Abstract
The COVID-19 pandemic has affected every aspect of medical care, including surgical treatment. It is critical to understand the association of government policies and infection burden with surgical access across the United States. To describe the change in surgical procedure volume in the US after the government-suggested shutdown and subsequent peak surge in volume of patients with COVID-19. This retrospective cohort study was conducted using administrative claims from a nationwide health care technology clearinghouse. Claims from pediatric and adult patients undergoing surgical procedures in 49 US states within the Change Healthcare network of health care institutions were used. Surgical procedure volume during the 2020 initial COVID-19-related shutdown and subsequent fall and winter infection surge were compared with volume in 2019. Data were analyzed from November 2020 through July 2021. 2020 policies to curtail elective surgical procedures and the incidence rate of patients with COVID-19. Incidence rate ratios (IRRs) were estimated from a Poisson regression comparing total procedure counts during the initial shutdown (March 15 to May 2, 2020) and subsequent COVID-19 surge (October 22, 2020-January 31, 2021) with corresponding 2019 dates. Surgical procedures were analyzed by 11 major procedure categories, 25 subcategories, and 12 exemplar operative procedures along a spectrum of elective to emergency indications. A total of 13 108 567 surgical procedures were identified from January 1, 2019, through January 30, 2021, based on 3498 Current Procedural Terminology (CPT) codes. This included 6 651 921 procedures in 2019 (3 516 569 procedures among women [52.9%]; 613 192 procedures among children [9.2%]; and 1 987 397 procedures among patients aged ≥65 years [29.9%]) and 5 973 573 procedures in 2020 (3 156 240 procedures among women [52.8%]; 482 637 procedures among children [8.1%]; and 1 806 074 procedures among patients aged ≥65 years [30.2%]). The total number of procedures during the initial shutdown period and its corresponding period in 2019 (ie, epidemiological weeks 12-18) decreased from 905 444 procedures in 2019 to 458 469 procedures in 2020, for an IRR of 0.52 (95% CI, 0.44 to 0.60; P < .001) with a decrease of 48.0%. There was a decrease in surgical procedure volume across all major categories compared with corresponding weeks in 2019. During the initial shutdown, otolaryngology (ENT) procedures (IRR, 0.30; 95% CI, 0.13 to 0.46; P < .001) and cataract procedures (IRR, 0.11; 95% CI, -0.11 to 0.32; P = .03) decreased the most among major categories. Organ transplants and cesarean deliveries did not differ from the 2019 baseline. After the initial shutdown, during the ensuing COVID-19 surge, surgical procedure volumes rebounded to 2019 levels (IRR, 0.97; 95% CI, 0.95 to 1.00; P = .10) except for ENT procedures (IRR, 0.70; 95% CI, 0.65 to 0.75; P < .001). There was a correlation between state volumes of patients with COVID-19 and surgical procedure volume during the initial shutdown (r = -0.00025; 95% CI, -0.0042 to -0.0009; P = .003), but there was no correlation during the COVID-19 surge (r = -0.00034; 95% CI, -0.0075 to 0.00007; P = .11). This study found that the initial shutdown period in March through April 2020, was associated with a decrease in surgical procedure volume to nearly half of baseline rates. After the reopening, the rate of surgical procedures rebounded to 2019 levels, and this trend was maintained throughout the peak burden of patients with COVID-19 in fall and winter; these findings suggest that after initial adaptation, health systems appeared to be able to self-regulate and function at prepandemic capacity.
Highlights
In February 2020, US physicians and public health personnel watched in real time the mounting deaths among patients and health care workers with COVID-19 and the associated resource shortages in Europe.[1,2] Soon thereafter, the New York City metropolitan area became the first US epicenter for COVID-19
After the initial shutdown, during the ensuing COVID-19 surge, surgical procedure volumes rebounded to 2019 levels (IRR, 0.97; 95% CI, 0.95 to 1.00; P = .10) except for ENT procedures (IRR, 0.70; 95% CI, 0.65 to 0.75; P < .001)
This study found that the initial shutdown period in March through April 2020, was associated with a decrease in surgical procedure volume to nearly half of baseline rates
Summary
In February 2020, US physicians and public health personnel watched in real time the mounting deaths among patients and health care workers with COVID-19 and the associated resource shortages in Europe.[1,2] Soon thereafter, the New York City metropolitan area became the first US epicenter for COVID-19. The most recent pandemic the US had faced, the 2009 influenza A (H1N1) virus pandemic was associated with mortality (0.02%) and hospitalization (0.45%) rates of less than one-half of 1 percent of the estimated 60.8 million people infected.[3] In contrast, COVID-19 was associated with unprecedented stress and demands on the New York City health system, with increased rates of mortality (9.6%) and hospitalization (26.6%).[4] On March 13, 2020, the US president declared a national emergency, leading to a shutdown of all nonessential activities throughout the United States.[5] The American College of Surgeons (ACS) and other major surgical specialty societies recommended minimizing, postponing, or canceling elective surgical procedures in mid-March and published guidelines for triage of elective procedures by surgical specialty.[6,7] The Centers for Medicare & Medicaid Services (CMS) and US Surgeon General issued statements and recommendations for postponement of nonessential surgical procedures.[6,8] Recommendations were driven by concerns that continuation of elective surgical treatments could potentially compromise hospital and intensive care unit (ICU) capacity and result in shortages in personal protective equipment (PPE) supplies. In line with national recommendations, 35 states had formal declarations by state governors or medical societies to postpone all nonessential surgical procedures, which was associated with a decrease in surgical procedure volume during the initial months of the pandemic shutdown.[9]
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