Trends in US Surgical Procedures and Health Care System Response to Policies Curtailing Elective Surgical Operations During the COVID-19 Pandemic.

Importance: 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. Objective: 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. Design, Setting, and Participants: 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. Exposures: 2020 policies to curtail elective surgical procedures and the incidence rate of patients with COVID-19. Main Outcomes and Measures: 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. Results: 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). Conclusions and Relevance: 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.

BJS commission on surgery and perioperative care post-COVID-19.

BACKGROUND: Coronavirus disease 2019 (COVID-19) was declared a pandemic by the WHO on 11 March 2020 and global surgical practice was compromised. This Commission aimed to document and reflect on the changes seen in the surgical environment during the pandemic, by reviewing colleagues' experiences and published evidence. METHODS: In late 2020, BJS contacted colleagues across the global surgical community and asked them to describe how severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) had affected their practice. In addition to this, the Commission undertook a literature review on the impact of COVID-19 on surgery and perioperative care. A thematic analysis was performed to identify the issues most frequently encountered by the correspondents, as well as the solutions and ideas suggested to address them. RESULTS: BJS received communications for this Commission from leading clinicians and academics across a variety of surgical specialties in every inhabited continent. The responses from all over the world provided insights into multiple facets of surgical practice from a governmental level to individual clinical practice and training. CONCLUSION: The COVID-19 pandemic has uncovered a variety of problems in healthcare systems, including negative impacts on surgical practice. Global surgical multidisciplinary teams are working collaboratively to address research questions about the future of surgery in the post-COVID-19 era. The COVID-19 pandemic is severely damaging surgical training. The establishment of a multidisciplinary ethics committee should be encouraged at all surgical oncology centres. Innovative leadership and collaboration is vital in the post-COVID-19 era.

Examining the impact of COVID-19 restrictions on the operative volumes of US general surgery residents.

BACKGROUND: In March 2020, the COVID-19 virus global pandemic forced healthcare systems to institute regulations including the cancellation of elective surgical cases, which likely decreased resident operative experience. The objective of this study was to determine whether the COVID-19 pandemic affected operative experiences of US general surgery residents. METHODS: The operative experience of general surgery residents was examined nationally and locally. Aggregate Accreditation Council for Graduate Medical Education (ACGME) case logs for 2018 to 2019 (pre-COVID) and 2019 to 2020 (COVID) graduates were compared using national mean cumulative operative volume for total major and surgeon chief cases. Locally, ACGME case logs were used to analyze the operative experience among residents at a single, academic center. Average operative volumes per month per resident during peak COVID-19 quarantine months were compared with those the previous year. RESULTS: Compared with 2019 graduates, 2020 graduates completed 1.5% fewer total major cases (1055 ± 155 vs 1071 ± 150, P = .011). This was most evident during chief year, with 8.4% fewer surgeon chief cases logged in 2020 compared with 2019 (264 ± 67 vs 289 ± 69, P < .001). Institutional data revealed that during the peak of the pandemic, residents across all levels completed 42.5% fewer total major operations (12 ± 11 vs 20 ± 14, P < .001). This effect was more pronounced among junior residents compared with senior and chief residents. CONCLUSION: The COVID-19 pandemic was associated with decreased resident case volume. The ramifications of the COVID-19 pandemic for operative competency and autonomy should be carefully examined.

Surgical care in Poland after COVID-19 outbreak: a national survey.

B a c k g r o u n d: During COVID-19 pandemic, it is necessary to collect and analyze data concerning management of hospitals and wards to work out solutions for potential future crisis. The objective of the study was to investigate how surgical wards in Poland are managing during rapid development of the COVID-19 pandemic. M e t h o d s: An anonymous, online survey was designed and distributed to surgeons and surgery residents working in surgical departments during pandemic. Responders were divided into two groups: Group 1 (responders working in a "COVID-19-dedicated" hospital) and Group 2 (responders working in other hospitals). Results: Overall, 323 responders were included in the study group, 30.03% of which were female. Medical staff deficits were reported by 21.15% responders from Group 1 and 29.52% responders from Group 2 (p = 0.003). The mean number of elective surgeries performed weekly prior to the pandemic in Group 1 was 40.37 ± 46.31 and during the pandemic was 13.98 ± 37.49 (p < 0.001). In Group 2, the mean number of elective surgeries performed weekly before the start of the pandemic was 26.85 ± 23.52 and after the start of the pandemic, it was 7.65 ± 13.49 (p <0.001). There were significantly higher reported levels of preparedness in Group 1 in terms of: theoretical training of the staff, equipping the staff and adapting the operating theater to safely perform procedures on patients with COVID-19. Overall, 62.23% of responders presume being infected with SARS-CoV-2. C o n c l u s i o n s: SARS-CoV-2 pandemic had a significantly negative impact on surgical wards. Despite the preparations, the number of responders who presume being infected with SARS-CoV-2 during present crisis is high.

A single-centre observational cohort study to evaluate volume and severity of emergency general surgery admissions during the COVID-19 pandemic: Is there a "lockdown" effect?

INTRODUCTION: The COVID-19 pandemic has led to changes in NHS surgical service provision, including reduced elective surgical and endoscopic activity, with only essential emergency surgery being undertaken. This, combined with the government-imposed lockdown, may have impacted on patient attendance, severity of surgical disease, and outcomes. The aim of this study was to investigate a possible 'lockdown' effect on the volume and severity of surgical admissions and their outcomes. METHODS: Two separate cohorts of adult emergency general surgery inpatient admissions 30 days immediately before (February 16, 2020 to March 15, 2020), and after UK government advice (March 16, 2020 to April 15, 2020). Data were collected relating to patient characteristics, severity of disease, clinical outcomes, and compared between these groups. RESULTS: Following lockdown, a significant reduction in median daily admissions from 7 to 3 per day (p < 0.001) was observed. Post-lockdown patients were significantly older, frailer with higher inflammatory indices and rates of acute kidney injury, and also were significantly more likely to present with gastrointestinal cancer, obstruction, and perforation. Patients had significantly higher rates of Clavien-Dindo Grade ≥3 complications (p = 0.001), all cause 30-day mortality (8.5% vs. 2.9%, p = 0.028), but no significant difference was observed in operative 30-day mortality. CONCLUSION: There appears to be a "lockdown" effect on general surgical admissions with a profound impact; fewer surgical admissions, more acutely unwell surgical patients, and an increase in all cause 30-day mortality. Patients should be advised to present promptly with gastrointestinal symptoms, and this should be reinforced for future lockdowns during the pandemic.

Surgical emergencies during SARS-CoV-2 pandemic lockdown: what happened?

OBJECTIVE: The pandemic from SARS-CoV-2 is having a profound impact on daily life of a large part of world population. Italy was the first Western country to impose a general lockdown to its citizens. Implications of these measures on several aspects of public health remain unknown. The aim of this study was to investigate the effects of the lockdown on surgical emergencies volumes and care in a large, tertiary referral center. MATERIALS AND METHODS: Electronic medical records of all patients visited in our Emergency Department (ED) and admitted in a surgical ward from February 21st 2020 to May 3rd 2020 were collected, analyzed and compared with the same periods of 2019 and 2018 and a cross-sectional study was performed. RESULTS: Number of surgical admissions dropped significantly in 2020 with respect to the same periods of 2019 and 2018, by almost 50%. The percentage distribution of admissions in different surgical wards did not change over the three years. Time from triage to operating room significantly reduced in 2020 respect to 2019 and 2018 (p<0.001). CONCLUSIONS: The lockdown in Italy due to SARS-CoV-2 pandemic arguably represents the largest social experiment in modern times. Data provided by our study provide useful information to health authorities and policymakers about the effects of activity restriction on surgical accesses and changing epidemiology due to an exceptional external event.

Where have the surgical patients gone during the COVID-19 pandemic?

A Commentary on Emergency Surgery at the Epicenter of the COVID-19 Pandemic.

Changes in Emergency General Surgery During Covid-19 in Scotland: A Prospective Cohort Study.

INTRODUCTION: Covid-19 has had a significant impact on all aspects of health care. We aimed to characterise the trends in emergency general surgery at a district general hospital in Scotland. METHODS: A prospective cohort study was performed from 23/03/20 to 07/05/20. All emergency general surgery patients were included. Demographics, diagnosis and management were recorded along with Covid-19 testing and results. Thirty-day mortality and readmission rates were also noted. Similar data were collected on patients admitted during the same period in 2019 to allow for comparison. RESULTS: A total of 294 patients were included. There was a 58.3 per cent reduction in admissions when comparing 2020 with 2019 (85 vs 209); however, there was no difference in age (53.2 vs 57.2 years, p = 0.169) or length of stay (4.8 vs 3.7 days, p = 0.133). During 2020, the diagnosis of appendicitis increased (4.3 vs 18.8 per cent, p = < 0.05) as did severity (0 per cent > grade 1 vs 58.3 per cent > grade 1, p = < 0.05). The proportion of patients undergoing surgery increased (19.1 vs 42.3 per cent, p = < 0.05) as did the mean operating time (102.4 vs 145.7 min, p = < 0.05). Surgery was performed in 1 confirmed and 1 suspected Covid-19 patient. The latter died within 30 days. There were no 30-day readmissions with Covid-19 symptoms. CONCLUSION: Covid-19 has significantly impacted the number of admissions to emergency general surgery. However, emergency operating continues to be needed at pre-Covid-19 levels and as such provisions need to be made to facilitate this.