key: cord-329704-vnazexhj
authors: Pelargos, Panayiotis E.; Chakraborty, Arpan R.; Adogwa, Owoicho; Swartz, Karin; Zhao, Yan D.; Smith, Zachary A.; Dunn, Ian F.; Bauer, Andrew M.
title: An Evaluation of Neurosurgical Practices During the COVID-19 Pandemic
date: 2020-10-13
journal: World Neurosurg
DOI: 10.1016/j.wneu.2020.10.025
sha: 
doc_id: 329704
cord_uid: vnazexhj

Objective To understand how the COVID-19 pandemic has affected the neurosurgical workforce. Methods A survey consisting of twenty-two questions assessing respondent’s operative experience, location, type of practice, subspecialty, changes in clinic and operative volumes, changes to staff, and changes to income since the pandemic began was distributed electronically to neurosurgeons throughout the United States and Puerto Rico. Results There were 457 respondents throughout the United States and Puerto Rico representing all practices types and subspecialties. Nearly all respondents reported hospital restrictions on elective surgeries. Most reported a decline in clinic and operative volume. Nearly 70% of respondents saw a decrease in the work hours of their ancillary providers, and almost half (49.1%) of respondents had to downsize their practice staff, office assistants, nurses, schedulers, etc. Overall, 43.6% of survey responders had experienced a decline in income, while 27.4% expected a decline in income in the upcoming billing cycle. More senior neurosurgeons and those with a private practice, whether solo or as part of a group, were more likely to experience a decline in income as a result of the pandemic as compared to their colleagues. Conclusion The COVID pandemic will likely have a lasting effect on the practice of medicine. Our survey results describe the early impact on the neurosurgical workforce. Nearly all neurosurgeons experienced a significant decline in clinical volume which leads to many downstream effects. Ultimately, analysis of the effects of such a pervasive pandemic will allow the neurosurgical workforce to be better prepared for similar events in the future.

downstream effects. Ultimately, analysis of the effects of such a pervasive pandemic will allow 23 the neurosurgical workforce to be better prepared for similar events in the future. procedures, triaging of urgent cases, deploying telemedicine for office visits, and altering the 39 traditional workflow of every day practice. For many, productivity has decreased, and 40 neurosurgeons' practices and income have been affected. 41

To better understand the ways the COVID-19 pandemic has affected the neurosurgical 42 workforce, we conducted an electronic survey of practicing neurosurgeons in various settings. 43

Specifically, we sought to understand how the pandemic has impacted case and clinic volume, 44 compensation, changes in clinic structure, employment of support staff, and attitudes towards 45 these changes. Categorical variables were summarized using counts and proportions and were compared among 73 grouping variables such as subspecialty and geographic region (high volume vs low volume) 74 using the Fisher's exact test. Cochran-Armitage trend test was used to assess the relationship 75 between number of years in practice and the reduction in income during the COVID-19 76 pandemic. High volume regions were defined as those states, districts, or territories with greater 77 than 10,000 cases of COVID-19 and low volume regions were defined as those with less than or 78 equal to 10,000 cases, as reported by the United States Centers for Disease Control and 79

Prevention on May 18, 2020. 16 80

All tests were two-sided, and a p value less than .05 was considered statistically 81 significant. Statistical analysis was performed using SAS (version 9.4, SAS Institute, Cary, NC) . 82

Demographics 85

The first email was opened by 4,088 AANS and CSNS members with 704 opening the 86 survey link. The second email was opened by 3,806 members with 24 opening the survey link. 87

In total, there were 457 respondents from all 50 states as well as from the District of Columbia 88 and Puerto Rico. The overall response rate was 8.7%. All practice types and subspecialties were 89 represented ( Figure 1 ). There were 80 survey responders from low volume regions and 340 from 90 high volume regions; 37 survey responders declined to give the location of their practice. Most 91 respondents were in practice for greater than twenty years (45.2%), while the remainder were 92 evenly distributed in terms of years of practice: 1-5 years (15.8%), 6-10 years ( that care was not negatively affected and 10.7% were unsure ( Figure 2 ). There was no 102 significant difference between effects to neurosurgery care when comparing respondents by their 103 years in practice, type of practice, or sub-specialty. 104

Most respondents (93.0%) reported a decline in their clinical volume: 4.2% experienced 105 1-25% decline, 16.2% experienced 26-50% decline, 39.6% experienced 51-75% decline, and 106 33.0% experienced 76-99% decline. Twenty-four respondents (5.3%) closed their practice 107 completely during the pandemic, while 1.3% of respondents experienced no change in clinic 108 volume and 0.4% reported an increase in their clinic volume ( Figure 3 ). Neurosurgeons in 109 practice greater than 20 years (8.3% vs. 2.8% for all others, p=.011), those in solo private 110 practice (19.4% vs. 4.2% for all others, p=.003), and those whose primary sub-specialty is spine 111 (10.1% vs. 3.2% for all others, p=0.001) were significantly more likely than their counterparts to 112 completely close their outpatient clinics during the pandemic (Figure 4 ). Of those who 113 continued to see patients in clinic, most continued to do so remotely, as 93.6% increased their 114 use of telemedicine. 115

Similarly, most respondents (91.4%) reported a decline in their operative volume: 5.9% 116 experienced 1-25% decline, 11.8% experienced 26-50% decline, 28.1% experienced 51-75% 117 J o u r n a l P r e -p r o o f decline, and 45.6% experienced 76-99% decline. Thirty-three respondents (7.2%) stopped 118 operating completely during the pandemic, while 0.9% reported no change in their operative 119 volume and 0.4% reported an increase in their operative volume ( Figure 5 ). Several groups 120

were found to be more likely than their counterparts to stop operating completely during the 121 pandemic period. Those in practice greater than 15 years were more likely to stop operating 122 during the pandemic than those in practice less than or equal to 15 years (9.4% vs. 3.7%, 123 p<.001). Neurosurgeons in solo private practice were more likely to stop operating than their 124 peers in other practice types (19.4% vs. 6.4%, p=.007). Spine surgeons were more likely to stop 125 operating than colleagues in other sub-specialties (15.1% vs. 3.8%, p<.001) ( Figure 6 ). Further, 126 the reduction in operative volume differed significantly (p=.03) between regions with high 127 volumes of COVID-19 cases compared to regions with low volumes of cases (Table 1) . 128

While there were generally fewer restrictions placed on outpatient surgery centers, 20.2% 129 of respondents decreased their use of the outpatient surgery center, while nearly one-tenth (9.4%) 130

continued to operate at the same or greater volume. Most respondents (70.4%) did not perform 131 surgeries at outpatient surgery centers prior to or during the pandemic. 132 133

Slightly more than half of respondents (51%) reported working with residents or fellows. 135

Of those, 78.9% felt that the education of their residents and/or fellows has suffered as a result of 136 the pandemic, and 17.7% felt that adequate adjustments were made to the educational program 137 so that their education would not suffer. Just over sixty percent of respondents noted a decrease 138 in resident and fellow clinical work hours during this period. 139 J o u r n a l P r e -p r o o f Similarly, nearly 70% of respondents saw a decrease in the work hours of their ancillary 140 providers. Only 0.9% of respondents reported increasing the work hours of their ancillary 141 providers to make up for the decrease in clinical hours worked by residents and fellows. Almost 142 half (49.1%) of respondents had to downsize their practice staff, office assistants, nurses, 143 schedulers, etc., due to the pandemic, while 50.9% did not have to make any changes to their 144 staff. 145 146

The pandemic has also had an effect on the academic pursuits of neurosurgeons. Of the 148 respondents who participate in research, nearly half (47%) stated that they were unable to enroll 149 patients into clinical trials during the pandemic period. Many respondents also had to downsize 150 or close their research laboratories (22%) or were unable to hire laboratory staff (7.3%). Further, 151 many experienced delays in publication of scholarly papers (12.9%), and 8.7% were unable to 152 obtain or experienced delay in obtaining grant funding. A small group applied for emergency 153 grant funding to study COVID-19 associated neurosurgical issues (1.7%) (Figure 7) . 154 155 Exposure to COVID-19 156

Only 14.7% of respondents reported their practice being affected due to themselves or a 157 partner being exposed to or contracting COVID-19 resulting in quarantine. Further, only 26.8% 158 of respondents were asked by their hospital to provide non-neurosurgical medical services to 159 COVID-19 patients. Just over 67% said they would be willing to provide non-neurosurgical 160 medical care to COVID-19 patients on a voluntary basis if needed, while 10.5% said they would 161 not be willing to provide non-neurosurgical medical care, and another 22.4% stated they were 162 J o u r n a l P r e -p r o o f not comfortable or qualified to provide these services. Neurosurgeons in practice less than 20 163 years were significantly more likely to be willing to provide non-neurosurgical care to COVID-164 19 patients than those in practice greater than 20 years (73.1% vs. 59.7%, p=.007). neurosurgeons, and 25% of peripheral nerve neurosurgeons experienced or expected to 180 experience a decline in income. These differences across subspecialties were statistically 181 significant (p=.003). Overall, there was no statistical difference found in income changes 182 between responders practicing in high volume versus low volume states (p=.162) ( Table 1) . Nonetheless, nearly two-thirds of participating neurosurgeons felt that care for their patients 213 suffered during this period and these effects were similar for all neurosurgeons regardless of their 214 seniority, type of practice, sub-specialty, or practice location. 215

Overall, nearly three-fourths of neurosurgeons experienced greater than 50% decline in 216 outpatient clinic volume with just over 5% of respondents closing their outpatient clinics during 217 the pandemic. These changes in clinic volume were similar in all states and regions regardless of 218 the volume of COVID-19 cases. This decline in clinic volume creates a major access problem 219 for our patients and an ethical dilemma in deciding which patients are "emergent" enough to be 220 seen or to have surgery. Those in solo private practices were disproportionately affected as 221 nearly 20% closed their outpatient clinics in response to the pandemic, a statistically significant 222 percentage compared to other practice types. Given that many solo practices are located in areas 223 which are already underserved, this may serve to perpetuate the patient access problem. While 224 this survey did not specifically address the types of patients or cases that were delayed, it may be 225 worth further study to determine which elective or semi-elective cases are universally considered 226 "urgent" or "emergent". For example, should surgery for a patient with newly diagnosed 227 glioblastoma be delayed for a number of weeks based on the fact that it is not truly emergent? 228

The pandemic has also brought out new ways in which we practice neurosurgery. Nearly 94% of 229 those that responded to our survey said that they increased their use of telemedicine. 230 J o u r n a l P r e -p r o o f

The reduction in operative volume was higher than previously reported during the early 231 pandemic period. 24 Nearly three-fourths of respondents had experienced a decline of greater 232 than 50% in operative volume with 7.3% stopping surgery completely. While the reduction in 233 operative volume was not significantly different across neurosurgeons with different experience 234 or type of practice, there was a statistically significant decline in operative volume in regions 235 with higher cases of COVID-19. Further, spine surgeons were more likely to stop operating 236 completely during the pandemic period. This decrease in inpatient operative volume did not 237 translate to a proportional increase in outpatient surgery center use as only 9.4% of respondents 238 continued to operate at the same or greater pace at the outpatient surgery center, while more than 239 double that decreased their use of the outpatient surgery center during the same period (20.2%). 240

The pandemic not only affected neurosurgeons and their patients, but it had similar effect 241 on neurosurgery trainees and ancillary providers. Over sixty percent of respondents noted a 242 decrease in resident and fellow clinical work hours, and nearly 80% expressed concern that their 243 education suffered as a result. 25 The shortfall in work by residents was not compensated for by 244 increased use of ancillary providers as less than 1% reported an increase in their ancillary 245 providers' work hours. Rather, 69.3% of survey responders saw a decrease in their ancillary 246 providers work hours and almost half had to decrease their practice staff. These limitations in 247 residents and ancillary providers may have led to a larger role for the staff neurosurgeon in call 248 coverage and inpatient hospital work which may have further limited patient access. 249

Given the decline in clinic and operative volumes, it can be expected that most 250 neurosurgeons would experience a decline in income during the pandemic. Overall, 71% of 251 respondents experienced or expected a decline in income during the pandemic while the 252 remaining 29% did not. Neurosurgeons who practiced in a private practice setting were more 253 J o u r n a l P r e -p r o o f likely to experience a decline in income than those who were hospital-employed (p<.001). 254

Those who were hospital-employed were more likely to experience a decline in income than 255 those in an academic setting (p<.001). This may be reflective of the fact that there are often 256 other non-clinical components of the compensation plan of the academic neurosurgeon which 257

were less likely to be affected by COVID-19 (i.e. research, teaching, etc.). There was a greater 258 decline in income of more senior neurosurgeons during the pandemic period. This likely reflects 259 the fact that senior neurosurgeons have well-developed elective referral bases and mature 260 practices that are more likely to be strongly affected by any limitation in elective work. It is also 261 possible that the more senior neurosurgeons were more vigilant about practicing social distance 262 measures. It is also important to consider that while the incoming revenues significantly 263 declined, practice expenses (payroll, insurance, office expenses, etc.) continue unchanged, which 264 led 39.9% of the respondents in our study to downsize their practice in an effort to limit these 265 expenses. This, in turn, may lead to issues for patient access in the future. 266

Overall, about two-third (67.1%) of respondents were willing to assist in the non-267 neurosurgical care of COVD-19 patients if needed. Neurosurgeons that have been in practice 268 more than 20 years stated they were less willing to provide non-neurosurgical medical care than 269 their counterparts in practice fewer than twenty years. Most neurosurgeons, however, were not 270 asked by their hospital to assist in the non-neurosurgical care of these patients, as only 26.8% of 271 respondents reported being asked by their hospital to do so. was also sent to non-board-certified neurosurgeons; therefore, it reasonable to expect that the 283 survey was sent to the majority of practicing neurosurgeons in the United States and Puerto Rico. 284

As with any survey, there is the opportunity for response bias. Our selected population was not 285 random, and it is quite possible that neurosurgeons most affected by the pandemic were non-286 responders due to their increased responsibilities working on the front lines caring for COVID 287 patients. Additionally, due to the rapid progression of the pandemic, the survey could not be 288 validated as a psychometric analysis tool prior to distribution. Therefore, the results should be 289 interpreted more in a descriptive fashion. 290

The COVID pandemic will likely have lasting effects on many aspects of the practice of 293 medicine. Our survey sheds light on the particular vulnerabilities of different practice types and 294 subspecialties to disasters of this nature. Nearly all neurosurgeons have seen a significant 295 decrease in clinical volume. This was most pronounced for more senior surgeons who have well 296 established elective practices and more likely for those who subspecialize in spine. As expected, 297 this decrease in volume has led to decreased income for neurosurgeons and their practices which 298 in many cases has led to restructuring of the practice itself. In the future, this may lead to 299 J o u r n a l P r e -p r o o f reduced patient access. There is little doubt that the lessons learned will shape our clinical 300 practice patterns, compensation models, and preparedness for future pandemics or disasters. 301

There are no conflicts of interest to report as pertained to this work. 304

The authors would like to acknowledge the support and collaboration from the CSNS Workforce 307

Committee. Without their assistance in survey distribution, this work would not have been 308 possible and certainly would not have been as complete. Finally, the authors appreciate and 309 acknowledge the willing participation of survey respondents nationally in this difficult time. Most respondents experienced a greater than 50% decline in their clinic volume, while over 5% 393 of respondents closed their clinic altogether during the pandemic. 394 395 Figure 4 . Change in clinic volume by years in practice, type of practice, and subspecialty during 396 the COVID-19 pandemic. Those in practice greater than 20 years were significantly more likely 397 to close their clinic than the remainder of their colleagues (8.3% vs. 2.8%, p=.011). Those in 398 solo private practice were significantly more likely to close their clinic than those in other 399 practice types (19.4% vs. 4.2%, p=.003). Those whose primary sub-specialty was spine were 400 significantly more likely to close their clinic than those in other sub-specialties (10.1% vs. 3.2%, 401 p=.001). Most respondents experienced a greater than 50% decline in their operative volume, while over 405 7% of respondents stopped operating altogether during the pandemic. 406 J o u r n a l P r e -p r o o f 407 Figure 6 . Change in operative volume by years in practice, type of practice, and subspecialty 408 during the COVID-19 pandemic. Those in practice greater than 15 years were significantly more 409 likely to completely stop operating than the remainder of their colleagues (9.4% vs. 3.7%, 410 p<.001). Those in solo private practice were significantly more likely to completely stop 411 operating than those in other practice types (19.4% vs. 6.4%, p=.007). Those whose primary 412 sub-specialty is spine were significantly more likely to completely stop operating than those in 413 other sub-specialties (15.1% vs. 3.8%, p <.001). J o u r n a l P r e -p r o o f (3) Q18 Has the COVID epidemic affected your academic and research pursuits? Select all that apply.

Have not been able to enroll patients in clinical research trials (1) Downsized or closed research lab (2) Unable or delayed in obtaining grant funding (3) I have applied for emergency COVID grant funding for study of COVID associated neurosurgical issues (4) Delay in publication of scholarly papers (5) Unable to hire laboratory staff (6) I do not participate in any clinical or laboratory research (7) J o u r n a l P r e -p r o o f Q19 Has your practice been negatively affected because you or one of your partners was exposed to or contracted COVID resulting in quarantine? o yes (1) o no (2) Q20 Have you been asked by your hospital to provide non-neurosurgical medical services to assist with COVID patients (i.e. critical care, medical care, ventilator management, ER triage, etc.)? 

S. -investigation, data curation, writing (original draft and revisions), visualization

BS -writing (original draft and revisions)

Owoicho Adogwa M.D.-data curation, writing (review and editing)

Zhao Ph.D. -validation and formal analysis, visualization

Smith M.D. -writing (original draft and revisions), writing (review

MBA -conceptualization, methodology, investigation, data curation, writing (original draft and revisions), writing (review and editing), project administration and supervision