The Impact of the COVID-19 10.2.20

The impact of the COVID-19 pandemic on

surgical case volumes at MPOG hospitals

Orestes Mavrothalassitis, MD

Resident Physician, Department of Anesthesia and Perioperative Care

University of California San Francisco

Introduction

• Significant national COVID-19 morbidity and mortality

– 7M confirmed cases in the US so far

– Over 200,000 deaths in the US so far

• Routine hospital operations have been disrupted

– Elective surgeries cancelled/postponed

– PACUs and operating rooms converted to ICUs

– Medical and non-medical staff reassigned to new roles

• Unclear timing, scope, variance, and consequences of changes to

perioperative patient care across the country

Study Design

• Observational study – 33 MPOG academic/private centers

• Inclusions

– Surgical procedures 01/2019 to 05/31/2020 (most recently available data)

– Adults (>=18yo)

– Patients from sites continuously submitting data through the study period

• Exclusions

– Patients without outcome status available (mortality)

Outcomes and Variables

Primary outcome

• Weekly surgical volume (total and by center)

Secondary outcome

• Case mix (proportion of each procedure and absolute numbers)

Exposure

• Date of surgery

• National COVID data

• Pandemic period (pre-, intra-, and ultimately post-pandemic)

Covariates

• Demographic data

• ASA status, comorbidities, preop lab and vitals data

Statistical Analysis

• Join point regression to identify significant time points

• Causal analysis with target maximum likelihood estimate (TMLE)

• Bias: unmeasured confounders

• Missing data: MICE and missingness indicators

Preliminary Results: Timeline of surgical volume reduction

Preliminary Results: Weekly surgical volume by center

Preliminary Results: Heterogeneity in volume reduction

Summary of Preliminary Results

• Dramatic decline in national surgical case volume during the week of

March 16

, 2020

• Nadir of national case volumes the week of April 6

, 2020 (71%

reduction compared to same week in 2019)

• Heterogeneity of volume reduction, with per-institution reductions

ranging from 33% to 72%

• Surprisingly, dramatic rebound in national surgical case volume to

near baseline by 05/31/2020 (despite surging COVID cases)

Next Steps

• Complete case mix analysis

• Questionnaire for each center to understand site-specific factors

influencing changes in case volume and case mix

• Evaluate impact of major public health

events/recommendations/mandates on observed national

perioperative trends

• Possible addition of patient-level COVID19 status MPOG data

• Follow-up outcomes study

Lessons Learned

• Wrestling with DataDirect

– Tool continues to evolve – MPOG central receptive to feedback on bugs or

enhancements; communicate early and often

• Not all variables are created equal

– Some variables exist in principle, but…

– Must keep in mind that the quality of real-world EHR data reflects the intended

primary use (e.g. clinical care / billing, rather than controlled experiment)

– Feedback from experienced MPOG collaborators is crucial! Don’t re-invent the wheel

• Recent rapid expansion of MPOG member hospitals

– Currently 51 and counting, great for the present and future of MPOG!

– Keep in mind there may be far fewer sites available for inclusion in your study if

you are looking back prior to 2019

Acknowledgements

UCSF

• Matthieu Legrand, MD, PhD (study PI)

• Romain Pirracchio, MD, PhD (lead statistician)

• Daniel Lazzareschi, MD

University of Michigan/MPOG support

• Michael Mathis, MD

• Sachin Kheterpal, MD, MBA

• Shelley Vaughn

• Mark Dehring

Washington University St. Louis

• Anshuman Sharma, MD, MBA

References

1. COVIDSurg Collaborative. Global guidance for surgical care during the COVID-19 pandemic.

Br J Surg 2020;

2. CMS Releases Recommendations on Adult Elective Surgeries, Non-Essential Medical,

Surgical, and Dental Procedures During COVID-19 Response | CMS [Internet]. [cited 2020

Aug 7];Available from: https://www.cms.gov/newsroom/press-releases/cms-releases-

recommendations-adult-elective-surgeries-non-essential-medical-surgical-and-dental

3. Sun E, Mello MM, Rishel CA, et al. Association of Overlapping Surgery With Perioperative

Outcomes. JAMA 2019;321(8):762–72.

4. Dong E, Du H, Gardner L. An interactive web-based dashboard to track COVID-19 in real

time. Lancet Infect Dis 2020;20(5):533–4.

5. De Filippo O, D’Ascenzo F, Angelini F, et al. Reduced Rate of Hospital Admissions for ACS

during Covid-19 Outbreak in Northern Italy. N Engl J Med 2020;383(1):88–9.