Interruption of Service
Of participants, 63.21% reported an interruption of service. Viewed by setting, 66.67% of ASCs reported an interruption in service, followed by Hospitals (62.50%), Office Endoscopy units (54.55%), and Academic Institutions (53.33%).
Service interruptions were highly correlated by state. As an example of the 10 respondents located in the state of New York, 80% reported an interruption of service while the 10 respondents from the state of California only 50% reported an interruption of services. In some states we had a single respondent, but of these, seven reported no interruption.
Loss of Colorectal Screening Capacity
While it is undeniable that an interruption of service results in financial disruption to the unit, of greater concern is the loss of colorectal screening capacity. In many states that limited or closed elective surgeries, colorectal screening on asymptomatic patients were included in the definition of elective surgeries. Of the 106 respondents, a total of 453 weeks of lost capacity was reported which equates to 2,265 days of endoscopy. We did not collect the number of rooms in each unit and therefore cannot estimate the number of deferred cases. However, unless these units are able to expand capacity by extending daily schedules, or working on weekends, this screening capacity may never be recaptured.
The majority of respondents, who did not report an interruption in service, did report a loss of capacity ranging from 5% to 80% with a mean of 28% and a median of 25%.
Service interruption of this magnitude is unprecedented, but these data do provide a guide in terms of the time it takes to regain capacity once services are resumed.
None of the respondents who experienced an interruption of service were able to immediately operate at 100% of their historic capacity. Four weeks after resuming services, Office Endoscopy units had regained 79% of their original capacity while ASCs reported regaining 61.5%, Academic Institutions had regained 61%, and Hospitals had regained 46%.
At six weeks, Office Endoscopy units had regained 96% of their previous capacity, ASCs had regained 73.5%, Academic Institutions regained 70%, and Hospitals 65%.
While we were unable to specifically discern why Office Endoscopy and ASC units were able to regain capacity more quickly than Academic Institutes and Hospitals, it is likely that the ability to operate as a focused factory resulted in advantages that Academic Institutes and Hospitals, who must balance service operations in a pandemic, did not have.
Supplies and Costs
All participants experienced difficulty in maintaining supplies and the resulting increase in cost associated with supply shortages. As reimbursement for endoscopy services is relatively fixed, an increase in the cost of supplies is likely to reduce margins.
The greatest increase in cost relates to the cost of personal protective equipment (PPE). A component of the increase comes from supply shortages but is also impacted by more frequent changes of PPE. Academic Institution participants reported the greatest increase in cost of PPE at 77%, followed by a 63% increase reported by ASCs, 57% increase reported by Office Endoscopy units, and 56% increase reported by participating Hospitals.
An increase in laundry expense is likely associated with more frequent changes in PPE and participants report the second highest increase in cost. Academic Institution participants reported the highest increase in laundry expense of 30%, followed by ASC participants of 29%, Hospitals at 28%, and Office Endoscopy units at an increase of 24%.
Medical supply expense, defined to exclude medication expense, was reported to increase by 29% in ASCs, 27% from Academic Institutes, 25% from Hospitals, and only a 9% increase expected by Office Endoscopy units.
Medication supplies also increased in cost due to the competition with treatment protocols for COVID-19 without a significant increase in manufacturing capacity. Hospitals reported the highest increase at 37%, an 18% increase reported by ASCs, an 8% increase reported by Academic Institutions, and 7% reported by Office Endoscopy units.
The increase in the cost of clinical labor is lower than other categories but as the cost of clinical labor is often greater than 40% of total cost, even small increases may result in large expenditures. Hospitals report the greatest increase in clinical labor at 16%, followed by 12% reported by Academic Institutions, 10% reported by ASCs, and 4% reported by Office Endoscopy units. A component of the larger increase in labor cost experienced by Hospitals and in Academic Institutions may reflect the relative higher base cost of labor compared to the cost of clinical labor in ASCs and Office Endoscopy units.