemia' ( Coronavirus disease (COVID) caused a worldwide outbreak requiring a complete reorganization of the health-226 care system and a new management of its personnel 9 . 227

Our analysis documented that our pandemic management was similar to those of the bordering regional 228 hospitals, with two separate pathways for patients and the personnel. The close monitoring of the infection as 229 well as the COVID-dedicated ward and operating rooms, played a crucial role in preventing the spread of the 230 contagion and guaranteed 24/7 vascular service with only one hospitalized patient transferred to the COVID 231 area after elective surgery. Assessment of the hospital was deeply modified: dedicated COVID areas were 232 created and different pathways were identified in order to separate COVID patients from COVID-free patients. 233

According to the Public Health Authority recommendations, medical and financial resources were reallocated 234 and personnel were re-employed in critical care areas. Several highly specialized surgical specialties, such as 235 Vascular Surgery, suffered a significant reduction of resources 10 and precise protocols for infection prevention 236 and control became necessary to guarantee the safety of patients and hospital personnel during their daily 237 activities 11-12 . 238

Limitations of daily activities, together with the fear of the contagion, caused a delay in the diagnosis of 239 vascular pathologies and the worsening of clinical outcomes, especially in limb-threatening ischemia patients. reimbursement of each inpatient procedure increased from 6,234 € to 6,796 € (+ 9.0%). Furthermore, the sub-Pre-pandemic era (+82.0% and +24.1%, respectively). This higher rate of reimbursement for each vascular 284 procedure and for 'complicated' vascular diseases may be translated as an additional economic loss for the 285 healthcare system, already stressed by direct costs of the outbreak. Mid-and long-term impacts on the Public 286

Health System of such assessment is still unknown and further studies are necessary to clarify these issues. 287

288

This study has several limitations. Firstly, it was an observational retrospective analysis and statistical analysis disease and acute limb ischemia 21-22 . Lastly, this analysis included data from a single Italian regional hospital, 295 which has economical roles slightly different from other regional centres, as described above, and a comparison 296 between different regional hospitals would be interesting to understand if our data were in line with the national 297 average. 

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