COVID – 19: The Rising Cost of Cardiac Surgery and Diseases – Osman – – Journal of Cardiac Surgery

1.1 An economic overview

The nationwide blockade to suppress SARS – CoV – 2 caused significant damage to the UK economy, causing gross domestic product (GDP) to contract by more than 20% in the second quarter of 2020.⁶ The government, in an effort to mitigate the economic impact, launched the largest public stimulus program in the postwar period.⁷ The combination of rising government spending, falling tax revenues and shrinking GDP pushed the UK’s debt-to-GDP ratio to a high of over 50 years.⁸ In less than a year, the 8 years of tax cuts under the coalition and conservative governments were canceled.

The impact of the pandemic on future NHS funding is ambiguous. In the short term, there may be an increase in spending as public mood becomes more aware of the importance of healthcare spending and a well-functioning NHS. However, with Chancellor Rishi Sunak already talking about the need for “tough decisions”,⁹ it seems likely that the significantly worse position of UK public finances could cause NHS spending to grow at a slower pace than it might otherwise. Since the NHS covers 24% of public spending,¹⁰ it would be difficult for any chancellor to reduce spending without affecting the health service.

Without improving cost efficiency, the UK’s aging population will likely need increasing spending on heart surgery simply to maintain the same level of service. This means that the long-term impact of COVID – 19 will only increase the need to find innovative ways to provide equivalent or greater cardiac care at a low unit cost.

1.2 Immediate impact of COVID – 19

The presence of a transmission guide supported by the government protocol of infection, prevention and control¹¹ had a significant impact on the provision of cardiac care. Many non-urgent electives have been postponed in an effort to reduce the burden on the health service and avoid nosocomial infections, especially since patients requiring heart care are likely to have a significantly higher mortality rate from infections than others.¹² Patients with coronary artery disease have an increased risk of mortality and morbidity from a COVID-19 infection because they share high-risk co-morbidities, such as hypertension, diabetes, and obesity, which are associated with worse outcomes. Additionally, patients undergoing more invasive heart surgery will need to spend more time in the ICU than those undergoing percutaneous coronary intervention (PCI). Guo et al. swabs collected and analyzed taken in different hospital sites to better understand the capabilities and transmission routes of the virus and subsequently reported a greater risk of SARS – Cov – 2 infection in ITU compared to general wards.¹³ To protect patients, clinicians can guide decision making by prioritizing less invasive therapies.

In the wake of the pandemic, the risk of nosocomial infection for surgical staff through intraoperative generation of fomites has led to changes in surgical practices. Standard procedural activities such as opening pressurized cavities and orifices such as the chest in a coronary artery bypass graft (CABG) are now considered high-risk. This is likely to affect the choice of intervention offered by doctors and chosen by patients.¹⁴

In addition to this, patient concern has significantly reduced the number of patients presenting to hospitals with myocardial heart attacks or strokes.¹⁵ A US study by Solomon et al.¹⁶ reported that weekly hospitalization rates for myocardial infarction fell by 43% during the pandemic. Delayed presentation can advance the disease which will reduce the effectiveness of the treatment offered. This can also force surgeons to carry out elective operations such as emergency cases which carry a higher risk and lower outcome.

Since the cost base of theaters and personnel is largely fixed, the immediate effect of this lower capacity is to increase unit costs of cardiac care, although it is currently too early to know the direct impact on costs.

1.3 Long-term effects of COVID – 19

The emerging evidence also suggests that there is a significant role for cardiology in the treatment of COVID-19 patients; while SARS – CoV – 2 is primarily a respiratory virus, it has been linked to an increased risk of myocardial infarction, myocarditis and heart failure. While the pathophysiology is still being researched, it has been theorized that SARS – CoV – 2 could accelerate the destabilization of inorganic calcium deposit resulting in endothelial cell dysfunction and, subsequently, heart disease.¹⁷ Also, contracting the virus can weaken the immune system¹⁸ which can make patients vulnerable to overlapping bacterial infections that could threaten healing, increase the risk of transplant infection, and interfere with lung gas exchange.¹⁹

Furthermore, the significant reduction in activity in cardiothoracic surgery will have a long-term impact on the development of the field in the UK; trainees will see delayed progression as a result of reduced operational exposure, cancellation of exams and teaching, and transfer to medicine and intensive care. Cardiothoracic surgeons, in particular, possess generic skills that can be easily transferred to the ITU, making them prime candidates for re-employment.²⁰ There is also the risk of long-term personnel problems with the government and the Trust’s strict detailed guidelines for self-isolation from the onset of new COVID-19 symptoms or in case of direct contact with COVID-19 positive individuals. the potential to wipe out entire teams that would negatively impact the workload of the remaining staff members and overall staff morale.²¹

To reduce hospital turnout, it is recommended that only urgent cases be examined in person, otherwise patients would have to be examined in a virtual clinic.²⁰ This is where patient notes and results are reviewed by the absent physician and clinical decisions are passed on to the remote patient.²² The effectiveness of video consultations has not been extensively studied, however, there are obvious limitations such as the inability to examine the patient, the inability to measure basic observations in real time such as heart rate and blood pressure, and problems with connectivity that reduce the amount of information available for acquisition. Remote consultations don’t work for everyone, especially for patients with language barriers and cognitive impairments. This is likely to lead to missed opportunities and long-term delayed introductions.

Additionally, clinical research has experienced significant delays due to the challenges of monitoring and recruiting study participants, while still complying with social distancing guidelines.²³

The combination of postponement of elective cardiovascular surgery, reduced acute care, and long-term heart damage directly resulting from COVID-19 is likely to cause an increase in demand for cardiac care, particularly from patients with more severe symptoms. There is solid evidence that COVID-19 has hindered the delivery of heart care; for example, a recent survey showed that 36% of primary PCI centers had to close during the pandemic.²⁴ The combination of increased demand and inhibited supply means it will likely take a few years for cardiology to recover from the impact of the pandemic.