National Trends in US Otolaryngology Surgical Volume During the Early COVID-19 Pandemic

Abstract

This cohort study describes changes in US otolaryngology surgical volumes during the early COVID-19 pandemic.

The coronavirus disease 2019 (COVID-19) pandemic resulted in tectonic shifts in the delivery of American health care, including surgical care. In the early days of the pandemic, the US Centers for Medicare & Medicaid Services (CMS) recommended that surgeons “postpone nonessential surgeries and other procedures,”¹ a recommendation endorsed by the American Academy of Otolaryngology–Head and Neck Surgery. Emergency declarations by many states to suspend elective procedures resulted in an abrupt cessation of surgery in the US in March 2020.² We sought to describe the resulting changes in US otolaryngology surgical volumes surrounding the COVID-19 pandemic.

Methods

We used the claims-based Vizient Clinical Data Base/Resource Manager (CDB; Vizient, Inc), which included data from 609 hospitals representing 97% of US academic medical centers and 160 community hospitals, to evaluate temporal trends in surgical care. Institutional review board approval and informed consent were waived by Johns Hopkins University because of the study’s use of deidentified data. Otolaryngology surgeries recorded in the Vizient CDB from March 1, 2019, through September 30, 2020, were used for this study. Otolaryngology procedures performed following the suspension of elective surgery in March 2020 through September 2020 were compared with the same calendar month in 2019 (eMethods in the Supplement). Data analysis was completed in R, version 4.0.3 (R Foundation for Statistical Computing) using the ggplot2, maps, usmap, and tidyverse packages.

Results

Data were available from 174 inpatient and 295 outpatient academic and community facilities. Monthly inpatient case volumes decreased in April 2020 compared with April 2019, particularly in the Middle Atlantic (39.8%) and West-South-Central (42.6%) divisions (Figure 1). By June 2020, inpatient case volumes were still 87.9% of prior-year levels across the country. Outpatient procedure volumes dropped more precipitously, with April 2020 volumes at 18.0% of pre–COVID-19 levels nationwide (Figure 2). By June 2020, outpatient procedure volumes returned to prepandemic levels in much of the country, except for the West-South-Central (69.7%) division. By September 2020, inpatient volumes were at 99.7% of 2019 levels, and outpatient volume was at 96.5% nationwide, with slightly slower recovery in the West-South-Central division (94.4%, 92.3%).

Figure 1. US Inpatient Otolaryngology Case Volume Reduction by Month in 2020 Compared With Same Month in 2019.

Figure 2. US Outpatient Otolaryngology Case Volume Reduction by Month in 2020 Compared With Same Month in 2019.

Discussion

These data show an abrupt decrease in US otolaryngology case volumes in April 2020, 1 month into the COVID-19 pandemic in the US. The initial reduction in outpatient procedure volumes was more pronounced than for inpatient surgery. Decreases in inpatient case volumes were greater in the Middle Atlantic and West-South-Central divisions where the pandemic was more severe.

The ongoing provision of nonelective surgery may explain why inpatient otolaryngology case volumes did not experience as sharp an initial reduction as outpatient surgeries. The reallocation of inpatient beds for the pandemic reduced capacity for inpatient surgical care and may have delayed recovery of inpatient case volumes in some regions, but outpatient volumes recovered more quickly parallel to changes in CMS guidelines that supported careful resumption of nonemergency surgical care.³ These results should be interpreted in the context that while Vizient data are collected from across the country, the data do not represent a statistical sample of US hospitals.

These data have clinical and financial implications for otolaryngologists, particularly in light of well-publicized concerns about a surge of cases in the coming winter.⁴ Reductions in surgical capacity during the initial surge led to a substantial surgical backlog whose recovery will be severely affected if cases surge, as predicted, in the winter months coincident with influenza. The CovidSurg Collaborative estimates that 81% of surgeries for benign disease and 38% of cancer surgeries were canceled or postponed during the pandemic.⁵ In Ontario, Canada, the estimated surgical backlog clearance time is 84 weeks without accounting for future COVID-19 surges.² A substantial association with medical center revenue has been widely reported, with the American Hospital Association projecting that American hospitals will lose $323 billion in 2020 as a result of the pandemic.⁶ These data suggest an urgent need for ongoing focused pandemic planning that addresses limitations in capacity, testing, and personal protective equipment while revenue streams are decreasing and surgical backlogs increase.

Supplement.

eMethods.