Abstract: It was in Ahmedabad, Gujarat that the public-private partnership of Covid-19 management in India began in April 2020. It was soon followed across the nation as Ahmedabad Model. This has yielded good results as far as Covid-19 management is concerned raising the bar for quality care and reducing the mortality rates across the nation. However, this is coming at a high cost of damage to non-COVID services in health care.
Ahmedabad Model: India started receiving its share of disease from March 2020. In view of global experience, the health ministry of India was quick to wake up and take precautionary steps to get prepared for the storm to arrive in India. During the month of April 2020, one of the most flooded regions was the district of Ahmedabad due to several different factors.
The city of Ahmedabad had the highest number of cases in India and with a high mortality rate. General hospitals were flooded with Covid-19 patients. That was a time when India and the world received what is now famous as the Ahmedabad Model of Health care for Covid-19. The civic authority made a memorandum of Understanding with multiple private sectors, corporate hospitals and decided to incorporate them in Covid-19 management.
These hospitals were classified as Covid-19 designated hospitals and Covid-19 referral centers depending upon their bed capacity and presence of infrastructure, especially availability of Critical Care Setup and ventilators. HCG Hospitals, Mithakhali, Ahmedabad was the first of this chain of hospitals. I was fortunate to be the Director, Department of Internal Medicine, HCG Hospitals, and became the first-ever private consultant to admit and examine and manage a patient of Covid-19.
In this article, we will discuss in brief, the pros and cons of Covid-19 management in a private hospital in India. Pros of management by a Private Hospital:
1. Freedom of protocol
2. Established infrastructure
3. Liberty of flexibility
4. Financial laxity
5. Expertise of best knowledge
6. Clinical audit
- Freedom of protocol: Fortunately for all of us, while MOU’s were created, all private hospitals were allowed to follow a standard protocol subject to decision by the protocol committee of the hospital. This allowed private set up to utilize the drugs freely and create own experienced based protocols subject to ICMR guidelines. So at a time when government hospitals were using Azithromycin, we stopped the use based on recent trials and that became a trendsetter later on. So the advantage with the private set up was quicker updating of protocols and applying newer modalities faster. Tocilizumab which was once used in plenty during April and May was gradually reduced in numbers and that also helped in changing the clinical outcome. It was possible for the team to meet every week and discuss the outcome and experiences and evidence-based information and make necessary changes in protocol.
2. Established Infrastructure: Private hospitals have an established infrastructure and all available manpower is steady and stable at their places and rotation (especially with medical manpower) seen in government hospitals is not seen or is less frequent in private set up. This allows us to create teamwork where every person of the team does the same thing every time and does what he knows the best. This enhances the quality of services and improves performance at every level.
3. Liberty of flexibility: This looks in contradiction to the previous point but the private set up has the liberty to be flexible. Depending upon the severity of the disease, comorbidities of the patient, day of onset of disease, one may deviate from the protocol and may make efforts to edit the same. Covid-19 is one disease where the world is learning and unlearning very fast. Every day some new knowledge percolates rubbing the remnants of the previous hypothesis.
Multiple drugs like ithromycin, HCQS, Doxycycline, Ivermectin, Colchicine were tried globally and at every private set up, few with varying success and few with varying failures. The introduction of newer antivirals was much more quickly absorbed by private set up and that led to the realization of the effectiveness of drugs like Remdesivir in moderate to severe disease and the private set up was quick to change the protocol to include these newer drugs.
Flexibility was also possible in using personal protection equipment kits (PPE). Newer protocols for doffing and donning could be applied for their use leading to better protective effects. Use better sanitizers and surfacemcleaners with improved surface cleaning techniques that were soon available and were rapidly applied in private setups.
4. Financial Laxity: This was probably the best reason for better clinical outcomes in private set up. Medical teams were allowed to use multiple modalities of diagnostic techniques and treatment without much concern for the cost for this what could be a lethal disease. Optimal use of Remdesivir in hospitalized patients and Favipiravir in outdoor patients probably changed the mortality rates at least in Ahmedabad.
Additional use of imaging modalities ( which was much restricted in government hospitals) allowed a rapid understanding of lung involvement and screening those patients likely to go for hypoxia. Similarly, blood investigations, especially for inflammatory markers could be carried out more frequently depending upon the clinical deterioration and this helped in deciding the prognosis However, financial laxity has always been a double-edged sword as we will see later on in the article.
5. Expertise of the best knowledge: Private hospitals had the edge of getting the best of opinions across the state in most of the circumstances and across the city in practically all the cases. One can always get the facility of the best of the intensivists, critical care specialists, pulmonologists, and also the services of the best of faculties from related branches like cardiology, neurology, and nephrology in addition to Covid-19 physicians.
This process helped to boost the experience of the local teams and share the data with others. No stone was kept unturned for a critically ill patient which gave satisfaction to the relatives and improved the outcome.
6. Clinical audit: Auditing is the best way to improve clinical outcomes. The private set up went on auditing the data at the discharge of every 50 patients. Audit keeps you on your toes and shows a mirror to your mistakes.
We go on making mistakes and call it our clinical experience. Clinical audit keeps a check on this so called “Clinical “experience”. Clinical audit was not only carried out for disease related issues but also related to prevention. Most of the institutes carried out an audit for the preventive effect of HCQS for health care workers.
Similarly, the audit of the patient satisfaction scale was also useful in improving the related services. In fact at HCG, we carried out surveillance for communication with patients’ relatives and found it to be much satisfactory. Every fortnight, new steps were introduced wherever an improvement was possible or warranted. We also warranted a death audit in Covid-19 to find out risk factors for mortality.
All such efforts done more frequently at private set up improve the quality of care given to patients. As compared to general hospitals, the mortality rate until now in corporate hospitals has remained much lower despite the fact that all private hospitals are accepting sicker patients.
Quality of care is also considered much better at private setups as compared with general hospitals, however none of these claims can be substantiated until a randomized trial is carried out or audits of both sectors are compared. Cons of management of Covid-19 by private set up:
1. Financial laxity
2. Cost for the institutes
3. Health care workers.
4. Government strategy
5. Patient doctor relationship
1. Financial laxity: As discussed above, financial laxity is one strong point for the advantages of Covid-19 management in private sector hospitals. However, the same has been a weakness also. As there are no presumed financial constraints, certain tests may be done unwarranted. This is one bitter truth which requires very stringent auditing as we do at our institute. For example, because of fear of getting quarantined, people try to run away from RT PCR in government institutes and get themselves imagined by HRCT Thorax which may point to possible COVID-19 infection but can not be an alternative to RT PCR and is also much expansive and also exposure to radiation is immense.
Thus in many areas of the country, radio imaging on day 1 has become the norm which is neither desirable nor ethical. This is the weak point when we think about private sector management for Covid-19. Similarly, antivirals like favipiravir may be overprescribed to those who may actually not need it. Inflammatory markers on day 1 are another unwarranted luxury which is an unwarranted punishment one may be paying for incorporating the private sector in the management.
In places where there is a stringent audit, the practice has been curtailed to a bare minimum but in areas where the resources are not available, education is not enough, and fear for Covid-19 is more or less a Taboo, the frequency of these and many other medical mishaps may be more.
2. Cost for the institutes: RT PCR being a moderate sensitive test (65% specificity) requires a repeat test if negative in highly suspected cases. This is a costly affair. This is just one example. Multiple such modalities exist which make treatment of Covid-19 highly expansive for patients but not lucrative for hospitals.
Contrary to the beliefs that Covid-19 designated hospitals are looting the patients, most of the hospitals are on the losing side. Most of the hospitals have to manage the stay and food for the employees. They have to manage for the sickness of the employees and manage for replacements. During Covid-19, government hospitals can issue a whip for medical officers and get them transferred to where needed in more numbers.
Even during such pandemics, the government can enforce residents from different unrelated departments (Dermatology) to get posted in Covid-19 wards. This facility is not available for private hospitals. Most of Covid-19 designated hospitals have lost non-COVID work practically completely. Their surgical work has gone down to zero.
Planned surgeries are going expansive as each requires incorporating Covid-19 related expansive investigations ( HRCT, RT PCR, Trop T, D Dimer) which puts additional expense on patients even for minor surgeries like cataract. Loss of revenue is unmatched and the occupancy rates are very low. Not only the number of people getting hospitalized is going down but the out-door patient department is becoming vacant.
Add to this the cost of maintaining Covid-19 infrastructure which requires creating triage and providing PPE kits to all the staff members. Fire safety in view of extensive use of sanitizers, plastic in PPE kits, curtains, excessive need for oxygen becomes of paramount importance.
3. Health Care Workers: Maintaining the safety of health care workers has been of prime importance. Looking at the dangerously high number of deaths in health care workers all across the globe and in India, protecting the HCW becomes a tough task.
This not only requires imparting regular education but also ensures providing the best quality protective gear for them. Regular breaks, enough nutrition, and frequent checking and immunization, all become important parameters to look after.
4. Government Strategy: Most of the MOU’s created by the government implies admission to 30-40 local administrative patients for a nominal charge. Most of the private hospitals are now capped for the upper limit of each hospitalization head, be it room charges or nursing charges, or diet charges. Certain treatment modalities are available only for government hospitals like Convalescent plasma therapy was till now available only to government hospitals only.
Similarly, initially Remdesivir was available only to government hospitals enrolled for the trial. Rapid antigen tests are available only for Government Hospitals. Actually, these tests are a very good screening tool and if made available for preoperative assessment, most of the problems for surgeries in private set up will regress but are not to be till now.
5. Patient Doctor Relationship: The biggest worry for private sector management of Covid-19 is the deteriorating patient-doctor relationship. Covid-19 management is in its infancy. Many things are in its fluidity. Diagnostic investigations are neither completely specific nor sensitive. Management protocols are changing day in and day out. Take a simple example of RT PCR which is considered to be a gold standard test for Covid-19.
However, if it is negative, it does not rule out COVID-19. Now a patient who has undergone a negative Covid-19 test prior to hospitalization is made to undergo the second test as per ICMR guidelines, the patient feels that this is a “manipulated” report. This causes distrust in the mind of the patient which disrupts the patient doctor relationship.
Even the hospitalization stay is dependent upon multiple factors and a cause of distrust amongst these two sides of treatment. At least, in India, this is becoming a big nuisance and is completely creating havoc in the health system. Conclusion: Any involvement of the
Privatisation in the health care system in the management of Covid-19 has a fascinating story. It has helped to manage the war against Covid-19 with reasonable power. It has not only reduced the burden on Government hospitals but has substantially improved the quality of care given to Covid-19 patients. It has helped to reduce mortality rates in hospitalized Covid-19 patients. Updated knowledge, the flexibility of treatment protocols, and their strict application have made this possible. This has come at an immense cost of financial penalty to patients and a huge loss of non-COVID revenue for hospitals. Non-COVID services are affected largely due to this situation leading to higher mortality in this group of patients.