The Centers for Medicare and Medicaid Services (CMS) released guidance late yesterday asking healthcare providers to postpone adult elective surgeries and procedures, including dental procedures, until further notice.
The move is an attempt to preserve the supply of ventilators and personal protective equipment such as masks and gowns while protecting patients and staff from exposure to the coronavirus. Dental exams in particular, which put the patient and provider in close proximity, pose one of the highest risks of transmission of the virus, and also deplete the supply of personal protective equipment, the agency said.
“Decisions remain the responsibility of local healthcare delivery systems, including state and local health officials, and those surgeons who have direct responsibility to their patients,” the agency said. “However, in analyzing the risk and benefit of any planned procedure, not only must the clinical situation be evaluated, but resource conservation must also be considered.”
CMS divided the types of procedures and its recommendations for those procedures into tiers. (See chart below.) Tier 1 includes outpatient and low-acuity procedures the agency recommends postponing, while Tiers 2 and 3 are for progressively more acute conditions.
Certain medtech firms will be harder hit than others given the new recommendations. Needham & Co. analyst Mike Matson said in an email that among the companies his firm covers, sacral modulation company Axonics Modulation Technologies (NSDQ:AXNX) and Cantel Medical (NYSE:CMD), which makes disposable products for endoscopies, will be most exposed to cutbacks on procedures in tiers 1 and 2.
Companies specializing in devices for higher-acuity procedures, including cardiovascular device firms AtriCure (NSDQ:ATRC), CryoLife Inc. (NYSE:CRY) and Cardiovascular Systems (NSDQ:CSII) might feel the pinch from cutbacks in the higher-tiered procedures, Matson said. Larger companies with broader product lines are exposed to a range of procedures and it is difficult to quantify the mix, he added.
CMS said the recommendations might change as the outbreak unfolds. “At all times, the supply of personal protective equipment (PPE), hospital and intensive care unit beds, and ventilators should be considered, even in areas that are not currently dealing with COVID-19 infections,” the agency added.
CMS recommended that hospitals and healthcare providers consider the following factors when deciding whether elective surgery should proceed:
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- Current and projected COVID-19 cases in the facility and region.
- The supply of personal protective equipment to the facilities in a particular healthcare system.
- Staff availability.
- Bed availability, especially intensive care unit (ICU) beds.
- Ventilator availability.
- Health and age of the patient, especially given the risks of concurrent COVID-19infection during recovery.
- Urgency of the procedure.
CMS recommended decisions about procedures be made in consultation with the hospital, surgeon, patient and other public health professionals. The agency made up this chart to guide decision-making:
| Tiers | Action | Definition | Locations | Examples |
| Tier 1a | Postpone surgery/procedure | Low acuity surgery/healthy patient Outpatient surgery Not life-threatening illness |
HOPD* ASC** Hospital with low/no COVID-19 census |
Carpal tunnel release EGD Colonoscopy Cataracts |
| Tier 1b | Postpone surgery/procedure | Low acuity surgery/unhealthy patient | HOPD ASC Hospital with low/no COVID-19 census |
Endoscopies |
| Tier 2a | Consider postponing surgery/procedure | Intermediate acuity surgery/healthy patient Not life-threatening but potential for future morbidity and mortality. Requires in-hospital stay |
HOPD ASC Hospital with low/no COVID-19 census |
Low risk cancer Non-urgent spine & ortho: including hip, knee replacement and elective spine surgery Stable ureteral colic Elective angioplasty |
| Tier 2b | Postpone surgery/procedure if possible | Intermediate acuity surgery/unhealthy patient | HOPD ASC Hospital with low/no COVID-19 census |
|
| Tier 3a | Do not postpone | High acuity surgery/healthy patient | Hospital | Most cancers Neurosurgery Highly symptomatic patients |
| Tier 3b | Do not postpone | High acuity surgery/unhealthy patient | Hospital | Transplants Trauma Cardiac with symptoms Limb threatening vascular surgery |
*Hospital Outpatient Department
** Ambulatory Surgery Center
