Results
The results from this retrospective data analysis are presented below. First, we take a look at the relative developments in monthly inpatient and outpatient case numbers, separated into
gynecology and obstetrics cases. Following this, we present a detailed evaluation of the top 25 recorded primary ICD diagnoses. In this context, we look in particular at the relative and
absolute differences in performance indicators for 2020 seen between the comparison with the previous year, 2019, and with the calculated four-year averages for 2016 to 2019. A central aspect
of this analysis comprises the differences between the primarily acute focus of medical care in the obstetrics clinic, compared with the predominantly elective focus of cancer treatment and
gynecological tumor surgery in the gynecology clinic. Following this, we present our insights from the retrospective observation of the services delivered in the period from 2016 to 2019,
compared relatively to current services and services delivered during the 2020 pandemic year. This enables us to map out the impact of the developing dynamics of the pandemic and the
associated restrictions and measures on the chronological evolution of clinical and financial performance indicators. Finally, we present the COVID-19 cases that were treated at the obstetrics
and gynecology clinic at the University Hospital of Marburg during 2020, and we provide an outlook on developments for central financial performance indicators relating to total costs and
revenues, duration of inpatient admissions, and the case mix index.
Inpatient Case Numbers Compared with the Previous Year
Obstetrics
The services provided at the clinic for obstetrics and perinatal medicine range from prenatal diagnostics and ultrasound to special fetal surgery procedures, through to obstetrics
monitoring, acute medical care in the delivery room, and follow-up care in the post-natal ward. Besides caesarean sections and surgical treatment of injuries sustained during childbirth,
the range of surgical services also includes special procedures for fetal surgery.
In direct comparison with 2019, the year immediately preceding the pandemic year 2020, we saw an increase in the number of obstetrics cases. The months of June and December proved to be
exceptions, showing a relative drop in the number of obstetrics cases, of 4% and 5% respectively, compared with the corresponding performance data from 2019, whereas data for the entire
year showed a monthly increase in the volume of services, with an 11% relative increase in case numbers. The highest relative monthly percentage increase of 32% was recorded in March
2020.
Gynecology
While the gynecology, gynecological endocrinology and oncology clinic also provides basic gynecological care as well as advice on all aspects of reproductive medicine, the main focus is
on gynecological tumor surgery. The available surgical expertise covers all areas of gynecological cancer and treatment for carcinomas of the breast, ovaries, endometrium, cervix and
vulva.
The gynecology clinic saw a relative drop in case numbers compared with the year immediately preceding. The relative monthly comparative data show a relative decrease in service volumes,
averaging 11%, for the first five months of 2020. The month of April 2020 showed the highest drop compared with the previous year, based on a relative drop in service volume by 23% for the
entire year of 2020. In the three following months, June, July and August, there was a transitory relative increase in case numbers, by an average of 11% compared with the previous year;
the case numbers then fell again during the autumn and winter months. In this context, the decline shown in the relative comparative data, with an 11% average monthly drop in case numbers,
appears to be comparatively high. The drop in relative case numbers continues throughout the observation period, ending at −6% for the whole year. Considering the equivalent performance
indicators for the study period from 2017 to 2019, we can see that the gynecology clinic previously recorded a relative increase in surgery case numbers of 6.7% and 8% respectively for the
comparison years 2017 to 2018 and 2018 to 2019.
Outpatient Case Numbers Compared with the Previous Year
Due to the different methods used to record services, we currently only have data for outpatient care at the university outpatient service up to September 2020. [Fig. 1 ] shows that the drop in outpatient case numbers was smaller than the drop in inpatient case numbers. For gynecology outpatient services, the relative drop in case
numbers in the months during the first lockdown (February to April 2020) was 7%, compared with a 14% drop in inpatient case numbers. The biggest relative drop in outpatient cases of 9%
occurred in March, while the biggest drop in monthly inpatient cases of 23% occurred in April. For university outpatient obstetrics services, there was not a single drop in monthly case
numbers. In fact, outpatient obstetrics services experienced a 15% increase in case numbers in 2020 compared with the previous year.
Fig. 1 Relative monthly change in inpatient and outpatient case numbers for gynecology and obstetrics (2020 compared with 2019).
Changes to ICD Primary Diagnoses
As well as observing trends relating to developments in case numbers for inpatient and outpatient care at the gynecology clinic, we also recorded and compared the most frequent ICD primary
diagnoses, and mapped this data so as to investigate not just changes in case volumes, but also the actual impact on demand for clinical treatment of particular illnesses.
Obstetrics
For this purpose, we compared data from 19597 cases treated in the obstetrics clinic over the past five years. The 25 most common ICD primary diagnoses, amounting to 4558 cases, represent
81.51% of all cases coded in 2020. Out of the top 25, births represented the largest service category at 56% of all primary diagnoses, followed by obstetric complications at 20%,
childbirth injuries at 9%, obstructed labor at 5%, and other events at 1%. The ICD diagnosis Z38.0 “Single liveborn infant, born in hospital” was the most frequent of all primary diagnoses
with an ICD code, at 36.68%; this diagnosis saw a growth of 28% at the University Hospital of Marburg in 2020 compared with the four previous years. The direct comparison between 2020 and
2019 also showed a 13% increase in ICD Z38.0 diagnoses. [Fig. 2 ] presents in detail the developments for the five most common ICD primary
diagnoses occurring in obstetric care at the University Hospital of Marburg, and explores the corresponding comparisons between 2020 and 2019 and the quarterly trends for the period from
2016 to 2019.
Fig. 2 Detailed analysis of top 5 ICD primary diagnoses in the gynecology and obstetrics clinic (2016–2020).
Gynecology
Just as for the data analysis for the obstetrics clinic, we also evaluated the ICD primary diagnoses for the past five years for the gynecological services. Overall, we captured and
compared 9487 cases that occurred during the observation period. The 25 most common ICD primary diagnoses in 2020, accounting for 1921 of the patients treated, represented 64% of all coded
primary diagnoses. Among these, malignant neoplasm of the breast came in the top position at 34%, followed by benign neoplasms at 25%, other diseases of the genital tract at 19%, and
malignant neoplasms of the abdomen at 14%. The most common ICD primary diagnosis, C50 “Malignant neoplasm of breast”, was made in 411 cases in 2020; a direct comparison between 2020 and
2019 shows a considerable drop in cases of 7.38% for this diagnosis. In terms of numbers, the biggest discrepancy between the four-year trend (+77%) and the direct comparison with the
previous year (+8%) was seen with ICD diagnosis T85.82 “Capsular fibrosis of breast due to breast prosthesis and implant”. [Fig. 2 ] illustrates
in detail the relative increases and decreases for the five most common diagnosis codes based on the ICD primary diagnosis in question for the relevant comparison periods.
Finally, in [Fig. 3 ] we arranged the 25 most common ICD codes for gynecology and obstetrics into etiological subgroups based on the first digit
of the ICD code, so as to illustrate proportional shifts in the range of case types.
Fig. 3 Proportional comparison of the range of ICD cases occurring in the gynecology and obstetrics clinic (from 2016 to 2020).
Changes to DRG
For the identified cases, we also analyzed the corresponding DRG codes. In addition to the diagnosis definition according to ICD code, this also gives an overview of the most prominent
surgical, interventional, and drug treatments delivered for the cases included in this study, as well as the final health cost of these cases based on a fixed sum per case.
Obstetrics
The 25 most common DRG codes represent 96.88% of all the cases included in this analysis. In 2020, 46% of the 25 most common DRG codes related to newborns, 28% to vaginal deliveries, and
19% to caesarean sections. Compared with the average value for the comparison period of 2016 to 2019, the relative proportion of newborns and vaginal deliveries among the top 25 DRG codes
increased by 3% and 10% respectively, while the relative frequency of caesarean sections decreased by 10%. At 37.06%, DRG P67E “Single liveborn infant, birth weight > 2,499 g”
represented the most commonly coded diagnosis-related group. This code was subject to a growth trend, with an increase of 67% during the period from 2016 to 2019, and 12% from 2019 to
2020.
Gynecology
The 25 most common DRG case groups for gynecology represent 79.44% of all coded diagnosis-related groups for the cases included in this analysis. Among the 25 most common DRGs, breast
operations accounted for 47%, and abdominal operations accounted for 44%. Compared with the 2016 to 2019 comparison period, there was an increase in the relative proportion of abdominal
operations among the top 25 DRGs, while the relative proportion of breast operations saw a decrease. This is reflected in the most frequently coded DRGs. While in the 2016 to 2019 period
the code J23Z “Major breast surgery procedures with malignant neoplasm” was still the most frequently coded DRG at 6.5%, in 2020, the DRG N21A “Hysterectomy for reasons other than
malignant neoplasm” took the top place with 7.13%.
Treated Cases of COVID-19
Based on the ICD code “U07.1 COVID-19, virus identified”, a total of 283 COVID-19 patients were hospitalized at the University Hospital of Marburg during the 2020 pandemic year. With a
total population of 245754, the district of Marburg-Biedenkopf recorded 5181 cases of COVID-19 in 2020. Moreover, 78.8% of the hospitalized COVID-19 cases were treated in an internal
medicine ward. Over the whole year of 2020, five patients with a COVID-19 infection were hospitalized at the obstetrics and gynecology clinic at the University Hospital of Marburg. All five
were obstetrics patients. This was because the patients in question were infected with COVID-19 perinatally, while patients with an active COVID-19 infection were excluded from admission to
the gynecology clinic through preoperative triage based on nasopharyngeal swab PCR testing or rapid antigen testing. If a patient with a primary gynecological diagnosis became infected and
was subsequently hospitalized, for example postoperatively in the context of adjuvant radiotherapy or chemotherapy, the patient was supposed to be transferred to an internal medicine ward
and treated there. However, we do not know of any cases where this occurred.
[Fig. 4 ] illustrates the developments in relative monthly case numbers in the gynecology and obstetrics clinic for 2020 compared with 2019, and
places this in the context of the chronological progression of national COVID-19 infections.
Fig. 4 Presentation of the chronological development in national COVID-19 infections and relative monthly changes to inpatient case numbers.
Effects on Key Financial Performance Indicators
[Fig. 5 ] illustrates the relative changes in total costs and total revenues, by month, for the 2020 pandemic year compared to 2019. For this
purpose, in order to represent the purely operational results of the gynecology department as an independent discipline, we have disregarded the proportional costs and revenues of the
gynecology clinic in relation to the overall business result for the University Hospital of Marburg, i.e., the proportional financial result, operating result and investment result, as well
as taxes.
Fig. 5 Presentation of the chronological development of relative monthly changes to total costs and total revenues of the gynecology clinic (2020 compared with 2019).
Overall, during the 2020 pandemic year there was a relative increase in total revenues and total costs of 10.6% and 7% respectively compared with 2019. Finally, we were able to determine a
relative increase of 98% in the net result for the gynecology clinic compared with the previous year. The gynecological case mix index dropped by 2.3%, while it rose by 3.4% for the hospital
as a whole. Similarly, there was a 25% relative drop in the number of short-term admissions, while the number of long-term admissions increased by 111%.
Discussion
In order to determine the significance of these results and the conclusions drawn from them for the regional and nationwide service obligations of the University Hospital of Marburg, it is
necessary to have a basic understanding of the regional situation regarding the provision of gynecology and obstetrics services. As the sole provider of inpatient gynecology and obstetrics
services in the district of Marburg-Biedenkopf, an area with approx. 250000 inhabitants, not only does the University Hospital of Marburg, in collaboration with over 80 registered physicians
and approx. 7 providers of basic inpatient care, form a close-knit service network; it also forms a critical part of the gynecology and obstetrics care infrastructure at state level, occupying
a facility covering 8660 km2 and serving approx. 850000 inhabitants of the Schwalm-Eder-Kreis, Vogelsberg, Waldeck-Frankenberg, Marburg-Biedenkopf and Lahn-Dill-Kreis districts in
North and Middle Hesse, as well as a large proportion of the approx. 500000 inhabitants of the Siegen-Wittgenstein and Hochsauerlandkreis districts of North-Rhine Westphalia. The next closest
maximum care hospitals are the Kassel Hospital, located 75 km to the north, and the Gießen University Hospital, located 35 km to the south, while approx. 50 km to the east and west the
Schwalmstadt and Dillenburg hospitals provide basic inpatient care for patients in peripheral locations, but cannot offer a comprehensive range of services. This is why the University Hospital
of Marburg acts as a central regional and interregional center of competence, not only for gynecological cancer diagnosis and treatment, but also for obstetrics services. In this context, a
closely structured collaboration between the peripheral providers of basic care, physicians providing outpatient treatment, and the neighboring maximum care hospitals in Kassel and Gießen has
evolved in order to guarantee a full range of gynecology services in the context of regional cancer centers and special diagnosis and treatment in the field of obstetrics and prenatal care. At
the national level, the University Hospital of Marburg delivers a public supply mandate which, especially in regard to gynecological cancer with a focus on abdominal tumors, clearly extends
beyond the described regional and interregional borders.
The changes in case numbers identified in this study give a striking illustration of the difference between gynecological tumor surgery, which is primarily elective, and obstetric services
which are primarily set up to deliver acute care. While the provision of obstetric services remains almost completely unaffected with regard to changes in monthly case numbers at the
University Hospital of Marburg, even showing a clear growth of 11% in inpatient services for the year as a whole compared to the previous year, gynecology services followed the national
chronological dynamics of the COVID-19 pandemic, recording a 6% drop in inpatient case numbers. This divergent development in the two departments is rooted in the primary measures taken by the
clinic management, which was refined over time through a targeted action plan developed in close consultation with the different departments.
The COVID-19 Action Plan and Influence Wielded by the Clinic Management
The initial management response to the spread of the COVID-19 pandemic consisted of imposing an almost complete halt on the elective surgery program, in order to free up staff and
ventilators in case they were needed, and to impose a complete contact ban on external visitors in order to prevent nosocomial infection of patients with COVID-19. In addition to this, there
was an abrupt decline in uptake of outpatient services, which we attributed to outpatients initially fearing an increased risk of infection in clinical settings, although the clinic
management did not place any explicit restrictions on the outpatient services offered. With the development of the pandemic over time, there has been increasing refinement of the pandemic
action plan and hygiene plan in consultation with the different medical departments; with regard in particular to the mandate of the gynecology department to provide oncology and obstetrics
services, these refinements served to guarantee an independent leadership style on the part of the clinic management, which was able to adapt to the evolving situation.
Establishing and refining the triage system
The entire university hospital adopted an extensive triage system which had already been proven internationally to be a key measure in enabling health providers to stay on top of the
volatile dynamics of the pandemic. At first, patients underwent PCR testing prior to hospitalization; this was later exchanged for the more cost-effective rapid antigen testing. Emergency
admissions underwent an identical process in a separate emergency area, and were only released from isolation and transferred to a ward after returning a negative test. At present,
patients and visitors may only enter the university hospital if they have returned a current negative rapid antigen test or if they have proof of double vaccination.
Implementation of structured hygiene measures
Due to ongoing refinements in the context of how the pandemic is evolving over time, we are only able to provide a basic outline of the clinic’s internal hygiene plan. As explained above,
pre-admission PCR testing, which has subsequently been extended to include nasopharyngeal rapid testing, is the key. Testing makes it possible to avoid unnecessary visits to the clinic by
people infected with COVID-19, for example in the context of routine follow-up outpatient appointments, while patients who do need to attend the clinic are steered directly into a COVID-19
workflow. In this context, this also means that pregnant women with COVID-19, after their baby has been delivered in the delivery room, are transferred to one of the COVID-19 wards, and
are cared for externally by the gynecology and obstetrics team while occupying a bed outside of the gynecology ward. Moreover, for inpatients or in cases of suspicion, repeat testing
provides an additional level of security. The entire hospital has imposed an explicit visitor ban. In consultation with the clinic management, there is some flexibility, with exceptions
made for cancer patients, palliative care patients, ICU patients, and obstetrics patients; demand differs in intensity according to the incidence rate at the given time, and these
exceptions are handled decentrally by the department in question. For gynecology, this means that cancer patients may receive visits from their partner or close relatives according to the
judgement of the chief medical officer of the ward. In the obstetrics clinic, partners are allowed to participate in the entire birthing process provided they have returned a negative
test. Similarly, partners have regular opportunities to visit the prenatal monitoring ward. Upon leaving the hospital premises, the individuals must expect repeat testing. Overall, these
arrangements reflect increased trust on the part of the clinic management in the efforts made by the gynecology and obstetrics clinic to maintain good hygiene; they have also been the
object of critical discussion. In our opinion, emotional support from loved ones is essential in the context of cancer and obstetrics patients. The gynecology and obstetrics clinic at the
University Hospital of Marburg would never envisage a complete ban on visitors in this context. The low number of COVID-19 cases in both clinics has proved that this does not constitute an
increased risk for the spread of infection. In the case of clinic staff who became infected with COVID-19, all of the primary infectious contacts were among their private
acquaintances.
COVID-19 workflow separated from regular service provision
Based on a successful triage process, intensive efforts were made right at the outset to separate the COVID-19 workflow completely from regular service provision by setting up an isolated
process, located in the emergency department, from which patients were transferred to an interdisciplinary COVID-19 unit. It has been demonstrated that regular service provision can and
must continue, even during a pandemic, so as not to jeopardize the treatment of other conditions or risk poorer medical outcomes. It is certainly possible to keep COVID-19 out of regular
inpatient and outpatient services, as can be seen from the example of the gynecology clinic at the University Hospital of Marburg, operating as a regional maximum care hospital.
Accordingly, at the Marburg location, cancelling outpatient appointments or shifting to video consultations proved either unnecessary or had already been initiated or established, for
example, the teledermatology video consultations held in the dermatology and allergies clinic at the University Hospital of Marburg. Through adequate triage and separation of the COVID-19
processes from regular gynecology services, it was possible to prevent nosocomial infection with COVID-19. Similarly, there were only a few individual cases of staff off work due to
illness or quarantine requirements. Through consistent testing of the clinic staff by the department for clinic hygiene after every confirmed contact with a COVID-19 patient, it was
possible to avoid closing entire departments and wards.
Establishing reliable modelling for regional utilization of capacities
Beyond this, the triage and separation of COVID-19-free processes from the pandemic response opened the way for informed modelling that could be used to predict regional capacity
utilization based on epidemiological and care-related parameters. Consequently, the management developed an important tool for predicting and proactively allocating treatment capacities
according to the regional dynamics of the pandemic. Considering the constantly recurring spikes in infections, the virus mutations, and the slow progress of vaccinations in Germany, the
hospital’s ability to proactively manage its own capacities is a key factor in remaining economically viable while still meeting its service mission as a leading regional health care
provider. This means that in the event of a rapid increase in incidence, the University Hospital of Marburg has the ability at any time to re-establish COVID-19 departments and intensive
care units and isolate them from other clinic operations, as was already done during the first wave of infections in 2020.
Boosting regional communication and collaboration between service providers
In the end, the ability for facilities to closely control their own capacities opens up the possibility for regional services to be managed independently, without having to rely on
unwieldy political measures. Because the pandemic initially destroyed patients’ trust that it would be safe to be treated in a hospital setting, and trust in the national crisis management
plan in the health care sector has been waning perceptibly during the course of the pandemic, it is especially important to boost communication at the regional level. As a leading regional
healthcare provider, we need to actively communicate the measures that have been implemented and the associated performance indicators; not only to assure safe treatment for COVID-19
patients, but also to guarantee a full range of services for all medical conditions going forward. For outpatient services in particular, intensive communication is key to retaining trust,
and maintaining a high level of demand for the services provided by the outpatient clinics.
The description of the action plan formulated by the clinic management at the University Hospital of Marburg shows that a structured hygiene plan combined with close consultation between
the management and the medical departments, with continuous improvement and refinement of the measures adopted, is key to avoiding internal infections. To achieve this, close consultation
is required between the various medical departments, the hospital management and the hygiene department. As long as the COVID-19 workflow can be kept separate from the usual operations,
the rate of infections within the region permitting, normal clinical operations can continue without restrictions.
Discussion on Obstetrics Services
The positive development in the number of obstetrics cases needs to be discussed critically in the context of the regional care situation during 2020. Basically, the case numbers in the
obstetrics clinic at the University Hospital of Marburg had increased during the previous years due to successive closure of obstetrics facilities in the outlying areas, for example the
obstetrics departments in the Biedenkopf and Wehrda district hospitals. This explains the fact that the number of births managed at the university hospital increased by 4.6% from 2017 to
2018, and by a further 15.2% between 2018 and 2019. However, since 2019, a stable, centralized service for obstetrics care has been in place. The next closest labor wards are located to the
north, east and west in the smaller outlying facilities of the Frankenberg District Hospital (approx. 35 km away), the Asklepios Schwalm-Eder clinics in the Schwalmstadt hospital (approx. 50
km away) and the Lahn-Dill clinics in Dillenburg (approx. 50 km away). However, none of the clinics mentioned above is able to provide comprehensive medical expertise or specialized prenatal
diagnosis and treatment; accordingly, in cases that exceed the limits of their competence, these facilities fall back on the services offered at the University Hospital of Marburg. The next
closest hospital providing maximum care for obstetrics patients, with comprehensive medical expertise, is the University Hospital of Gießen (located approx. 35 km to the south). In the
Marburg-Biedenkopf district, the Geburtshaus Marburg midwife service provides an alternative option for natural deliveries. To our knowledge, none of the facilities mentioned above had to
close or restrict their services during the 2020 pandemic year due to COVID-19; accordingly, we have not observed any direct external effects on the uptake of obstetrics services. However,
there were clear differences in the practices adopted with regard to hygiene and limiting contact. Through consistent, fine-grained PCR testing and rapid antigen testing at the University
Hospital of Marburg it remained possible at all times for partners to attend the birthing process, while most regional service providers imposed major restrictions on partners being present
during the birth. At the University Hospital of Marburg, this offer was limited to partners of the woman in question; other friends or family members were not allowed to attend the birth.
Moreover, this arrangement represented an absolute exception in the inpatient setting; in all other departments, such as ICU units, exceptions to allow visitors were only made in the case of
end-of-life care. One year after the pandemic outbreak of the novel coronavirus with its single-stranded RNA genome, the consequences of a COVID-19 infection for pregnancies during the
prenatal, perinatal and postnatal stages remain unclear; possible effects relating to an increase in pregnancy complications in the presence of COVID-19 infection are still being discussed,
and to date, there is no standardized, scientifically proven treatment regime for pregnant women infected with COVID-19 [1 ]
[2 ]
[3 ]
[4 ]
[5 ]. Accordingly, in our opinion, there are two factors responsible for the positive trend in case numbers in the obstetrics department.
Firstly, the high level of trust that patients have in receiving safe, COVID-19-free care in the delivery ward of a maximum care university hospital has led to increased demand for the
obstetrics services offered at the University Hospital of Marburg. Secondly, many couples chose to have their babies delivered at the Marburg university hospital delivery suite due to our
policy of allowing partners to attend the birth provided that they underwent a nasopharyngeal PCR test or a rapid antigen test for COVID-19, a service which was not always offered by the
other regional providers.
Discussion on Gynecology Care
The 6% drop in relative numbers of gynecology cases goes against the growth trend of the previous two years, which saw an increase of 6.7% and 8% respectively. Based on the observations set
out above, this can be attributed to the massive restrictions placed on the elective surgery program, a game-changing measure which was established at the national level as a primary health
policy measure responding to the accelerated dynamics of the pandemic. The principle on which this measure was based, i.e., freeing up ventilation capacity and minimizing the risk of
intraoperative infection between medical staff and patients, has so far not been confirmed at the regional level at the University Hospital of Marburg. In our opinion, the reduction in
gynecology case numbers does not mean that it is not possible to provide gynecological tumor surgery with adequate protection for the patients, some of whom are immunosuppressed. Our
observations of the COVID-19 cases handled at the university hospital proves that it is possible, with reliable pre-admission triage, to prevent patients contracting nosocomial COVID-19
infections with a high level of confidence. With the approval of COVID-19 rapid antigen tests, enabling preoperative triage in the context of pre-admission testing of cancer patients to be
organized more efficiently, the prevailing opinion that is now expressed in the literature is that treatment of gynecological tumors should continue in accordance with the generally accepted
treatment guidelines, provided that this does not jeopardize any critical regional infrastructure or lead to a shortage of staff or ventilators. Many international studies from Italy, the
USA, Korea, Croatia and China indicate that it is possible to deliver safe treatment of gynecological tumors even during a global pandemic, without increasing the risk to patients of
nosocomial infection or a higher rate of mortality associated with COVID-19 [6 ]
[7 ]
[8 ]
[9 ]
[10 ]
[11 ]
[12 ]
[13 ]
[14 ]
[15 ].
Considering the comparison we undertook of changes in relative monthly case numbers in inpatient and outpatient services, it is clear that the obstetrics services remained largely
unaffected by the COVID-19 pandemic. For gynecology services at the University Hospital of Marburg, the fact that the negative impact on outpatient services was less severe than the impact
on inpatient care can be seen as a positive aspect. Moreover, the outpatient gynecology services were much quicker to recover from the negative developments than the inpatient services. In
May 2020, after just three months, outpatient services had returned to normal service delivery, while inpatient case numbers only returned to levels seen in the previous year in July 2020,
after five months. In our opinion, this is due to the fact that patients were initially hesitant to make use of outpatient services during the pandemic for fear of contracting a COVID-19
infection in a hospital setting. Through targeted communication, we were able to quickly rebuild patients’ trust in receiving safe treatment at the university hospital outpatient clinics.
The prolonged negative trend in the inpatient setting can be attributed primarily to restrictions made to the elective surgery program, which were only gradually eased as we moved into
summer.
Considering the developments in case numbers, the big losers were the patients diagnosed with “Capsular fibrosis of breast due to breast prosthesis and implant” (T85.82) and “Hypertrophy of
breast” (N62). However, this development is not so surprising given that these ICD codes are for reduction mammoplasty or reconstruction with implants; it illustrates the fact that, during
the pandemic, the elective surgery program and available capacities were focused in a targeted way on cancer patients who required prompt treatment. Overall, however, if we consider the ICD
diagnosis codes, we can establish that in 2020, the first year of the pandemic, at the regional level there had already been a concerning decline in the number of C50 “Malignant neoplasm of
breast” and C56 “Malignant neoplasm of ovary” diagnoses, each dropping by 7.4% and 14% respectively. In our opinion, it seems logical that the rate of cancer cases would not decrease due to
a global epidemic of an infectious disease; for this reason, the decrease in the number of gynecological cancer operations performed, combined with a decrease in initial cancer diagnoses,
presents a critical risk to quality of care and to the rate of mortality associated with cancer.
In pandemic hotspots such as New York City, critical restrictions were imposed on the treatment of gynecological cancers. According to records kept by the New York Presbyterian Hospital
Association, 39% of all gynecological tumor patients received treatment that was modified due to COVID-19. Of these modifications, surgical procedures were most often affected, making up
67%, while chemotherapy and radiation therapy were modified respectively in 22% and 19% of cases[16 ]. Matsuo et al. carried out a
retrospective study investigating the risks of changing treatment procedures for early-stage cervical carcinoma in response to recommendations that gynecological tumor surgery should be
deferred, or at times completely replaced with chemoradiotherapy. For the patient cohort with IB to IIA stages of squamous cell carcinoma, adenocarcinoma, and adenosquamous carcinomas of the
cervix, for which the gold standard treatment consists of laparoscopic surgery or open abdominal hysterectomy, the authors of this study were able to establish a significantly increased risk
of parametrial tumor invasion, as well as a moderate increase in mortality [17 ]. The future impact of delaying gynecological surgery,
as well as initial diagnoses potentially being made at a later TNM stage, will only become clear in the coming years through epidemiological monitoring and analysis; this needs to be the
subject of meticulous scientific observation.
The final comparison of the range of diagnoses shows that the number of gynecological malignancies dropped in absolute terms by 23.5 cases, while the proportion of underlying malignant
diseases among the top 25 ICD codes fell from 50% to 47%. Moreover, the proportion of benign neoplasms also fell by 1%, or 4.25 cases, compared with the previous year, while the number of
ICD-coded diagnoses for other diseases of the reproductive tract rose by 36.75 cases, increasing their proportion of overall cases from 17% to 19%. Based on a total of 1221 cases, which
represents the total number of cases for the 25 most common ICD codes, accounting for 63.56% of all ICD-coded diagnoses for 2020, we are only able to make very limited observations regarding
any shift in the range of diagnoses. However, the results indicate that there was a decrease in the number of tumor cases treated as part of the case load at the University Hospital of
Marburg, which did not reflect the actual incidence of malignant diseases, and that, contrary to this trend, the proportion of other diseases of the reproductive tract treated at the
hospital actually increased during the pandemic year.
Economic Perspective
Due to the positive trend in case numbers, we did not find it necessary to present the progress of key financial performance indicators for the obstetrics clinic at the University Hospital
of Marburg. The case-related performance data also show that the key financial performance indicators remained largely unaffected by the pandemic. Accordingly, a detailed presentation and
discussion of the overall financial result with regard to the COVID-19 pandemic does not promise any insights worthy of discussion.
In contrast, the chronological progression of relative revenues for the gynecology department, following the changing dynamics of the pandemic during the 2020 business year, shows greater
fluctuations than does a pure consideration of case numbers. During the first wave of infections there was a clear drop in revenues for the months of March and April, averaging a 10%
decrease compared with the previous business year 2019. However, in contrast to the relative changes in case numbers, there was a rebound in revenues in May; these recovered much more
quickly than the surgery case numbers which were heavily reduced due to restrictions. On the other hand, the negative trend that occurred in September with the second wave of infections,
with a 33% drop in total revenues, was significantly larger than could be expected in the first instance based on developments in case numbers. The negative impact of the second wave of
pandemic infections on revenues was distinctly greater than the equivalent impact from the first wave. This contrasts with the clear impact that the first wave had on surgery case numbers,
described above in our case number analysis. The rapid increase in total revenues in December can be attributed to the accounting practice of deferring additional fees until the last month
of the year.
An observation of cost trends in relative comparison to the previous year shows a clear increase in costs, with the greatest cost burden clearly occurring during the summer months. This is
consistent with the clear increase in surgical case numbers during the summer of 2020, serving to offset the impact of the first wave of the pandemic, which logically resulted in increased
costs. The fact that costs continued to increase despite the relative decrease in case numbers described above, i.e., in March through to May or September, October, and November, can be
explained by separating out the monthly trends for staffing costs and materials costs. This showed that the predominantly variable cost of materials followed the monthly dynamics of the case
numbers, dropping in synchrony with the waves of infection, while staffing costs for 2020 rose on average by 16%. We can, therefore, conclude that the fixed costs of the gynecology clinic,
which include staffing costs, remained unaffected by the monthly trends caused by the pandemic; accordingly, we can determine a 7% increase in total costs for gynecology services for the
whole year of 2020.
Essentially, the number of short-term admissions (above the threshold length for admission but below the average length of admission) fell by 25% compared with 2019; in contrast, long-term
admissions (above the average length of admission but below the upper threshold for length of admission) increased by 111% in response to a decrease in absolute case numbers in the 2020
pandemic year. This indicates a relative increase in the duration of hospital admissions as a response to the drop in patient turnover; because of impending reductions based on DRGs where
the minimum threshold period for admission was exceeded, this cannot be explained from a purely economic perspective. Interestingly, however, the gynecology and obstetrics clinic showed only
a minimal decrease in the case-related case mix index (CMI) as a key indicator for the overall complexity of the cases treated, with a 2.3% drop for gynecology and no change for obstetrics,
while for the University Hospital of Marburg as a whole, the case complexity according to the CMI solidified, with an increase of 3.4%. In our opinion, one factor that contributed to this
was the reactive, cross-departmental focus on complex diseases and tendency to avoid elective hospital admissions in the context of the pandemic. Another factor was the high average CMI
value, at 2.3, for the 283 treated COVID-19 cases; of these cases, those that required hospital admission were patients with multiple morbidities who had an average of 16.5 coded secondary
diagnoses compared with 2.9 for the gynecology patients treated in 2020. The clear increase in the average length of admission, combined with a slight decrease in overall complexity of the
treated cases, shows that during the 2020 pandemic year the gynecology clinic responded to the lower rate of patient throughput by adopting a more conservative discharge policy, but without
actively changing its range of services. Active revenue management and the receipt of additional off-budget payments led to an improved operational result, with an increase in net revenue
despite increased cost and reduced case numbers.
From this we can see that the two waves of COVID-19 infections and associated measures had an impact on the net financial result. Initially, the 98% relative increase in the gynecology
clinic’s net financial result appears to be substantial; however, it can be explained due to changes in accounting practices and changes to the revenue structure, such as the six-fold
increase in additional charges. It does not, therefore, reflect the clinic’s real operational result. Accordingly, the 7% increase in total costs compared with the previous year and a 3%
decrease in DRG revenues provide an unambiguous indicator for the impact of the pandemic on the clinic’s overall financial result. Thus we are able to establish that our observations
relating to case numbers are reflected in the financial results, and that the obstetrics clinic was able to maintain a stable economic performance, while the gynecology clinic was subject to
the changing dynamics of the pandemic and achieved an increase in its net financial result due to additional charges assigned in the bookkeeping procedure.
Conclusion
The goal of this article was to evaluate the impact of the coronavirus pandemic on inpatient and outpatient case numbers at a supraregional maximum care university hospital, to identify any
effects on trends relating to the range of clinical services provided and structured measures of economic performance in the form of ICD primary diagnoses and DRG codes, and to determine how
long it took to return to a pre-pandemic level of service provision. In this process, we hoped to uncover any shortfalls in the care provided.
Our analysis of the case data showed that obstetrics services, including both inpatient and outpatient services, remained largely unaffected, and continued to follow the growth trend from the
previous year. In our assessment, this is based on two factors: the trust that patients have in receiving safe, high-quality care at our university facility, and the fact that the University
Hospital of Marburg allowed prospective fathers to attend the entire birthing process, in spite of the pandemic, provided that they underwent nasopharyngeal PCR testing or a rapid antigen
test.
In contrast, for gynecology services, we were able to demonstrate that the pandemic had a considerable negative impact on case numbers and on inpatient services. Based on inpatient case
numbers, the impact on elective cancer surgery was clearly greater than the impact on outpatient services.
In the gynecology clinic it took just three months for outpatient services to return to a pre-pandemic level of medical care and financial performance, while inpatient services took five
months to return to the performance levels of the previous year.
Based on ICD and DRG codes, the range of services in both subareas remained largely unaffected in 2020 compared with 2019. However, the location-based relative decrease in C50 “Malignant
neoplasm of breast” and C56 “Malignant neoplasm of ovary” diagnoses, by 7.4% and 14% respectively, is a clear cause for concern, and needs to be the subject of detailed epidemiological
analysis and scientific follow-up.
The effects of the pandemic can be identified in the progression of the financial KPIs; however, the extent of the economic impact differs from that observed in the case data.
