After a dramatic drop in nonessential surgery rates early in the pandemic, U.S. hospitals quickly adapted to new safety protocols, and rates returned to normal, Stanford Medicine research shows.
Stanford Medicine researchers found that after the March 2020 COVID-19 shutdown, nonurgent surgery rates dropped, but within months they bounced back and remained at pre-pandemic levels, even as coronavirus infections peaked during the fall and winter of 2020.
The study, published online Dec. 8 in JAMA Network Open, contradicts the assumption that the COVID-19 pandemic has continually curtailed nonessential surgeries across the country.
“It’s an untold story,” said Sherry Wren, MD, professor of general surgery and senior author on the paper. “It’s the opposite of what all the headlines say.”
Using administrative claims from more than 13 million surgical procedures in 49 states, the study compared the number of surgeries performed each week in 2019 with the corresponding week in 2020.
As expected, the researchers found a 48% decrease in surgical volume during the seven weeks after mid-March, when the Centers for Medicare and Medicaid Services recommended that hospitals minimize, postpone or cancel elective surgeries. Elective surgeries include those that are medically necessary but can wait more than a few days.
“If you think back to that time,” Wren said, “nobody was sure if they had enough personal protective equipment, and doing operations clearly burns through your PPE. There was also the fear of not having adequate hospital beds and ICU beds and ventilators.” In that initial climate of uncertainty and fear, she said, postponing as many surgeries as possible made sense.
Health systems learn to adapt
But 35 days after issuing its initial proclamation to curtail elective surgeries, the Centers for Medicare and Medicaid Services issued safe resumption guidelines, which focused on adequate facilities, pre-procedure COVID-19 testing, and supplies of protective equipment. “If you could manage those things,” Wren said, “you could operate.
By July 2020, the nation’s hospitals had ramped up surgical operations with improved safety protocols, and surgery rates began to return to — or even surpass — their 2019 levels. By the end of the year, the total volume of surgeries was only 10% below the 2019 volume.
The JAMA study looked at 11 major surgical categories, from cataract surgeries to transplant patients. With the exception of ear, nose and throat surgeries, which maintained a persistent decrease of about 30%, surgical volume in every major category returned to pre-pandemic levels by July 2020.
The quick rebound likely resulted from a number of factors, Wren said, including the advent of COVID-19 testing and regional differences in the prevalence of COVID-19 cases. The majority of surgeries in the United States can be performed on an outpatient basis, so many surgeons could operate without filling up inpatient beds, she said. Additionally, because surgical procedures often generate much of a hospital’s revenue, there was strong financial pressure for hospitals to reopen their operating rooms.
“When the ball started rolling again, it actually rolled faster,” said Arden Morris, MD, professor of surgery and one of the authors on the paper. “Since June 2020, Stanford surgeons have been operating at a capacity that we’ve never operated at before. And while that may not be true at every single institution, many other surgeons across the country have anecdotally reported that they’re busier than they’ve ever been.”
Operating rooms open despite new COVID-19 surges
Even when a second surge in COVID-19 cases occurred during the fall and winter of 2020, the researchers found, surgical procedures continued at normal or even elevated rates. When they compared COVID-19 infections and surgical volumes on a state-by-state basis for all of 2020, the researchers found that more COVID cases correlated with fewer surgeries during the initial shutdown, but not during the surge period, when there was an eightfold increase in COVID-19 cases.
“This tells us that we learned something, institutionally and nationally, about how to provide care during a time of crisis,” Morris said. “Even as supply lines were compromised; as we were trying to preserve PPE; and, most importantly, as we limited transmission of this highly transmissible virus, we managed to provide care at essentially the same rates as usual.”
The researchers will continue studying pandemic trends to better understand how to triage surgical care, both during an acute crisis like COVID-19 and in regions of the world where medical resources are always scarce. “We’re trying to tease out valid ways of asking, ‘What is the minimum necessary number of operations and of what type, in order for a society to function?’” Morris said.
“We know a new COVID surge will be associated with the upcoming winter holidays,” she said, “especially now that there’s a highly contagious new variant. But this research makes me hopeful that we’ll be able to maintain high-quality care during the next surge because of everything we’ve learned.”
The other co-authors of the paper are Stanford medical student and lead author Aviva Mattingly; health economist Liam Rose, PhD, of the Stanford Surgery Policy Improvement Research and Education Center (S-SPIRE); Hyrum S. Eddington, data manager at S-SPIRE; Amber Tricky, PhD, MS, senior biostatistician at S-SPIRE; and Mark Cullen, MD, former professor of medicine and population health at the Stanford School of Medicine.
This study was funded by a seed grant from the Stanford University School of Medicine Department of Surgery.