Telemedicine in Spine Surgery: Global Perspectives and Practices.

STUDY DESIGN: Cross-sectional, anonymous, international survey. OBJECTIVES: The COVID-19 pandemic has resulted in the rapid adoption of telemedicine in spine surgery. This study sought to determine the extent of adoption and global perspectives on telemedicine in spine surgery. METHODS: All members of AO Spine International were emailed an anonymous survey covering the participant's experiences with and perceptions of telemedicine. Descriptive statistics were used to depict responses. Responses were compared among regions. RESULTS: 485 spine surgeons participated in the survey. Telemedicine usage rose from <10.0% to >39.0% of all visits. A majority of providers (60.5%) performed at least one telemedicine visit. The format of "telemedicine" varied widely by region: European (50.0%) and African (45.2%) surgeons were more likely to use phone calls, whereas North (66.7%) and South American (77.0%) surgeons more commonly used video (P < 0.001). North American providers used telemedicine the most during COVID-19 (>60.0% of all visits). 81.9% of all providers "agreed/strongly agreed" telemedicine was easy to use. Respondents tended to "agree" that imaging review, the initial appointment, and postoperative care could be performed using telemedicine. Almost all (95.4%) surgeons preferred at least one in-person visit prior to the day of surgery. CONCLUSION: Our study noted significant geographical differences in the rate of telemedicine adoption and the platform of telemedicine utilized. The results suggest a significant increase in telemedicine utilization, particularly in North America. Spine surgeons found telemedicine feasible for imaging review, initial visits, and follow-up visits although the vast majority still preferred at least one in-person preoperative visit.

Patient knowledge, personal experience, and impact of the first wave of the COVD-19 pandemic in an Irish oncology cohort.

BACKGROUND: Oncology patients have had to make many changes to minimise their exposure to COVID-19, causing stress. Despite education, some patients still do not recognise potential COVID symptoms. AIMS: We assessed patient knowledge of COVID, and its impact on their behaviours, concerns, and healthcare experience. METHODS: A 16-page questionnaire was distributed to 120 oncology patients attending the day unit of a tertiary Irish cancer centre for systemic anti-cancer therapy (May/June 2020). The Irish 7-day COVID incidence during this period ranged from 2 to 11 cases/100,000 people. RESULTS: One hundred and one responses were received, 1% had tested positive for COVID, and 31% had undergone testing. Participant insight into their knowledge about COVID and their own behaviour was limited in some cases. Seventy-five percent reported total compliance with restrictions, but many were not fully compliant. Self-reported confidence in knowledge was high, but did not predict demonstrated knowledge. Sixty percent did not recognise two or more symptoms; 40% did not self-identify as high-risk. Patients reported more health-related worry (72%), loneliness (51%), and lower mood (42%) since the pandemic began. Financial toxicity worsened, with increased financial worry (78%), reductions in household income (40%), and increased costs due to lockdown (62%). Use of facemasks introduced new communications barriers for 67% of those with hearing loss. CONCLUSIONS: Despite self-reported confidence in knowledge, some patient's recognition of COVID symptoms and the preventative strategies they should use are not optimal, highlighting the need for further education in this regard. COVID has been a significant stressor for patients and more practical, financial, and psychological supports are needed.

COVID-19 and Social Capital Loss: The Results of a Campus Outbreak.

This study examines the effects of a COVID-19 outbreak on levels of social capital on a college campus, drawing on survey data collected from students at two colleges-one that experienced an outbreak and one that did not. Social capital is examined as an individual level resource and as a campus level normative tool used to fight collective action problems. We test the hypothesis that the outbreak, as a "shock" to the campus, diminished social capital. We also test hypotheses on gender, race, and ethnicity and social capital, informed by prior research. Our findings suggest that the outbreak did reduce social capital at both the individual and campus levels, though individual social capital had a mitigating effect that increased campus social capital. We find also that gender was significantly linked to campus social capital, while race was predictive of individual level social capital.

The Impact of COVID-19 Pandemic on Spine Surgeons Worldwide: A One Year Prospective Comparative Study.

STUDY DESIGN: Survey. OBJECTIVE: In March of 2020, an original study by Louie et al investigated the impact of COVID-19 on 902 spine surgeons internationally. Since then, due to varying government responses and public health initiatives to the pandemic, individual countries and regions of the world have been affected differently. Therefore, this follow-up study aimed to assess how the COVID-19 impact on spine surgeons has changed 1 year later. METHODS: A repeat, multi-dimensional, 90-item survey written in English was distributed to spine surgeons worldwide via email to the AO Spine membership who agreed to receive surveys. Questions were categorized into the following domains: demographics, COVID-19 observations, preparedness, personal impact, patient care, and future perceptions. RESULTS: Basic respondent demographics, such as gender, age, home demographics, medical comorbidities, practice type, and years since training completion, were similar to those of the original 2020 survey. Significant differences between groups included reasons for COVID testing, opinions of media coverage, hospital unemployment, likelihood to be performing elective surgery, percentage of cases cancelled, percentage of personal income, sick leave, personal time allocation, stress coping mechanisms, and the belief that future guidelines were needed (P<.05). CONCLUSION: Compared to baseline results collected at the beginning of the COVID-19 pandemic in 2020, significant differences in various domains related to COVID-19 perceptions, hospital preparedness, practice impact, personal impact, and future perceptions have developed. Follow-up assessment of spine surgeons has further indicated that telemedicine and virtual education are mainstays. Such findings may help to inform and manage expectations and responses to any future outbreaks.

Circadian rhythm disruption in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Implications for the post-acute sequelae of COVID-19.

Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) is a common and disabling disorder primarily characterized by persistent fatigue and exercise intolerance, with associated sleep disturbances, autonomic dysfunction, and cognitive problems. The causes of ME/CFS are not well understood but may coincide with immune and inflammatory responses following viral infections. During the current SARS-CoV2 coronavirus pandemic, ME/CFS has been increasingly reported to overlap with persistent "long COVID" symptoms, also called the post-acute sequelae of COVID-19 (PASC). Given the prominence of activity and sleep problems in ME/CFS, circadian rhythm disruption has been examined as a contributing factor in ME/CFS. While these studies of circadian rhythms have been pursued for decades, evidence linking circadian rhythms to ME/CFS remains inconclusive. A major limitation of older chronobiology studies of ME/CFS was the unavailability of modern molecular methods to study circadian rhythms and incomplete understanding of circadian rhythms outside the brain in peripheral organ systems. Major methodological and conceptual advancements in chronobiology have since been made. Over the same time, biomarker research in ME/CFS has progressed. Together, these new developments may justify renewed interest in circadian rhythm research in ME/CFS. Presently, we review ME/CFS from the perspective of circadian rhythms, covering both older and newer studies that make use of modern molecular methods. We focus on transforming growth factor beta (TGFB), a cytokine that has been previously associated with ME/CFS and has an important role in circadian rhythms, especially in peripheral cells. We propose that disrupted TGFB signaling in ME/CFS may play a role in disrupting physiological rhythms in sleep, activity, and cognition, leading to the insomnia, energy disturbances, cognition problems, depression, and autonomic dysfunction associated with ME/CFS. Since SARS-like coronavirus infections cause persistent changes in TGFB and previous coronavirus outbreaks have caused ME/CFS-like syndromes, chronobiological considerations may have immediate implications for understanding ME/CFS in the context of the COVID-19 pandemic and possibly suggest new avenues for therapeutic interventions.

Social capital as mediating factor on COVID-19 induced psychological distress: The case of college students living through an outbreak.

This investigation examines the interplay between individual-level social capital, psychological distress, and the effects of a coronavirus disease 2019 (COVID-19) outbreak on a college campus. Data were collected from students at two colleges in early 2021. Hypotheses were formed based on prior research on social capital and the COVID pandemic. A structural equation model was constructed to allow the modeling of both latent and observed variables. The Kessler-6 measures were used to create a latent psychological distress variable, which was the dependent variable. Predictor variables include whether the student experienced the outbreak, the student's race and gender, and the level of reported individual social capital (having supportive and rewarding relationships). Our findings suggest that the most robust predictor of reduced psychological distress was individual social capital, which also served as an intermediary between the outbreak and distress. Social capital mediates psychological distress in an outbreak.

Love and peace across generations: Biobehavioral systems and global partnerships.

Children's environments - especially relationships with caregivers - sculpt not only developing brains but also multiple bio-behavioral systems that influence long-term cognitive and socioemotional outcomes, including the ability to empathize with others and interact in prosocial and peaceful ways. This speaks to the importance of investing resources in effective and timely programs that work to enhance early childhood development (ECD) and, by extension, reach communities at-scale. Given the limited resources currently devoted to ECD services, and the devastating impact of COVID-19 on children and communities, there is a clear need to spur government leaders and policymakers to further invest in ECD and related issues including gender and racial equity. This essay offers concrete examples of scholarly paradigms and leadership efforts that focus on child development to build a peaceful, equitable, just, and sustainable world. As scholars and practitioners, we need to continue to design, implement, assess, and revise high-quality child development programs that generate much-needed evidence for policy and programmatic changes. We must also invest in global partnerships to foster the next generation of scholars, practitioners, and advocates dedicated to advance our understanding of the bio-behavioral systems that underlie love, sociality, and peace across generations. Especially where supported by structural interventions, ECD programs can help create more peaceful, just, and socially equitable societies.

Provider confidence in the telemedicine spine evaluation: results from a global study.

PURPOSE: To utilize data from a global spine surgeon survey to elucidate (1) overall confidence in the telemedicine evaluation and (2) determinants of provider confidence. METHODS: Members of AO Spine International were sent a survey encompassing participant's experience with, perception of, and comparison of telemedicine to in-person visits. The survey was designed through a Delphi approach, with four rounds of question review by the multi-disciplinary authors. Data were stratified by provider age, experience, telemedicine platform, trust in telemedicine, and specialty. RESULTS: Four hundred and eighty-five surgeons participated in the survey. The global effort included respondents from Africa (19.9%), Asia Pacific (19.7%), Europe (24.3%), North America (9.4%), and South America (26.6%). Providers felt that physical exam-based tasks (e.g., provocative testing, assessing neurologic deficits/myelopathy, etc.) were inferior to in-person exams, while communication-based aspects (e.g., history taking, imaging review, etc.) were equivalent. Participants who performed greater than 50 visits were more likely to believe telemedicine was at least equivalent to in-person visits in the ability to make an accurate diagnosis (OR 2.37, 95% C.I. 1.03-5.43). Compared to in-person encounters, video (versus phone only) visits were associated with increased confidence in the ability of telemedicine to formulate and communicate a treatment plan (OR 3.88, 95% C.I. 1.71-8.84). CONCLUSION: Spine surgeons are confident in the ability of telemedicine to communicate with patients, but are concerned about its capacity to accurately make physical exam-based diagnoses. Future research should concentrate on standardizing the remote examination and the development of appropriate use criteria in order to increase provider confidence in telemedicine technology.

P39. Telehealth and spine care: Surgeon experiences and perceptions

BACKGROUND CONTEXT Telehealth use in spine surgery has become widespread due to the COVID-19 pandemic. The degree of global adoption remains unknown. To our knowledge, this is the first global survey to directly evaluate provider perspectives surrounding telemedicine use-cases. PURPOSE To elicit the extent of adoption of international spine telehealth. We aimed to explore telemedicine platform used, ease of use, and acceptable use-cases. STUDY DESIGN/SETTING Cross-sectional email survey, international. PATIENT SAMPLE Spine Surgeons. OUTCOME MEASURES Perspectives and practices of spine telemedicine. METHODS An anonymous, cross-sectional email survey was sent to the members of AO Spine. Survey questions covered provider experiences with and perceptions of telemedicine. Descriptive statistics were used to depict responses and responses were compared amongst regions. RESULTS A total of 485 spine providers responded to the survey. As of May 2020, telemedicine usage comprised >39.0% of all visits — up from <10.0% of visits pre-pandemic. A majority of providers (60.5%) performed at least 1 telemedicine visit. The format of “telemedicine” varied widely by region: African (45.2%) and European (50.0%) providers were more likely to use phone calls (no video), whereas North (66.7%) and South American (77.0%) surgeons more commonly used audio-visual telemedicine (p<0.001). North American providers used telemedicine the most during COVID-19 (>60.0% of all visits). There were 81.9% of all providers who “agreed/strongly agreed” telemedicine was easy to use. Respondents tended to “agree” that imaging review, the initial appointment, and postoperative care could be performed using telemedicine. Almost all (95.4%) surgeons preferred at least one in-person visit prior to the day of surgery. CONCLUSIONS Our study noted significant geographical differences in the rate of telemedicine usage and the platform of telemedicine utilized. Spine surgeons found telemedicine feasible for imaging review, initial visits, and follow-up visits although the vast majority still preferred at least one in-person preoperative visit. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Spine surgeon perceptions of the challenges and benefits of telemedicine: an international study.

INTRODUCTION: While telemedicine usage has increased due to the COVID-19 pandemic, there remains little consensus about how spine surgeons perceive virtual care. The purpose of this study was to explore international perspectives of spine providers on the challenges and benefits of telemedicine. METHODS: Responses from 485 members of AO Spine were analyzed, covering provider perceptions of the challenges and benefits of telemedicine. All questions were optional, and blank responses were excluded from analysis. RESULTS: The leading challenges reported by surgeons were decreased ability to perform physical examinations (38.6%), possible increased medicolegal exposure (19.3%), and lack of reimbursement parity compared to traditional visits (15.5%). Fewer than 9.0% of respondents experienced technological issues. On average, respondents agreed that telemedicine increases access to care for rural/long-distance patients, provides societal cost savings, and increases patient convenience. Responses were mixed about whether telemedicine leads to greater patient satisfaction. North Americans experienced the most challenges, but also thought telemedicine carried the most benefits, whereas Africans reported the fewest challenges and benefits. Age did not affect responses. CONCLUSION: Spine surgeons are supportive of the benefits of telemedicine, and only a small minority experienced technical issues. The decreased ability to perform the physical examination was the top challenge and remains a major obstacle to virtual care for spine surgeons around the world, although interestingly, 61.4% of providers did not acknowledge this to be a major challenge. Significant groundwork in optimizing remote physical examination maneuvers and achieving legal and reimbursement clarity is necessary for widespread implementation.

COVID-19 and the rise of virtual medicine in spine surgery: a worldwide study.

PURPOSE: The COVID-19 pandemic forced many surgeons to adopt "virtual medicine" practices, defined as telehealth services for patient care and online platforms for continuing medical education. The purpose of this study was to assess spine surgeon reliance on virtual medicine during the pandemic and to discuss the future of virtual medicine in spine surgery. METHODS: A comprehensive survey addressing demographic data and virtual medicine practices was distributed to spine surgeons worldwide between March 27, 2020, and April 4, 2020. RESULTS: 902 spine surgeons representing seven global regions responded. 35.6% of surgeons were identified as "high telehealth users," conducting more than half of clinic visits virtually. Predictors of high telehealth utilization included working in an academic practice (OR = 1.68, p = 0.0015) and practicing in Europe/North America (OR 3.42, p < 0.0001). 80.1% of all surgeons were interested in online education. Dedicating more than 25% of one's practice to teaching (OR = 1.89, p = 0.037) predicted increased interest in online education. 26.2% of respondents were identified as "virtual medicine surgeons," defined as surgeons with both high telehealth usage and increased interest in online education. Living in Europe/North America and practicing in an academic practice increased odds of being a virtual medicine surgeon by 2.28 (p = 0.002) and 1.15 (p = 0.0082), respectively. 93.8% of surgeons reported interest in a centralized platform facilitating surgeon-to-surgeon communication. CONCLUSION: COVID-19 has changed spine surgery by triggering rapid adoption of virtual medicine practices. The demonstrated global interest in virtual medicine suggests that it may become part of the "new normal" for surgeons in the post-pandemic era.

Assessing the Early Impact of the COVID-19 Pandemic on Spine Surgery Fellowship Education.

STUDY DESIGN: This was a cross-sectional study. OBJECTIVE: The objective of this study is to report the impact of COVID-19 on spine surgery fellow education and readiness for practice. SUMMARY OF BACKGROUND DATA: COVID-19 has emerged as one of the most devastating global health crises of our time. To minimize transmission risk and to ensure availability of health resources, many hospitals have cancelled elective surgeries. There may be unintended consequences of this decision on the education and preparedness of current surgical trainees. MATERIALS AND METHODS: A multidimensional survey was created and distributed to all current AO Spine fellows and fellowship directors across the United States and Canada. RESULTS: Forty-five spine surgery fellows and 25 fellowship directors completed the survey. 62.2% of fellows reported >50% decrease in overall case volume since cancellation of elective surgeries. Mean hours worked per week decreased by 56.2%. Fellows reported completing a mean of 188.4±64.8 cases before the COVID-19 crisis and 84.1% expect at least an 11%-25% reduction in case volume compared with previous spine fellows. In all, 95.5% of fellows did not expect COVID-19 to impact their ability to complete fellowship. Only 2 directors were concerned about their fellows successfully completing fellowship; however, 32% of directors reported hearing concerns regarding preparedness from their fellows and 25% of fellows were concerned about job opportunities. CONCLUSIONS: COVID-19 has universally impacted work hours and case volume for spine surgery fellows set to complete fellowship in the middle of 2020. Nevertheless, spine surgery fellows generally feel ready to enter practice and are supported by the confidence of their fellowship directors. The survey highlights a number of opportunities for improvement and innovation in the future training of spine surgeons. LEVEL OF EVIDENCE: Level III.

Correction to: Learning from the past: did experience with previous epidemics help mitigate the impact of COVID-19 among spine surgeons worldwide?

Unfortunately, the 13th author name has been incorrectly published in the original publication. The complete correct name is given below.

COVID-19: Current and future challenges in spine care and education - a worldwide study.

BACKGROUND: The COVID-19 pandemic has impacted spine care around the globe. Much uncertainty remains regarding the immediate and long-term future of spine care and education in this COVID-19 era. STUDY DESIGN: Cross-sectional, international study of spine surgeons. METHODS: A multi-dimensional survey was distributed to spine surgeons around the world. A total of 73 questions were asked regarding demographics, COVID-19 observations, personal impact, effect on education, adoption of telemedicine, and anticipated challenges moving forward. Multivariate analysis was performed to assess factors related to likelihood of future conference attendance, future online education, and changes in surgical indications. RESULTS: A total of 902 spine surgeons from seven global regions completed the survey. Respondents reported a mean level of overall concern of 3.7 on a scale of one to five. 84.0% reported a decrease in clinical duties, and 67.0% reported a loss in personal income. The 82.5% reported being interested in continuing a high level of online education moving forward. Respondents who personally knew someone who tested positive for COVID-19 were more likely to be unwilling to attend a medical conference 1 year from now (OR: 0.61, 95% CI: [0.39, 0.95], P = .029). The 20.0% reported they plan to pursue an increased degree of nonoperative measures prior to surgery 1 year from now, and respondents with a spouse at home (OR: 3.55, 95% CI: [1.14, 11.08], P = .029) or who spend a large percentage of their time teaching (OR: 1.45, 95% CI: [1.02, 2.07], P = .040) were more likely to adopt this practice. CONCLUSIONS: The COVID-19 pandemic has had an adverse effect on surgeon teaching, clinical volume, and personal income. In the future, surgeons with family and those personally affected by COVID-19 may be more willing to alter surgical indications and change education and conference plans. Anticipating these changes may help the spine community appropriately plan for future challenges.

Spine Surgery and COVID-19: The Influence of Practice Type on Preparedness, Response, and Economic Impact.

STUDY DESIGN: Cross-sectional observational cohort study. OBJECTIVE: To investigate preparation, response, and economic impact of COVID-19 on private, public, academic, and privademic spine surgeons. METHODS: AO Spine COVID-19 and Spine Surgeon Global Impact Survey includes domains on surgeon demographics, location of practice, type of practice, COVID-19 perceptions, institutional preparedness and response, personal and practice impact, and future perceptions. The survey was distributed by AO Spine via email to members (n = 3805). Univariate and multivariate analyses were performed to identify differences between practice settings. RESULTS: A total of 902 surgeons completed the survey. In all, 45.4% of respondents worked in an academic setting, 22.9% in privademics, 16.1% in private practice, and 15.6% in public hospitals. Academic practice setting was independently associated with performing elective and emergent spine surgeries at the time of survey distribution. A majority of surgeons reported a >75% decrease in case volume. Private practice and privademic surgeons reported losing income at a higher rate compared with academic or public surgeons. Practice setting was associated with personal protective equipment availability and economic issues as a source of stress. CONCLUSIONS: The current study indicates that practice setting affected both preparedness and response to COVID-19. Surgeons in private and privademic practices reported increased worry about the economic implications of the current crisis compared with surgeons in academic and public hospitals. COVID-19 decreased overall clinical productivity, revenue, and income. Government response to the current pandemic and preparation for future pandemics needs to be adaptable to surgeons in all practice settings.

Personal Health of Spine Surgeons Can Impact Perceptions, Decision-Making and Healthcare Delivery During the COVID-19 Pandemic - A Worldwide Study.

OBJECTIVE: To determine if personal health of spine surgeons worldwide influences perceptions, healthcare delivery, and decision-making during the coronavirus disease 2019 (COVID-19) pandemic. METHODS: A cross-sectional study was performed by distributing a multidimensional survey to spine surgeons worldwide. Questions addressed demographics, impacts and perceptions of COVID-19, and the presence of surgeon comorbidities, which included cancer, cardiac disease, diabetes, obesity, hypertension, respiratory illness, renal disease, and current tobacco use. Multivariate analysis was performed to identify specific comorbidities that influenced various impact measures. RESULTS: Across 7 global regions, 36.8% out of 902 respondents reported a comorbidity, of which hypertension (21.9%) and obesity (15.6%) were the most common. Multivariate analysis noted tobacco users were more likely to continue performing elective surgery during the pandemic (odds ratio [OR], 2.62; 95% confidence interval [CI], 1.46-4.72; p = 0.001) and were less likely to utilize telecommunication (OR, 0.51; 95% CI, 0.31-0.86; p = 0.011), whereas those with hypertension were less likely to warn their patients should the surgeon become infected with COVID-19 (OR, 0.57; 95% CI, 0.37-0.91; p = 0.017). Clinicians with multiple comorbidities were more likely to cite personal health as a current stressor (OR, 1.32; 95% CI, 1.07-1.63; p = 0.009) and perceived their hospital's management unfavorably (OR, 0.74; 95% CI, 0.60-0.91; p = 0.005). CONCLUSION: This is the first study to have mapped global variations of personal health of spine surgeons, key in the development for future wellness and patient management initiatives. This study underscored that spine surgeons worldwide are not immune to comorbidities, and their personal health influences various perceptions, healthcare delivery, and decision-making during the COVID-19 pandemic.

Learning from the past: did experience with previous epidemics help mitigate the impact of COVID-19 among spine surgeons worldwide?

PURPOSE: Spine surgeons around the world have been universally impacted by COVID-19. The current study addressed whether prior experience with disease epidemics among the spine surgeon community had an impact on preparedness and response toward COVID-19. METHODS: A 73-item survey was distributed to spine surgeons worldwide via AO Spine. Questions focused on: demographics, COVID-19 preparedness, response, and impact. Respondents with and without prior epidemic experience (e.g., SARS, H1NI, MERS) were assessed on preparedness and response via univariate and multivariate modeling. Results of the survey were compared against the Global Health Security Index. RESULTS: Totally, 902 surgeons from 7 global regions completed the survey. 24.2% of respondents had prior experience with global health crises. Only 49.6% reported adequate access to personal protective equipment. There were no differences in preparedness reported by respondents with prior epidemic exposure. Government and hospital responses were fairly consistent around the world. Prior epidemic experience did not impact the presence of preparedness guidelines. There were subtle differences in sources of stress, coping strategies, performance of elective surgeries, and impact on income driven by prior epidemic exposure. 94.7% expressed a need for formal, international guidelines to help mitigate the impact of the current and future pandemics. CONCLUSIONS: This is the first study to note that prior experience with infectious disease crises did not appear to help spine surgeons prepare for the current COVID-19 pandemic. Based on survey results, the GHSI was not an effective measure of COVID-19 preparedness. Formal international guidelines for crisis preparedness are needed to mitigate future pandemics.