SA hospital groups pinched as elective surgeries end and occupancies plummet

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Though the health-care sector is normally seen as a defensive investment and on the surface should benefit from a health crisis such as the coronavirus pandemic, it is also feeling a significant effect from the lockdown and other remedial measures, which have curtailed most revenues other than those from COVID-19 treatment, reports Business Day

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Since the middle of March, when elective surgeries were cancelled, South African hospital groups have been experiencing reduced occupancies, to as low as 40% from highs of 65%-70% previously. The expectation is that occupancies will continue to fall and many hospitals may actually need to be temporarily closed if elective surgeries continue to be restricted. Surgical cases account for 50%-60% of private hospital revenue and generate a higher margin. The loss of electives for the duration of the pandemic should translate into demand deferred, as opposed to lost, but in the short term this puts pressure on income, and in the absence of being able to meaningfully cut staff given the dire need of nurses for the pandemic, this leaves private hospitals exposed to pressure on liquidity and covenant levels.

However, the report says, there have been calls from various medical societies to motivate the lifting of the restrictions on some elective surgeries that could lead to possible fatalities should they continue to be postponed. While it is believed that under strict hygiene protocol there may be some progress in this regard, the exact stance to be taken by the government as the lockdown is eased is still uncertain. The peak of COVID-19 cases is expected to come in September, and that is still a long way off for some patients who require necessary but elective surgeries.

According to the report, the pharmaceutical companies have been less affected. While experiencing a change in demand in various product streams, they have not yet seen significant interruptions to supply chains, despite several logistical hurdles such as border closures, regional lockdowns and flight restrictions. Logistics channels within and out of Europe and the East are presently slower than normal, causing delays in incoming raw materials and finished goods. However, production sites and third-party manufacturers of active pharmaceutical ingredients have not been affected and are in full production.

The pandemic has disrupted routine hospital services globally, and, according to a City Press report, estimates that 146,000 elective surgeries in this country could be cancelled as a result of the crisis. Worldwide, the CovidSurg Collaborative, a research network of 5,000 surgeons from 120 countries, has projected that based on a 12-week period of peak distribution to hospital services due to COVID-19, 28.4m elective surgeries will be cancelled or postponed this year. The report says the modelling study shows that each additional week of disruption to hospital services will result in a further 2.4m cancellations. Led by researchers from the University of Birmingham, UK and the University of Cape Town, they collected detailed information from surgeons in 359 hospitals across 71 countries on plans for the cancellation of elective surgery. This data was then statistically modelled to estimate the total number of cancelled surgeries across 190 countries.

The researchers projected that worldwide 72.3% of planned surgeries will be cancelled during the peak period of COVID-19 related disruption. Most cancelled surgeries will be for non-cancer conditions. Orthopaedic procedures will be cancelled most frequently, with 6.3m orthopaedic surgeries cancelled worldwide over a 12-week period. It is also projected that globally 2.3m cancer surgeries will be cancelled or postponed.

The report says in South Africa, more than 146,000 operations will be cancelled, including 12,000 cancer procedures. These cancellations will create a backlog that will need to be cleared after the COVID-19 disruption ends.

Professor Bruce Biccard, second chairperson in the department of anaesthesia and perioperative medicine at UCT, said: “Each additional week of disruption to hospital services results in an additional 12,000 surgeries being cancelled. Following the surge in the epidemic, we are going to need a continuous assessment of the situation, so that we can plan a safe resumption of elective surgery at the earliest opportunity.

During the COVID-19 pandemic elective surgeries have been cancelled to reduce the risk of patients being exposed to the virus in hospital

Aneel Bhangu, consultant surgeon and senior lecturer at the National Institute for Health Research unit on global surgery at the University of Birmingham, said: “During the COVID-19 pandemic elective surgeries have been cancelled to reduce the risk of patients being exposed to the virus in hospital, and to support the wider hospital response, for example by converting operating theatres into intensive care units.

“Although essential, cancellations place a heavy burden on patients and society. Patients’ conditions may deteriorate, worsening their quality of life as they wait for rescheduled surgery. In some cases, for example cancer, delayed surgeries may lead to a number of unnecessary deaths.”

Abstract
Background: The COVID‐19 pandemic has disrupted routine hospital services globally. This study estimated the total number of adult elective operations that would be cancelled worldwide during the 12 weeks of peak disruption due to COVID‐19.
Methods: A global expert‐response study was conducted to elicit projections for the proportion of elective surgery that would be cancelled or postponed during the 12 weeks of peak disruption. A Bayesian beta‐regression model was used to estimate 12‐week cancellation rates for 190 countries. Elective surgical case‐mix data, stratified by specialty and indication (cancer versus benign surgery), was determined. This case‐mix was applied to country‐level surgical volumes. The 12‐week cancellation rates were then applied to these figures to calculate total cancelled operations.

Results: The best estimate was that 28,404,603 operations would be cancelled or postponed during the peak 12 weeks of disruption due to COVID‐19 (2,367,050 operations per week). Most would be operations for benign disease (90.2%, 25,638,922/28,404,603). The overall 12‐week cancellation rate would be 72.3%. Globally, 81.7% (25,638,921/31,378,062) of benign surgery, 37.7% (2,324,069/6,162,311) of cancer surgery, and 25.4% (441,611/1,735,483) of elective Caesarean sections would be cancelled or postponed. If countries increase their normal surgical volume by 20% post‐pandemic, it would take a median 45 weeks to clear the backlog of operations resulting from COVID‐19 disruption.
Conclusions: A very large number of operations will be cancelled or postponed due to disruption caused by COVID‐19. Governments should mitigate against this major burden on patients by developing recovery plans and implementing strategies to safely restore surgical activity.

Authors
CovidSurg Collaborative, Dmitri Nepogodiev, Aneel Bhangu

Full Business Day report

Full City Press report

British Journal o Surgery abstract

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