The great challenge of something such as COVID-19 is that we don’t have the time to do decades of research to understand the effectiveness — or lack of effectiveness — of any given approach. We have to act. That means, though, that we could be “successful” at handling COVID-19 yet still fail society due to unmeasured impacts.
In other words, if we ban elective surgery — and define elective surgery as anything that gets scheduled as opposed to an emergency — we don’t know the full negative ramifications of making people wait an unknown amount of time to have their elective surgery. We also don’t know how people will react when limits are lifted. Will they really believe it is safe to engage with the medical system again?
We know of one close associate whose father was suffering and possibly needed surgery. He lived in New York metro area, and his wife was afraid of him catching COVID-19 and held off on visiting the hospital or calling an ambulance. It is entirely possible that he would have lived had he been treated.
When this passes, there will be many studies trying to understand the full medical impact of the COVID-19 pandemic, and this will include the impact of policy choices. In other words, if there is a Second Wave or a different pandemic down the road, would it be desirable to set up “virus-free’ hospitals so that people would not be afraid to get treatment?
We don’t know, but there is a most interesting study about to be published that starts to take us down this road. We asked Mira Slott, Pundit Investigator and Special Projects Editor, to find out more:
Q: The COVID-19 pandemic has thrown many industries, including the produce industry, into a tailspin and has spawned many transformations. As in most cases, addressing one big problem leads to other problems. To flatten the curve and reduce the strain of the impact of the COVID-19 pandemic, many hospitals and health systems halted a wide range of elective surgeries and procedures. A significant number of those procedures were cancer-related treatments, which are now expected to surge after the pandemic. This will challenge the capacity and quality of the healthcare delivery system, spurring your new research at Johns Hopkins.
As produce industry executives navigate the impacts of COVID-19 and strategies going forward, sometimes the most valuable lessons and insights can be gleaned through other industry perspectives.
A: The food industry is also tied to health. With the COVID-19 crisis, what your industry has been doing is very important in keeping Americans fed, but also from a health perspective — and I would argue from a cost perspective — the produce industry has been very resilient.
This research addresses the implications and management of post-pandemic demand surge of dermatologic surgery, with a possible second wave of disease outbreak in mind.
Q: Since this study is focused specifically on skin cancer, how applicable will its modeling/methodology and analysis be to other cancers, other diseases, surgeries and procedures?
Could this research provide wider applications across the healthcare system and can this analysis be transferred to hospital operations and supply chain management systems more broadly?
Does this open the door to other research? For example, what was the effect of parents holding off on getting their children vaccinated during the pandemic? Will this lead to an increase in measles outbreaks. Could this study methodology be applied to increased complexities of dental work due to patients holding off on seeing their dentist…
A: These are good questions. The project is motivated by the current situation in the Cutaneous Surgery and Oncology Unit in the Department of Dermatology at Johns Hopkins School of Medicine. Due to the COVID-19 pandemic, all elective surgeries have been deferred for at least three months. These skin cancers will continue to grow during this time and require expedited treatment when restrictions on care are relaxed.
An immediate concern is how pandemic-related deferrals of elective surgeries and how post-pandemic demand surges will impact revenue-generation, patient out-of-pocket costs, and most importantly, patient outcomes.
These concerns are not distinct to Johns Hopkins Dermatology and present a compelling research question widely applicable to a myriad of healthcare delivery settings disrupted by the current and future pandemics.
Q: What is your research plan?
A: We are conducting this research with three aims: First, to assess the operational and financial impacts of COVID-19-related surgery postponements on dermatological surgery nationwide; Second, to connect the impact of delayed surgery to clinically meaningful metrics of disease and patient-reported outcomes; and Third, to model and quantify the benefit of flattening the curve.
The project takes a multidisciplinary approach to understand the personal and financial cost of deferring skin cancer surgery while modeling efforts to flatten the “second wave,” such that each patient may receive comprehensive and expedited care. The database created will serve as a springboard for further projects exploring the intersection of physician-reported outcomes, cost of care, and individual financial burden in cancer therapy…
Q: Are there other studies with similar metrics that have looked at effects of patient care delays during pandemics or crises?
A: Research on non-Ebola care during the 2014-2016 West African Ebola virus epidemic suggests that flattening the post-pandemic demand curve for elective surgeries requires a broad view of the supply chain. Our research will incorporate both supply-and-demand side considerations. Based on our modeling and analysis, we will demonstrate the operational, financial and clinical implications of post-pandemic demand surge and suggest proactive steps to manage the surge.
We believe our research will have broad impact beyond the motivating setting by incorporating behavioral, incentive, and policy issues into the modeling and analysis of disaster preparedness and response, and to inspire new research from the healthcare operations management and health service research communities.
Q: What is the connection of measuring complexity in delay in treatment and patient costs and how it relates to actions to flatten the curve? What confounding factors are you regressing out, and what factors are you gathering that are important to understand impacts.
A: This study is about flattening the curve for the post-pandemic surge in skin cancer procedures specifically. Now if you go to the hospital, a lot of these procedures are being postponed. We’re looking at skin cancer patients that have tumors. There’s no way we’re not doing the surgery because the tumor needs to be removed. So, it’s just deferred, which means the tumor will just be getting bigger.
We must be more pro-active in the planning process to coordinate with patients, the primary care physicians and specialists and hospitals for treatments and surgeries, because if we don’t do this, we will have a surge that will far exceed the capacity of the healthcare system.
I’m also working on related research on colon cancer patients, a collaborate study between Johns Hopkins and Imperial College in the UK. There is real concern about all the postponements in surgeries and the cancellations and pent up demand because when these patients all come back, the hospitals won’t be ready.
Q: Are these patients still unable or afraid to come in for treatment?
A: They are coming back now in Maryland. Maryland has allowed elective procedures to begin again at hospitals. So, patients are coming back really slowly because they are still afraid, and there are challenges. Everyone must wear a mask, and there are strict restrictions in the waiting room, and other hospital limitations. The other thing is… patients are still kind of concerned about getting infections, so even though patients are being invited back, they are continuing to postpone procedures.
So, there is a supply issue and there is a demand issue. These reservations have occurred in other pandemics. This happened with the Ebola crisis in West Africa, and there are indications that is what we’re going to see here, that after the emergency is over, the huge increase in patients will overwhelm the system.
Q: To flatten the curve of COVID-19, people were ordered to shelter in place, and social-distance one another to reduce the number of coronavirus hospital cases, thus securing enough equipment, beds, ventilators, PPE, N95 masks and gear. In other words, decrease the number of sick coronavirus patients and increase the supply and capacity to treat them.
A: You don’t want your case load to overwhelm the medical facilities. Either increase your medical capability or reduce your patient load… We should either try to reduce the surge on post-pandemic patients or be pro-active to help prepare the healthcare industry to handle it.
There are three different components — the hospital perspective, the patient perspective, and the supply/demand side — that factor into how the patient demand will build up and the effect on the supply chain.
Looking at the operational side with any industry and how the supply chain interconnects is critical. The produce industry as an example…
So, people don’t walk into surgery. They have to see a general care physician first, then an oncologist before they are referred to a surgeon. Understanding the supply chain of the care is important.
During the coronavirus, patients weren’t seeing their primary physician for three months, but right now, you see cases where they’re going to their primary physicians, who are sending them to do tests, biopsies, etc., and some of them will be more serious than others. So, we have to understand the hierarchy of the supply chain.
By looking at the risk of delaying the cases, there are two aspects. If by delaying cases, are we putting lives in danger or making cases more complicated, involving more surgeries? On one hand, people have underlying conditions and are prone to coronavirus dangers. Are we putting more people at risk of contracting the coronavirus by treating their medical conditions.
You must balance and manage the risks. From a hospital perspective, you need to understand demand.
The other piece is from the patient perspective; people are hesitant from a mental health perspective. Part of the reason is this COVID-19 pandemic has been a traumatic experience for all Americans, and for some incredibly traumatic.
Most people know someone from their families — a friend, or a friend of a friend, directly or indirectly affected. Understanding that quality aspect of mental health. We want to look at a patient’s anxiety as the economy is re-opening in deciding procedures.
Q: Do you think some of this anxiety could be based in real concerns of possibly getting infected with COVID-19? If the hospital didn’t have the proper gear and masks, procedures in place… This was an issue widely reported. Or perhaps the patients don’t have health insurance, or are afraid they won’t be able to afford the costs of the surgery…
A: Yes. There is a subjective concern, the psychological, behavioral side, and also the aspect of how well equipped the hospitals are. Do they have enough PPE; is there a chance of patient contamination…?
The fees and charges are another deterrent. Insurance fees for paying out of pocket can be huge.
Hospitals need to be really well prepared with social distancing, getting enough PPE for staff and patients, and accommodating testing… for instance, with organ transplants, if a patient needs a kidney, the recipient and donor have to undergo a lot of testing. It takes time and also capacity.
It requires coordination, and can create multiple bottlenecks in the system.
Something as basic as a waiting room can be a bottleneck. When people come back to the hospital, are you asking them to sit in a waiting room? That’s something we’re trying to understand in terms of patient anxiety and then provide accommodation to minimize the chance of infection, and also intervene on the mental health effects.
Q: Could you talk more about the parameters of the study? And what factors are being considered in the metrics?
A: First of all, we are measuring healthcare in the U.S., mostly focusing on Johns Hopkins Hospital. We’re looking specifically at skin cancer patients, comparing cases from 2019 without delay or cancellation before the COVID-19 pandemic to cases in 2020, where all elective surgeries have been deferred for at least three months.
In 2020 we see hundreds of backlogs in skin cancer cases. With skin cancer cases, you’re always going to have delays with treatments, because they involve a complicated process, and you’re not going to do them tomorrow. So, the patient condition is getting worse over time. What effect will the additional time waiting for the treatment have on the outcome and on complications?
After the case is performed, you can look at what treatment was used, and the effect on the patient’s medical condition, the financial impact, i.e., was the patient paying more for the treatment.
People with high mortality rates are prioritized. Most of the delays are with people whose condition could progress, but it might not be that much, so we want to look at patients of comparable conditions, and to understand, because of this COVID shock, how does this influence patient outcomes.
Q: So, the severity of the case would be one factor, in that those with high mortality rates would be prioritized for treatment. What other factors are involved in the metrics? For example, will you attempt to identify age of patient, gender, economic situation, other underlying health problems, etc., in analyzing the data?
A: This is a really interesting development. We’re doing an empirical study on patient characteristics and demographics to identify comparable kinds of patients. So, these two groups from 2019 to 2020 are almost one in being as comparable as possible, which is critical when analyzing the data.
Q: To clarify, this is research you’re just starting now?
A: We just got approved and got the funding from Johns Hopkins Department of Health, and the other part approved is from grants. The study is perfectly timed.
Our hypothesis is that delays in procedures are going to result in an overcompensation for demand. First of all, people who are coming back have worse conditions, and worse conditions are going to require more complex treatments.
Another problem will be the shock to hospitals. It’s also going to require more expenses. The costs will impact the health providers and also the patients with more out-of-pocket expenses. There are other pieces on how we are going to mend the situation and the negative implications, but this is the hypothesis.
Q: How does this relate to your study with Imperial College in the UK?
A: As I mentioned earlier, I’m part of another study, looking at UK and U.S. hospitals, with a focus on colon cancers, how the procedures and testing have been affected, and how patient outcomes have been affected. We started this study back in March and have already published information on this.
That study I’m participating in as part of the U.S. team at Johns Hopkins with the UK team at Imperial College. There are many, many things to look at.
Q: Are there notable differences in focusing on colon cancer as opposed to skin cancer? Comparing U.S. and UK outcomes could take your research to a whole new level… are you incorporating the differences in healthcare systems, cultures, etc., in handling of the coronavirus pandemic?
A: Yes. There are four phases of the study. In terms of patient outcomes, it’s too early to see whether the providers and the different natures of the healthcare systems are making the situation better or worse. Phase 4 objectives are to compare the impact of COVID-19 on the UK’s NHS and USA model of health care in terms of service provision and cost, and to propose a standardized model of delivering colorectal cancer services for future outbreaks using our collected data and prediction model.
Q: The premise for your research is that actions to flatten the COVID curve at hospitals creates a new curve in cancer-related elective procedures and treatments. How does your research actually lead to flattening that curve?
A: That is the significance of these studies. We are really, really paying attention to what’s going to happen, and the goal is to devise an action plan to minimize those impacts. We need a plan; if things don’t go as planned, we need options. What if we have a second wave?
The action is to understand the different parts of the supply chain and actively reach out to determine whether patients should be prioritized in terms of when they get biopsies and when they get surgery. There is a need to coordinate with people down the supply chain, so you can control the hundreds of referrals, and you have a more orderly process.
The other thing — really the basic minimum — is to try to understand the patients before they come to the surgical suite. The patient has to go through many stages. Surgeons need visibility to prepare, to ensure hospitals can get enough PPE, to have enough testing, because if you just react two weeks before, it will cause a lot of inefficiencies and problems.
Q: Are you saying the patient/hospital supply chain system is disconnected, and lacks visibility now?
A: Yes. It’s problematic. There is not that much visibility… physicians basically work in silos with their patients, and they rarely speak to each other. We hope through this research to promote a culture of coordination, at least in terms of information flow, to move from no information to some information, to make it better than it is now. This is how many patients I’m seeing right now, because eventually people are seeing their primary physicians, and more will see dermatologists. If members downstream have some information of what’s going on upstream, they can be better prepared to manage the demand surges.
Q: Your expertise and research in operations and supply chain management are extensive. I saw that you received scientific acclaim for your studies back in 2015 on remedies to flu vaccine delivery problems and research on contracting for on-time delivery in the U.S. influenza vaccine supply chain. This seems interesting with the current issues related to a COVID-19 vaccine… do you see some connections with the studies you did in the past and what you are doing now?
A: The connection comes from the fact that people have to plan ahead, operationally in terms of production and delivery. In our influenza study, most people need a flu vaccine in October, early November. We must understand the flu shot supply chain is very complicated, with so many different segments.
After the FDA has decided what should be produced — and it takes time to figure out what viruses should be protected against — it’s too late in the process. The production process involves many stages and issues. So, you really have to be proactive in starting the production even before FDA tells you what to produce to ensure you have what’s needed on time. That comes with risk, and you may have to discard a whole lot of product. It requires coordination with hospitals and pharmacists to have incentives to do that.
We don’t know when the COVID-19 pandemic will be over, and when it will come back, and what hospital demand will look like. We need to be proactive, knowing that, and work with different members of the whole supply chain to provide the best quality medical care.
Q: What you describe sounds like a broader systemic issue in orchestrating cost efficient and effective supply chain management… How do you coordinate that? Do you think it should be managed at a national level?
A: Ideally, you want there to be national coordination, but most of the healthcare system in the U.S. is highly decentralized. Even if the White House does coordinate some response, the healthcare system in the states has to provide the care to the patient. I do think the federal government is in a very good position to unify the coalition to help improve the healthcare supply chain and ensure PPE gets to hospitals and healthcare facilities, but eventually we have to work through individual healthcare systems.
This is why Johns Hopkins is working proactively to identify many of the issues, to help develop guidelines other hospitals could be using.
Q: Won’t those guidelines change based on different hospital structures and specialties, regions of the country, maybe a small rural hospital versus a large urban one in a densely populated area, supply and demand, etc. And where and who is getting COVID-19 now?
A: Changes at Johns Hopkins will be different than changes at Baltimore Medical Center, which is more like a community hospital. Because community hospitals don’t have as many COVID patients, we want to be aware of the differences across specialties and across different regions of the United States. Look at New York and COVID-19 infections and mortality rates. We have many different population densities and travel patterns…
Q: That’s an advantage to have this integrated expertise…
A: Nobody can do this alone. The public health side is important, but also the business side. How can we do things on the operation marketing side to solve the problems. We have to work across the silos.
Q: Is there a reason why this research is just focusing on skin cancer? Going back to an earlier question, can the modeling and methodology you’re using to measure personal and financial costs in delays with skin cancer tumor growth be transferable to other cancers, or other elective surgeries, or does each specialty need its own research and modeling? For example, the study you’re working on with Imperial College focuses on colon cancer… are there too many differences?
A: You have different parts of the medical care — the generalists, the primary care physicians, the specialists, and the surgeons… For this study, the key difference between skin cancer and colon cancer is the surgery involved. If you are a skin cancer surgeon, you have your own kingdom; you have your own physical space and you don’t have to share with the rest of the hospital. You’re also doing most of your work on an outpatient basis.
Other types of surgeries are in shared spaces, so you’re sharing operating rooms, and other things. The key difference with skin cancer care is you’re relatively insulated.
Q: That insulation is interesting because it separates some of the issues related to COVID-19.
A: Yes. And bigger departments are a concern. This provides a better understanding of how COVID-19 impacts delays in terms of practice because you don’t have to consider the interdependencies of other specialties when modeling.
Q: Are you studying whether there was a higher percentage chance of skin cancer patients dying if they stayed home and delayed treatment to avoid the risk of getting COVID-19? There are people who argue, for instance, that the cure is worse than the disease in relation to lockdowns and social distancing?
A: That’s a very good question. The chance of patients dying because of waiting for treatment with skin cancer is extremely low. Skin cancer is a very common type of cancer in the U.S. The mortality is low just because of medical pathology and the treatments and therapies, and people know what to do. The risk is much more that the tumor will grow and there could be other complications. Also in terms of the psychological anxiety, if I’ve known I’m a cancer patient, it affects my identity.
Q: So, mortality is low with skin cancer, but delaying treatment could lead to more complex surgery and higher medical costs that could have been avoided if they had gone in earlier. It’s about the personal health and financial tolls.
A: Yes. Exactly. The key drivers and risk factors for mortality when infected with COVID-19 could be your age and underlying medical conditions, so that group of patients is better off waiting.
Q: What is the timeline for your research plan?
A: To understand more broadly the impacts of COVID-19 related surgery postponements on dermatologic surgery, we’re surveying dermatologic surgeons across the U.S. to collect and assess data on operational and financial impacts. We’re also collecting data on patient care and outcomes to quantify, using clinically meaningful metrics, the effect of delay in surgery on surgical complexity and the difference in cost of treatment.
We will also survey patients about their psychological distress resulting from delayed cancer surgery and ongoing infection risk in the ambulatory setting.
Q: Could you clarify whether the data analysis and clinical metrics modeling are focused on Johns Hopkins Hospital, or more broadly?
A: More broadly, understanding impacts of practices overall, but the modeling on patients is focused on John Hopkins Hospital. Johns Hopkins is a very large oncology hospital, so I personally feel this is sufficiently representative, with people coming from other states for skin cancer treatment. So, I wouldn’t be overly concerned on the statistical veracity, like I would if it was a small-scale community hospital. The impact will be different in areas like New York for sure.
Our collaborative research between Johns Hopkins and Imperial College in the UK, which is focused on colon cancer, gives us another perspective.
Q: That sounds fascinating. The influences of the different healthcare systems in the U.S. and U.K. add an entirely new element to the analysis…
A: The financial models are vastly different from here. For the study, we’re looking at how the payment system effects how people are getting their care and the different outcomes, a comparison between the U.S. and UK, and how the different healthcare systems are playing a role in response to COVID-19.
Q: And the U.S. and UK’s timing and responses to COVID-19 were different as well. When you’re setting up your modeling for the Johns Hopkins research on impacts of COVID-19 delays on skin cancer surgeries, you’re using a baseline of patients in 2019 before the pandemic.
A: Yes. And we are comparing characteristics and procedure times in 2020 as a result of delays in surgery due to the pandemic.
Q: So, there are certain patients who may have delayed surgery whether there was COVID-19 or not. Perhaps they couldn’t afford the treatment, or didn’t have health insurance, but when you’re doing your modeling, you’re taking that into account…
A: Yes, and after COVID-19, the economic hardships could also have an impact, if some patients now can’t afford to pay their mortgage… It’s no different from the produce business, when modeling and anticipating people’s attitudes and behaviors, how the consumer is going to react. If people are staying at home and restaurants are closed, how is that effecting grocery shopping…
Q: From your vantage point and expertise, are there steps that could have been taken early on in the U.S. to avert the exponential spread of COVID-19 and lockdown measures to alleviate the surge of cases at hospitals…?
A: There’s been a lot of discussions that we could have handled the crisis better as a country. A lot of people think we are not doing very well at containing the COVID-19, which has resulted in a staggering number of deaths. We didn’t do our best as a country, but as good or better than many European countries in terms of per capita.
We obviously could have avoided a lot of deaths if we had acted differently. By building up our PPE stockpiles and having our own expedited, efficient manufacturing lines, we could have definitely helped avoid infections.
And we have a lot of nurses, doctors, and technicians infected. Around 40 percent of the deaths are attributed to the elderly and long-term care facilities with unchecked infections. Those things could have been avoided if we had better PPE and testing.
Our PPE supply chain failed. Nurses, physicians, and first line workers are our heroes, fighting this enemy. They do need this protection, and many couldn’t get N95 masks. Looking back, I attribute this to supply chain barriers and lack of coordinated actions. I believe this is transferable to the pandemic curve. We’re still facing PPE shortages. There are a lot of lessons to learn.
Q: Those lessons connect to your research to flatten the curve of elective procedures with the anticipated post-pandemic demand surge…
A: Yes. And if you know there’s a high percentage chance of a second wave of COVID-19, are you going to take proactive measures and ensure necessary procedures are in place? We need to anticipate and plan ahead to expand health care facilities and secure the necessary PPE … a lot of mayors and governors are taking actions across the country, but we must have a contingency plan.
The beauty of America is the ingenuity and spirit of individuals and communities to get this done, with collective reflections of the failures, and resilience to adapt with a view of what’s next.
Our ability to project what is needed has not shown to be very good in this pandemic. In the epicenter of the US outbreak, we spent a fortune converting the Javits Center into a hospital, which was barely used. We sent a Navy hospital ship, the USNS Comfort, which was also barely used. Many temporary hospitals — in the Tennis Center, the Brooklyn Cruise Terminal and elsewhere — took in few or no patients.
This was a big issue, costing hundreds of millions of dollars, but could be put in the “better safe than sorry” category. A more serious question is whether we did harm by depriving non-COVID patients of medical treatment. The answer is probably yes, but we don’t know, yet, how serious the harm was.
With global travel as it is, there is no reason to think that we will never have another outbreak of this type. We need to understand the impact of our actions so as to be better prepared for a possible bounce-back of cases on COVID-19 and for the possibility of future pandemics.
We thank Tinglong Dai for helping to do the research that will provide direction for the future.