COVID-19 and a Window into Healthcare Providers' Resiliency

As contemporaneous data emerge from publicly funded healthcare providers, the COVID-19 pandemic provides a unique opportunity to measure their resiliency. Resiliency matters because it connotes a higher level of confidence in being able to provide needed healthcare during times of health, social or environmental stress or calamity. At the beginning of the first wave of the COVID-19 pandemic in early 2020, there were warnings regarding hospitals' ability to successfully manage large surges of critically ill COVID-19 patients who were expected to soon be presenting at hospitals in every province and territory. Shortly thereafter, hospitals implemented policies to clear hospital beds – there were public reports that hospitals rapidly went from nearly full occupancy to below 50% (CIHI 2020a; Howlett 2020; Zeidler 2020).

The fact that hospitals were able to free thousands of their beds so quickly was a remarkable metamorphosis. As recently as 2019, hospital occupancy in Ontario was often above 95% and grappling with seemingly immovable patients waiting for other settings of care (Bender and Holyoke 2018; Government of Ontario 2019).

Measuring Hospital Resiliency

Clearing hospital beds and quickly transitioning many patients to other care settings provided evidence that hospitals, in conjunction with their community's other health and social care providers, had adaptive resilience (Thomas et al. 2013). This is a valuable attribute that indicates that hospitals are able to absorb health-related disasters while continuing to provide critical healthcare to their communities.

But clearing hospitals came at what cost? There is no evidence yet from provinces or territories that moving patients from hospitals earlier than planned caused detectable increases in premature mortality or excess morbidity. Perhaps this evidence will emerge; though if it does not, and if these gains in hospital efficiency can be maintained without jeopardizing patient outcomes, it would show the hospitals' ability to quickly build new and effective processes of care.

Yet, the financial resilience of hospitals is still very murky. In the short term, the majority of hospitals' funding comes from global budgets, and they should have no problem meeting their fixed costs since they have very little wiggle room to reduce spending. In the medium term, provincial and territorial governments will reckon with fewer patients having had access to elective treatments while surgical wait lists continued to expand. In British Columbia, for example, the policy response was to commit hundreds of millions of new spending to increase surgical capacity (Government of British Columbia 2020). In the longer term, governments' intentions to bankroll expanded capacity are unclear, and the consequences may be some combination of financial insecurity for hospitals and their skilled staff, erosion of services or longer waits for non-life-threatening care.

Resiliency in Other Sectors

Perhaps the cost of clearing hospitals was borne by long-term care? While this public health emergency has shown some evidence of resilience among hospitals, the same cannot be said for long-term care. A confluence of resident, staff, care home, health system and social care factors contributed to, in some instances, disastrous outcomes for residents of long-term care, their families and the staff (Holroyd-Leduc and Laupacis 2020). It will take years to unpack the impact of the lack of resiliency in long-term care and repair the gaps that COVID-19 revealed (Armstrong et al. 2020; Webster 2021).

Some statistical evidence shows that privately provided physician care demonstrated adaptive resilience, with over 50% of care being provided virtually within a few months of the onset of the pandemic (CIHI 2020b). Maintaining these transformative changes in the delivery of physician care may particularly benefit those residing in rural or remote areas and for whom travel is expensive and inconvenient.

Beyond long-term care and physician care, clear indicators of resilience from other sectors are yet to emerge. Nursing homes and home care similarly grappled with an influx of patients discharged from hospitals earlier than usual. Because these sectors are financed by a mix of private and public funds, their financial resilience is particularly important for maintaining stability in capacity for healthcare provided in the community.

Monitoring Resilience for the Future

The unfolding saga of the COVID-19 pandemic and the stressors that it induced upon the provinces' and territories' healthcare providers have shown some strengths and weaknesses of the regions' health and social care systems.

It is highly desirable for provinces and territories to have resilient healthcare providers who will continue to deliver healthcare irrespective of the challenges of future large-scale disasters. Health system resiliency matters because we want to avoid unnecessary suffering and premature death.

The features of provinces' and territories' resiliency will include the ability to adapt to new challenges, such as the COVID-19 pandemic; transform practices to incorporate new technologies; and remain solvent. With these points in mind, provinces and territories should develop a process for monitoring and investing in strengthening the resilience of all healthcare sectors on an ongoing basis.

This Issue of Healthcare Policy

This issue of Healthcare Policy is led by a discussion and debate article, which engages the reader to consider the short- and longer-term health and social consequences of higher levels of alcohol consumption induced by the COVID-19 pandemic (Hartney 2021). Concerningly, the author notes that due to provincial infection-control policies and social distancing recommendations from public health offices, access to healthcare and social services for over-consumption may be commensurately less accessible during this time of heightened need. The article calls for federal and provincial governments to enact policies to enhance access to prevention programs designed to lessen alcohol overuse, especially among high-risk groups, in order to mitigate future health and social harms.

The discussion and debate article is followed by a rejoinder, whose authors jointly focus on provinces' policies to loosen controls that increase the availability of alcohol during the pandemic (Lange and Rehm 2021). The authors reinforce the associations between boredom, stress and convenience with alcohol overuse. The rejoinder extends the discussion of pandemic-related alcohol overuse by calling for provinces to reduce the availability of alcohol and for enhanced screening and interventions to target alcohol overuse.

Research Papers

This issue's first research paper focuses on the prevalence of mental health problems among nurses in British Columbia (Havaei et al. 2021). Referencing complex and intertwined work-related risk factors, the paper states that elevated levels of depression, anxiety and other mental health problems have been associated with absenteeism, nurses' feelings of reduced personal accomplishment and emotional overextension and exhaustion. Applying a cross-sectional survey design, the authors found excess mental health problems among nurses and recommend confidential assessment of nurses' mental health and structural changes in their workflow in order to address the causal factors that lead to mental health problems.

Next, a team of authors conducted a scoping review of patients' preferences for healthcare among those with specific health conditions (Peckham et al. 2021). Citing reforms to align healthcare and improve patient-centredness, the authors undertook an extensive review of the literature to identify and measure the needs, desires and preferences of patients. The review found five themes of preferences across a number of health states: personalized care, information, choice, holistic care and coordinated/continuity of care. This study has policy implications relevant to determining who should be a part of the care team, how to effectively engage with patients of differing health states and how to design healthcare improvement initiatives that align with the preferences of patients.

Targeting overcrowding and extended waits in hospitals' emergency departments, the next paper reports on the findings of a quantitative analysis of emergency department lengths of stays in a sample of urban regions' hospitals in western Canada (Kreindler et al. 2021). Anchored with cross-sectional data from the National Ambulatory Care Reporting System, the extensive modeling found no clear evidence of high or low performers. The authors conclude that to relieve the pressure on emergency departments, policies to support new models of ambulatory care are needed, including those that reflect local needs and their community's capacity.

In the context of language proficiency and inadequate patient–provider communication, the next paper analyzes two data sets to measure concordance between physicians' and patients' use of non-official languages in a sample of the largest urban areas of Canada (Ariste and Matteo 2021). Data sourced from Scott's Medical Database and the 2016 Census highlighted instances of discordance between physicians' use of non-official languages and the percentage of the community speaking the same non-official languages. The authors conclude by describing the complex ethnic and gender differences they found and outline a number of policy options for provinces to enhance the supply of physicians that speak the same language as the community.

The final paper in this issue reports on the findings of a time-driven activity-based costing study in an ophthalmology integrated practice unit at the Kensington Eye Institute in Ontario (Sadri et al. 2021). Time-driven activity-based costing is a process for accurately attributing input costs to health outcomes through close measurement of clinical workflow. The information gained from this process informs decision makers about where to allocate their efforts and resources to reduce unwarranted variability or inefficiencies. This study demonstrated that the time-driven activity-based costing process was feasible and generated actionable information for the Kensington Eye Institute. The paper concludes with recommendations for scaling up this process to improve value from healthcare spending.