Cardiovascular procedural deferral and outcomes over COVID-19 pandemic phases: A multi-center study

Abstract

Background The COVID-19 pandemic has disrupted routine cardiovascular care, with unclear impact on procedural deferrals and associated outcomes across diverse patient populations. Methods Cardiovascular procedures performed at 30 hospitals across six Western states in two large, non-profit healthcare systems (Providence St. Joseph Health and Stanford Healthcare) from December 2018-June 2020 were analyzed for changes over time. Risk-adjusted in-hospital mortality was compared across pandemic phases with multivariate logistic regression. Results Among 36,125 procedures (69% percutaneous coronary intervention, 13% coronary artery bypass graft surgery, 10% transcatheter aortic valve replacement, and 8% surgical aortic valve replacement), weekly volumes changed in two distinct phases after the initial inflection point on February 23, 2020: an initial period of significant deferral (COVID I: March 15 to April 11) followed by recovery (COVID II: April 12 onwards). Compared to pre-COVID, COVID I patients were less likely to be female (p=0.0003), older (p<0.0001), Asian or Black (p=0.02), or Medicare insured (p<0.0001), and COVID I procedures were higher acuity (p<0.0001), but not higher complexity. In COVID II, there was a trend towards more procedural deferral in regions with a higher COVID-19 burden (p=0.05). Compared to pre-COVID, there were no differences in risk-adjusted in-hospital mortality during both COVID phases. Conclusions Significant decreases in cardiovascular procedural volumes occurred early in the COVID-19 pandemic, with disproportionate impacts by race, gender, and age. These findings should inform our approach to future healthcare disruptions.

Impact of the COVID-19 Pandemic on Cardiovascular Health in 2020

“… 25 Studies of hospitalized patients with heart failure in Japan and the United States as well as of patients undergoing percutaneous coronary intervention in the United States and England showed no change in in-hospital mortality. 15 , 17 , 26 In a comprehensive study including all citizens with a diagnosis of CVD in Denmark, inpatient mortality decreased by 8%. In-hospital mortality following CVD events increased by 5%-20% in Germany, Austria, and China.…”

Risk of Cardiovascular Events After COVID-19

“…6−8 However, the impact of COVID-19 on long-term CV outcomes is incompletely understood. 8,9 The COVID-19 pandemic disrupted the delivery of standard CV care, 10 which led to increased CV mortality in populations presumably unexposed to the SARS-CoV-2 virus. 11,12 Although higher than expected all-cause mortality during the pandemic has been recognized, 13 it is unclear whether either asymptomatic or symptomatic SARS-CoV-2 infections may have played a causal role.…”

Quality and process improvement of the multidisciplinary Heart Team meeting using Lean Six Sigma

“…Furthermore, an improved administration of the HT resulted in better organisation of the waiting lists, and thus provided better insights of the patient’s conditions, priority and risk of adverse events. This is especially necessary in times when the risk of adverse events is increased by longer referral to treatment times, caused by lower productivity due to the resource scarcity that developed during the COVID-19 pandemic 12–15. The project is in concordance with the STEEEP principles focused on quality through the involvement of the patient and referral’s preferences, process efficiency, better insight and organisation of the waiting list, timeliness and effectiveness.…”

“…This again could affect the entire care pathway, since suboptimal preparation of patients can lead to last-minute cancellations 11. Due to the COVID-19 pandemic, the time to treatment is increased since resources and capacity are progressively limited 12–15. Prolonged time to treatment for patients with severe CAD and valve pathology can plausibly lead to more adverse events (both prior the invasive procedure and perioperatively) 12 14 16 17.…”