Modeling the elective vascular surgery recovery after coronavirus disease 2019: Implications for moving forward

The Sustained Impact of the COVID-19 Pandemic on Vascular Surgical Care Delivery

OBJECTIVE

The COVID-19 pandemic necessitated postponement of vascular surgery procedures nationally. Whether procedure volumes have since recovered remains undefined. Therefore, our objective was to quantify changes in procedure volumes and determine whether surgical volume has returned to its pre-pandemic baseline.

METHODS

This study was a retrospective cross-sectional study between 2018 and 2023 utilizing the US Fee-for-Service Medicare 5% National Sample as part of the VA Disrupted Care National Project. We studied patients who underwent one of three procedures: abdominal aortic aneurysm (AAA) repair for intact aneurysms, carotid endarterectomy (CEA), and major lower extremity amputation (LEA). The case volume of each quarter of 2020-2023 was compared to its corresponding pre-pandemic quarter in 2019. We then performed a sub-analysis of these trends by sex, age, and race.

RESULTS

We identified 21,031 procedures: 4,411 AAA repair, 8,361 CEA, and 8,259 LEA. The average percent change during the baseline pre-pandemic period from 2018 to 2019 was -4.3% for AAA repair, -8.5% for CEA, and -2.6% for LEA. Compared to Q2 of 2019, Q2 of 2020 demonstrated that AAA repair procedures decreased by 47%, CEA by 40%, and LEA by 14%. While procedures initially rebounded in Q3 of 2020, volumes did not return to their pre-pandemic baseline, demonstrating a persistent volume reduction (-16% AAA, -22% CEA, and -11% LEA). Thereafter, procedure counts again declined in Q1 of 2022 (-25% AAA, -34% CEA, and -25% LEA).

CONCLUSIONS

Despite a perception that vascular surgical care was singularly disrupted at the outset of the pandemic, there has been a sustained reduction in vascular surgical volume since 2019. Not only have procedure volumes not returned to pre-pandemic baseline, but it also appears that there has been a cumulative incremental impact on overall procedure volume. The impact of these findings on long term population health remain uncertain and necessitate a better understanding of post-pandemic care delivery.

A reinforcement learning-based optimal control approach for managing an elective surgery backlog after pandemic disruption

Contagious disease pandemics, such as COVID-19, can cause hospitals around the world to delay nonemergent elective surgeries, which results in a large surgery backlog. To develop an operational solution for providing patients timely surgical care with limited health care resources, this study proposes a stochastic control process-based method that helps hospitals make operational recovery plans to clear their surgery backlog and restore surgical activity safely. The elective surgery backlog recovery process is modeled by a general discrete-time queueing network system, which is formulated by a Markov decision process. A scheduling optimization algorithm based on the piecewise decaying [Formula: see text]-greedy reinforcement learning algorithm is proposed to make dynamic daily surgery scheduling plans considering newly arrived patients, waiting time and clinical urgency. The proposed method is tested through a set of simulated dataset, and implemented on an elective surgery backlog that built up in one large general hospital in China after the outbreak of COVID-19. The results show that, compared with the current policy, the proposed method can effectively and rapidly clear the surgery backlog caused by a pandemic while ensuring that all patients receive timely surgical care. These results encourage the wider adoption of the proposed method to manage surgery scheduling during all phases of a public health crisis.

Association of Elective Surgical Volume With State Executive Order Curtailing Elective Surgery in Michigan During the COVID-19 Pandemic

OBJECTIVE

Our objective was to evaluate changes in elective surgical volume in Michigan while an executive order (EO) was in place curtailing elective surgery during the COVID-19 pandemic.

SUMMARY BACKGROUND DATA

Many state governors enacted EOs curtailing elective surgery to protect scare resources and generate hospital capacity for patients with COVID-19. Little is known of the effectiveness of an EO on achieving a sustained reduction in elective surgery.

METHODS

This retrospective cohort study of data from a statewide claims-based registry in Michigan includes claims from the largest private payer in the state for a representative set of elective operations on adult patients from February 2 through August 1, 2020. We reported trends in surgical volume over the period the EO was in place. Estimated backlogs in elective surgery were calculated using case counts from the same period in 2019.

RESULTS

Hospitals achieved a 91.7% reduction in case volume before the EO was introduced. By the time the order was rescinded, hospitals were already performing elective surgery at 60.1% of pre-pandemic case rates. We estimate that a backlog of 6419 operations was created while the EO was in effect. Had hospitals ceased elective surgery during this period, an additional 18% of patients would have experienced a delay in surgical care.

CONCLUSIONS

Both the introduction and removal of Michigan's EO lagged behind the observed ramp-down and ramp-up in elective surgical volume. These data suggest that EOs may not effectively modulate surgical care and could also contribute to unnecessary delays in surgical care.

The clinical effect and safety of new preoperative fasting time guidelines for elective surgery: a systematic review and meta-analysis

BACKGROUND

Traditional fasting and no drinking schemes (fasting for 8-12 hours and no drinking for 4-6 hours) affect the metabolism of the body. The new guidelines put forward by the American Association of Anesthesiologists (fasting for 6 hours, no drinking for 2 hours) obviously reduce the time of fasting and no drinking, but the clinical efficacy and safety need to be further confirmed. In this study, a meta-analysis of randomized controlled trials (RCTs) using the new guidelines and traditional protocols was conducted to provide an evidence-based foundation for elective surgery.

METHODS

The articles were searched in PubMed, EBSCO, MEDLINE, Science Direct, Cochrane Library, CNKI, China Biomedical Resources Database, Wanfang Database, Weipu, and Western Biomedical Journal Literature Database. RCTs related to fasting before surgery during the screening period were selected. Chinese and English search keywords included elective surgery, preoperative, fasting and no drinking, patient comfort, thirst, hunger, collapse, hypoglycemia, preoperative gastric volume, preoperative gastric juice pH, and intraoperative gastric volume. The RevMan 5.3 software provided by Cochrane collaboration network was used to evaluate the quality of included documents. Two professionals independently screened the literature, extracted data, and assessed the risk of bias.

RESULTS

A total of 6 studies were included. The incidence of hunger in patients undergoing elective surgery in the experimental group and control group was significantly different [Z=3.90; relative risk (RR) =0.58; 95% confidence interval (CI): 0.44, 0.76; P<0.0001]. The incidence of thirst was significantly different between the experimental group and control group (Z=7.22; RR =0.21; 95% CI: 0.13, 0.32; P<0.00001).

DISCUSSION

Meta-analysis results confirmed that the new guidelines can significantly reduce the hunger and thirst of patients, improve their satisfaction after surgery, and can be applied clinically.

The impact of the COVID-19 pandemic on vascular surgery: Health care systems, economic, and clinical implications

The novel severe acute respiratory syndrome coronavirus-2 (coronavirus disease 2019 [COVID-19]) pandemic is responsible for more than 500,000 deaths in the United States and nearly 3 million worldwide, profoundly altering the landscape of health care delivery. Aggressive public health measures were instituted and hospital efforts became directed at COVID-19–related concerns. Consequently, routine surgical practice was virtually halted, resulting in billions of dollars in hospital losses as pandemic costs escalated. Navigating an uncertain new landscape of scarce resource allocation, exposure risk, role redeployment, and significant practice pattern changes has been challenging. Furthermore, the overall effect on the financial viability of the health care system and vascular surgical practices is yet to be elucidated. This review explores the economic and clinical implications of COVID-19 on the practice of vascular surgery in addition to the health care system as a whole.

The ophthalmic surgical backlog associated with the COVID-19 pandemic: a population-based and microsimulation modelling study

BACKGROUND

Jurisdictions worldwide ramped down ophthalmic surgeries to mitigate the effects of COVID-19, creating a global surgical backlog. We sought to predict the long-term impact of COVID-19 on the timely delivery of non-emergent ophthalmology sub-specialty surgical care in Ontario.

METHODS

This is a microsimulation modelling study. We used provincial population-based administrative data from the Wait Time Information System database in Ontario for January 2019 to May 2021 and facility-level data for March 2018 to May 2021 to estimate the backlog size and wait times associated with the COVID-19 pandemic. For the postpandemic recovery phase, we estimated the resources required to clear the backlog of patients accumulated on the wait-list during the pandemic. Outcomes were accrued over a time horizon of 3 years.

RESULTS

A total of 56 923 patients were on the wait-list in the province of Ontario awaiting non-emergency ophthalmic surgery as of Mar. 15, 2020. The number of non-emergency surgeries performed in the province decreased by 97% in May 2020 and by 80% in May 2021 compared with the same months in 2019. By 2 years and 3 years since the start of the pandemic, the overall estimated number of patients awaiting surgery grew by 129% and 150%, respectively. The estimated mean wait time for patients for all subspecialty surgeries increased to 282 (standard deviation [SD] 91) days in March 2023 compared with 94 (SD 97) days in 2019. The provincial monthly additional resources required to clear the backlog by March 2023 was estimated to be a 34% escalation from the prepandemic volumes (4626 additional surgeries).

INTERPRETATION

The estimates from this microsimulation modelling study suggest that the magnitude of the ophthalmic surgical backlog from the COVID-19 pandemic has important implications for the recovery phase. This model can be adapted to other jurisdictions to assist with recovery planning for vision-saving surgeries.