key: cord-320065-zxh8u4eg
authors: Patel, Pious D.; Kelly, Katherine A.; Reynolds, Rebecca A.; Turer, Robert W.; Salwi, Sanjana; Rosenbloom, S. Trent; Bonfield, Christopher M.; Naftel, Robert P.
title: Tracking the Volume of Neurosurgical Care during the COVID-19 Pandemic
date: 2020-06-27
journal: World Neurosurg
DOI: 10.1016/j.wneu.2020.06.176
sha: 
doc_id: 320065
cord_uid: zxh8u4eg

Abstract Objective This study quantifies the impact of COVID-19 on the volume of adult and pediatric neurosurgical procedures, inpatient consults, and clinic visits at an academic medical center. Methods Neurosurgical procedures, inpatient consults, and outpatient appointments at Vanderbilt University Medical Center were identified in the time periods of March 23, 2020 through May 8, 2020 ("During COVID-19") and March 25, 2019 through May 10, 2019 ("Before COVID-19"). Neurosurgical volume was compared between these periods. Results A 40% reduction in weekly procedural volume was demonstrated during COVID-19 (median 75 [IQR 72-80] to 45 [43-47], p<0.001). There was a 42% reduction for weekly adult procedures (62 [54-70] to 36 [34-39], p<0.001), and 31% reduction for weekly pediatric procedures (13 [12-14] to 9 [8-10], p=0.004). Among adult procedures, the most significant decreases were seen for spine (p<0.001), endovascular (p<0.001), and cranioplasty (p<0.001). There was not a significant change for adult open vascular (p=0.291), functional (p=0.263), cranial tumor (p=0.143), or hydrocephalus (p=0.173) procedural volume. Weekly inpatient consults to neurosurgery decreased by 24% (99 [94-114] to 75 [68-84], p=0.008) for adults. Weekly in-person adult and pediatric outpatient clinic visits witnessed a 91% decrease (329 [326-374] to 29 [26-39], p<0.001). Weekly telehealth encounters increased from 0 [0-0] to 151 [126-156] (p<0.001). Conclusion There were significant reductions in neurosurgical operations, clinic visits, and inpatient consults during COVID-19. Telehealth was increasingly used for assessment. The long-term impacts of reduced neurosurgical volume and increased telehealth utilization on patient outcomes should be explored.

The SARS-CoV-2 novel coronavirus and associated disease, COVID-19, was initially identified Rapidly evolving guidelines emphasized social distancing as a necessary strategy to reduce viral 36 spread. 6, 7 Subsequently, a series of Federal recommendations and executive orders from 31 37 states recommended the cancellation of elective scheduled medical procedures. [8] [9] [10] [11] However, the 38 dichotomization of elective versus non-elective procedures has been criticized for inadequately 39 risk-stratifying patients. 12 Within neurological surgery, concerns exist about potential harms 40 created by delays in care. 13 Potential adverse effects due to delayed elective procedures vary by 41 neurosurgical subspecialty, be it vascular, oncology, functional, spine, or pediatrics. Patients 42 with tumors amenable to endoscopic endonasal resection may be particularly at risk, as many 43 institutions have followed guidelines to indefinitely cancel these cases due to the aerosolizing 44 nature of this approach. 14-16 The impact of COVID-19 on neurosurgical case volume has been 45 anecdotally reported through social networks, news media, and editorial pieces. 13, 17, 18 A survey 46 study assessing global neurosurgical volume changes during COVID-19 found that roughly half 47 of the respondents reported greater than 50% decrease in total operative volume. 19 However, 48 these estimates and reports have yet to be quantified in the scientific literature.

In addition to procedures, inpatient consultations and outpatient encounters have been affected 51 by COVID-19. To limit viral exposure, hospital administrators have adopted new protocols for 52 in-hospital telehealth consults to the emergency department (ED) in addition to telehealth 53 consultation for outpatient clinics. 20, 21 Patient volume is also decreased as adult and pediatric 54 EDs experience declines in non-COVID-related patients. 22 The Federal government has May 8, 2020 were collected and categorized into the "during COVID-19" period. This was the 7- 76 week time period immediately following the signing of a Tennessee gubernatorial executive 77 order preventing "non-essential procedures." 9 Patient records from an analogous 7-week period 78 from March 25, 2019 through May 10, 2019 were collected and categorized as "before COVID-79 19." In addition to these time periods, data were collected from the 59 week period spanning Hydrocephalus was defined as ventriculoperitoneal shunt insertion or revision or endoscopic 140 third ventriculostomy. Other procedure was defined as any procedure that did not fall into the 141 above categories. Procedure subcategories that have lower clinical likelihood of being 142 categorized into the "high acuity" tiers 3a or 3b, defined by the ACS guidelines, are marked with 143 an asterisk in Table 2 (1,253 adult, 232 pediatric), and 3,736 outpatient clinic encounters (3,158 adult and 578 182 pediatric) met inclusion criteria during the "before COVID-19" and "during COVID-19" periods.

The median age of our cohort for adults and pediatrics was 60 consults, and clinic visits by 40%, 28%, and 47%, respectively (Figures 1-3) . The impact on 257 procedures and clinic visits was noted across both pediatric and adult practices, although less 258 marked for children. In adults, the most impacted subspecialty services were elective spine and 259 endovascular cases, but significant reduction was also seen for cranioplasties. When for adults or children. This trend could be attributed to the many "essential workers" who 341 continue to commute to work as well as the unchanged rate of firearm-related crimes in the 342 Nashville area, trends also witnessed in other major cities such as Chicago and Philadelphia. 43-45 343 The reinstatement of normal societal operations in the post-pandemic period may increase 344 inpatient consultations once more, but the extent remains to be seen. While this study examines many important neurosurgical practice changes in response to the 360 COVID-19 pandemic, it is important to note the study limitations. As a single center study, there 361 was insufficient statistical power to analyze results for many individual surgical procedures; 362 therefore, most procedures were grouped together within their parent neurosurgical subspecialty.

A more in-depth analysis could be completed with data from multiple institutions. A multi-364 institutional study would also help account for regional variability in the US due to COVID-19 365 local disease burden, state and local ordinances, and unique hospital-driven regulations in 366 response to the pandemic. This study's focus on a large, tertiary, Level 1 trauma center limits its 367 generalizability to smaller hospitals that treat fewer traumas or transfer patients. While an 368 attempt was made to analyze the pandemic's effect on satellite, largely-elective neurosurgical 369 practices in the VUMC system, this investigation was limited by low sample size. Secondly, this 370 report only includes data through the first 7 weeks after the gubernatorial order to cease elective 371 surgery, which is a short period of time. Since one aim of this article was to help institutions 372 understand the disease's immediate impact on their neurosurgical volume, expediency was 373 deemed key. As more data from the pandemic and post-pandemic period become available, a 374 more robust analysis of procedural changes may be performed. Similarly, the "before COVID-375 19" period was defined using a period of 7 weeks from 2019 that were analogous to the "during 376 COVID-19" period. While this reduces the effects of seasonal variation, the resultant decrease in 377 sample size increases the likelihood of type II error. Thirdly, this analysis was unable to 378 differentiate return or follow-up outpatient visits from new patient visits due to a limitation in the 379 electronic medical record's categorization of encounter type after implementing telehealth visits. The COVID-19 pandemic led to significant, measurable decreases in neurosurgical caseload, 392 inpatient consults, and outpatient clinic visits. All subspecialties were affected, but spine 393 incurred the largest impact in both inpatient and outpatient settings. These results may be 394 generalizable to similarly large, Level 1 trauma centers, and may also inform the design of multi-395 institutional analyses aimed at measuring the nationwide effect of the pandemic. As elective 396 procedures and in-person clinical encounters resume, the effects of reduced volume during 397 COVID-19 on long-term patient outcomes warrants further investigation. Despite the decline of 398 in-person neurosurgical clinic visits, telehealth visits witnessed a marked increase over the study 399 period, which is indicative of quick practice adaptability to a rapidly changing situation. The 

CPT codes Spine 20250, 20930, 20931, 20936, 20937, 22015, 22100, 22101, 22102, 22110, 22116, 22206, 22207, 22210, 22212, 22214, 22216, 22224, 22325, 22326, 22533, 22551, 22552, 22554, 22556, 22558, 22585, 22586, 22590, 22595, 22600, 22610, 22612, 22614, 22630, 22632, 22633, 22634, 22800, 22802, 22804, 22840, 22842, 22843, 22844, 22845, 22846, 22849, 22850, 22852, 22853, 22854, 22855, 22856, 38724, 62287, 62350, 62351, 63001, 63003, 63005, 63011, 63012, 63015, 63016, 63017, 63020, 63030, 63035, 63042, 63045, 63046, 63047, 63048, 63055, 63056, 63081, 63082, 63085, 63266, 63271, 63275, 63276, 63277, 63280, 63281, 63282, 63283, 63286, 63287, 63303, 63662, 63688, 63709, 63740, 75705, 20692AO, 22558T, 22842TL, 22843GR, 22845C, 22845T, 22846C, 63047M, 63048M, C9757, PBONSPINE Endovascular 36013, 36215, 36216, 36218, 36221, 36223, 36224, 36226, 36227, 36245, 36470, 36620, 37215, 37216, 37217, 37218, 37236, 61624, 61626, 61630, 61635, 75650, 75671, 0075T, 36215P, 36216P, 36217P, 36218P, 75650T, STROKE Open Vascular 61154, 61156, 61312, 61313, 61314, 61680, 61682, 61686, 61692, 61697, 61700, 61702, 61711, 70552 Functional 20670, 20680, 61533, 61534, 61536, 61537, 61538, 61540, 61541, 61566, 61760, 61860, 61863, 61864, 61867, 61880, 61885, 61886, 61888, 62355, 63650, 63655, 63661, 63664, 63685, 64555, 64568, 64570, 64575, 64585, 95970, 95971, 95972, 61781A, 61867-50, 61868-50, 61215, 62365, 62369, 63170, 63190, 63195 , J0475, J0476 Craniotomy for deep brain stimulation 61860, 61863, 61864, 61867, 61867-50, 61868-50 Cranial tumor 31257, 31259, 61140, 61510, 61512, 61514, 61516, 61518, 61519, 61520, 61521, 61524, 61526, 61546, 61548, 61570, 61601, 61605, 61608, 61750, 61751, 62164, 62165, 61520A, 61526A Hydrocephalus 49324, 49325, 49418, 62161, 62220, 62230, 62256, 62258 

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☒ The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.☐The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: