Impact of COVID-19 geographic distribution on advanced age plastic surgeons: A cross-sectional analysis

Dear Sir,

The outbreak of severe acute respiratory syndrome coronavirus 2, responsible for coronavirus disease 2019 (COVID-19), was first identified in Wuhan, China, and has since spread worldwide. Among countries struggling to contain the spread of COVID-19, the United States (U.S.) has been particularly heavily affected. Since recording a new single-day peak of 83,010 cases on October 23, 2020,¹ the U.S. has continued to experience record highs in daily confirmed COVID-19 cases and hospitalizations. Increased susceptibility to severe COVID-19 has been noted in certain populations (e.g., individuals over age 60).² Advanced age patients are at increased risk of COVID-19 morbidity and mortality, and represent a potential for nosocomial transmission to healthcare providers.³

Plastic surgeons are at especially high risk of COVID-19 nosocomial infection. Many head and neck procedures involve exposure to oral and nasal passages. Indications for surgery include traumatic/urgent (e.g., facial fractures) and cosmetic (e.g., rhinoplasty) reasons, and both physical examination and subsequent procedures expose plastic surgeons to the patient's airway, with potential transmission of COVID-19 via respiratory and aerosol droplets.³ Given the surge in COVID-19 cases across the U.S., identifying geographic regions with susceptible physicians may allow for risk stratification, and provide guidelines for predicting and reducing transmission and mortality.³ In this study, we compared the geographic distribution of US plastic surgeons ≥ 60 years of age to cumulative COVID-19 cases to better inform clinical guidelines.

Demographic data regarding practicing U.S. plastic surgeons age ≥ 60 were obtained from the most recent American Association of Medical Colleges (AAMC) State Physician Workforce Reports (2018).⁴ COVID-19 latitude and longitude data on cumulative cases (as of November 15, 2020) were gathered from the Environmental Systems Research Institute.⁵ The two data collections were superimposed in QGIS geospatial mapping software (version 3.12.1), onto state boundary files provided by the U.S. Census Bureau. States were grouped into color-coordinated quintiles based on relative proportion of plastic surgeons age ≥ 60, and case volumes were adjusted via logarithmic scale to create proportionally-sized data points, resulting in a heatmap representing the COVID-19 risk faced by older plastic surgeons across the country (Figure 1). States with fewer than 10 plastic surgeons age ≥ 60 were excluded as, due to privacy reasons, greater than 10 physicians for a given category was the threshold for data publication by the AAMC. The COVID-provider ratio (CPR) was calculated by dividing cumulative COVID-19 cases by the number of plastic surgeons age ≥ 60, providing a more granular determination of risk for each state. This study was considered IRB exempt.

Figure 1.

Geospatial distribution of cumulative COVID-19 cases and plastic surgeons age ≥ 60 in the United States. States were grouped into color-coordinated quintiles based on relative proportion of older plastic surgeons, and cumulative COVID-19 case volumes were adjusted via logarithmic scale to create proportionally-sized data points.

There were 7205 clinically-active U.S. plastic surgeons in 2018, of whom 2781 (38.6%) were ≥ 60 years of age. The five states with the highest percentage of plastic surgeons age ≥ 60 were South Dakota (71.4%), Hawaii (66.7%), Montana (65.0%), Alabama (55.4%), and New Mexico (54.2%), while the five states with the highest CPRs were Iowa (12,089), Wisconsin (10,439), Arkansas (10,167), Oklahoma (9388), and Nevada (7934). The proportion of plastic surgeons age ≥ 60 ranged from 30.3% in Arizona to 71.4% in South Dakota (Table 1 ).

Table 1.

United States plastic surgeon workforce profile^† and confirmed COVID-19 cases by state, as of November 15, 2020.

	Total Number of Plastic Surgeons	Number of Plastic Surgeons ≥ 60	Percentage of Plastic Surgeons ≥ 60 (%)	Confirmed COVID-19 Cases	COVID-Provider Ratio‡
Alabama	74	41	55.4	215,843	5264
Arizona	156	47	30.3	273,053	5810
Arkansas	33	13	39.4	132,166	10,167
California	1127	439	39.0	1018,638	2320
Colorado	117	50	42.7	159,234	3185
Connecticut	86	32	37.2	88,645	2770
Florida	652	267	41.0	875,096	3278
Georgia	206	87	42.2	422,905	4861
Hawaii	27	18	66.7	16,652	925
Idaho	23	12	52.2	81,317	6776
Illinois	233	85	36.5	562,985	6623
Indiana	94	41	43.6	244,887	5973
Iowa	31	15	48.4	181,334	12,089
Kansas	63	21	33.3	117,505	5595
Kentucky	84	36	42.9	136,137	3782
Louisiana	88	37	42.0	201,981	5459
Maryland	181	68	37.6	164,090	2413
Massachusetts	174	55	31.6	186,142	3384
Michigan	178	69	38.8	275,792	3997
Minnesota	96	34	35.4	216,028	6354
Mississippi	53	18	34.0	133,340	7408
Missouri	110	49	44.5	240,209	4902
Montana	20	13	65.0	45,987	3537
Nebraska	32	15	46.9	94,922	6328
Nevada	49	15	30.6	119,006	7934
New Jersey	245	92	37.6	274,736	2986
New Mexico	24	13	54.2	63,171	4859
New York	594	238	40.2	551,163	2316
North Carolina	189	73	38.6	309,118	4234
Ohio	215	79	36.7	290,243	3674
Oklahoma	42	16	38.1	150,205	9388
Oregon	80	26	32.5	54,937	2113
Pennsylvania	261	101	38.7	264,222	2616
Rhode Island	19	10	52.6	41,529	4153
South Carolina	90	33	36.7	194,014	5879
South Dakota	16	10	71.4	64,182	6418
Tennessee	135	63	46.7	305,120	4843
Texas	637	221	34.7	1051,922	4760
Utah	72	22	30.6	151,141	6870
Virginia	189	77	40.7	200,799	2608
Washington	133	54	40.6	127,731	2365
West Virginia	30	16	53.3	32,792	2050
Wisconsin	86	31	36.0	323,604	10,439

Abbreviations: COVID-19, coronavirus disease 2019.

† States with fewer than 10 plastic surgeons age ≥ 60 (i.e., Alaska, Delaware, Maine, New Hampshire, North Dakota, Vermont, and Wyoming) were excluded due to lack of published information.

‡ COVID-provider ratio was calculated by dividing the number of confirmed COVID-19 cases for a given state by the number of plastic surgeons age ≥ 60 in that state.

In this study, we provide a cross-sectional analysis of the risk faced by older U.S. plastic surgeons during the COVID-19 pandemic. We identified several states with a particularly high CPR (Iowa, Wisconsin, Arkansas, Oklahoma, and Nevada), indicating both a high proportion of plastic surgeons age ≥ 60 and high COVID-19 disease burden. While South Dakota (6418) is among only the top 10 in CPR values, we remain concerned by this state having both the highest percentage of plastic surgeons age ≥ 60 (71.4%) and the highest COVID-19 test positivity rate (22.4%, as of November 15, 2020) in the nation.¹ These findings, along with the nearly 2.5-fold difference in proportion of older plastic surgeons across states (30.3% to 71.4%), provide justification for prioritization of PPE supply toward plastic surgeons in “higher risk” states.

We recommend that local entities (e.g., state plastic surgery societies) encourage hospital/university systems and private practices to take appropriate measures to guarantee the safety of the older plastic surgery workforce. These measures might include transitioning plastic surgeons age ≥ 60 to telemedicine services and modifying operating room protocol to minimize aerosolization and droplet transmission.³ Moreover, we suggest that plastic surgeons be overly cautious in PPE usage (e.g., wearing a N95 respirator and eye protection, at minimum) when treating urgent cases asymptomatic for COVID-19. Limitations to this study include not exploring individual factors associated with COVID-19 severity (e.g., comorbidities, smoking history) and region-specific data (e.g., differing institutional practices) being unavailable for analysis. Regardless, we hope that our findings will assist in workforce management and continued assessment of safety guidelines. Plastic surgeons in higher-risk states, especially those over age 60 and/or with additional comorbidities, should strictly adhere to Centers for Disease Control and hospital guidelines, and consider delaying elective surgeries whenever possible.

Financial disclosure

The authors report no funding sources relevant to this work.

Declaration of Competing Interest

The authors report no conflicts of interest relevant to this work.

Ethical approval

Not required.