The US health care system has come under marked pressure because of the SARS-CoV-2 (COVID-19) pandemic. Public health policies that were created to provide guidance and direction have largely revolved around two goals: (1) decreasing the rate of transmission through “social distancing” and the use of personal protective equipment and (2) reallocating resources, including beds, ventilators, medications, and personnel, to prepare for and treat an increasing number of infected patients. As part of this rapidly changing health care environment, state and federal regulatory bodies as well as professional societies have published guidelines, recommendations, or mandates for elective health care.
On March 15, 2020, the Commonwealth of Massachusetts Department of Public Health issued guidance that required postponement of nonessential elective procedures.1 A separate mandate on the same day required insurers to compensate providers for medically necessary ambulatory visits performed via telemedicine.2 Shortly thereafter, on March 18, the Centers for Medicare & Medicaid Services recommended that all elective surgeries and nonessential medical, surgical, and dental procedures be delayed nationwide.3 Additionally, the American College of Surgeons provided subspecialty- and disease-specific guidelines for delaying elective surgeries.4 The American Academy of Orthopaedic Surgeons issued guidelines on April 2, 2020, recommending that each locality should make decisions based on the availability of resources and personnel, with the inclusion of appropriate professional colleagues in the process. General definitions of the terms “elective,” “urgent-somewhat elective,” “urgent only,” and “emergent only” were offered to aid members in decision making.5
Effective March 16, 2020, the day after the Commonwealth's mandate was issued, the authors' hospital system instituted those restrictions on ambulatory surgery and extended them to include ambulatory clinic encounters and office procedures. Nonurgent clinic visits and surgical procedures were deferred immediately. Urgent clinic visits that could not be addressed remotely through telemedicine were allowed. Urgent and emergent surgical procedures continued to proceed. The guidelines allowed individual practitioners to determine the urgency of ambulatory visits and surgical cases, and all surgical cases required review and approval at the divisional or departmental level to ensure uniformity and compliance.
The primary goal of this study was to determine the quantitative early effect of the response to COVID-19 on an academic orthopedic surgery department based at a metropolitan level I trauma center. The restrictions included, but were not limited to, the Massachusetts state-mandated restrictions on elective health care. The department includes 32 surgeons and 12 nonoperative physicians who perform inpatient, outpatient, and in-office procedures; conduct office visits; and treat both traumatic/urgent and elective cases. The authors hypothesized that the volume of ambulatory clinic encounters, office procedures, and surgical procedures and cases would decrease significantly during this period and that the volume of nonelective care would continue unchanged.
Materials and Methods
This study was performed under institutional review board approval. The authors used their billing database to retrospectively identify all patient encounters for providers in an academic orthopedic surgery department that occurred during the first 4 weeks postmandate (PM) (March 16, 2020, through April 12, 2020). They similarly identified encounters from two control periods: the 4 weeks immediately premandate (IPM) (February 17, 2020, through March 15, 2020) and the same dates 1 year before the postmandate period (OYPM) (March 16, 2019, through April 12, 2019). A period of 4 weeks was chosen to allow for a uniform number of weekdays and weekends.
All ambulatory clinic visits and office procedures were included. Surgical procedures were recorded by Current Procedural Terminology (CPT) codes and operative cases. The weekly and total encounter volume and work relative value units (RVUs) were obtained for the study periods. The type of ambulatory visit (ie, in-person visit, telephone encounter, or video encounter) was recorded as well.
During the 2 most recent periods (PM and IPM), surgical cases were categorized into 5 types: fracture or dislocation, acute soft tissue or nerve injury, infection, oncology, and elective or nonurgent. This classification allowed the authors to evaluate whether there was a change in the relative composition of operative cases and the proportion of nonelective procedures.
Descriptive statistics were calculated for volume and RVUs during the study periods. A convenience sample was used. Comparisons of average weekly volume and RVUs were performed with Student's t test. The standard significance criterion of alpha=0.05 was used.
Ambulatory Clinic Encounters
The authors identified 1796 ambulatory clinic encounters during the PM period. During the 4-week IPM period, the total volume of ambulatory clinic encounters was 7054; during the OYPM period, the total volume was 7726. The mean weekly volume was 449 during the PM period, which showed a 74% to 77% decrease from the mean weekly volume of 1763.5 during the IPM period (P=.0009) and 1931.5 during the OYPM period (P<.0001) (Figure A, available in the online version of the article). The mean weekly work RVUs also decreased significantly from 1844.6 (IPM) and 2001.4 (OYPM) to 257.6 (PM) (P=.0004 and P<.0001, respectively) (Figure B, available in the online version of the article).
Weekly ambulatory encounter volume.
Weekly ambulatory encounter work RVUs.
The overall volume and percentage of telemedicine visits increased dramatically. During the IPM period, only 1 telephone encounter and 17 video encounters occurred among 7054 total encounters (0.3%). In the PM period, telemedicine encounters accounted for 1459 of 1796 encounters (81.2%), and of these, 58% were telephone encounters and 42% were video encounters. Telemedicine visits were not being performed during the OYPM period (Table 1).
Classification of Clinic Visits
During the PM period, 67 office procedures were performed. During the 4-week IPM period, the volume was 1330, and during the OYPM period, the volume was 1443. The mean weekly volume of office procedures decreased by 95% from 332.5 and 360.8 for the IPM and OYPM periods, respectively, to 16.8 during the PM period (P=.0002 and P<.0001, respectively) (Figure C, available in the online version of the article). The mean weekly work RVUs also decreased significantly from 267.9 and 313.7 (IPM and OYPM, respectively) to 36.4 (PM) (P=.0003 and P<.0001, respectively) (Figure D, available in the online version of the article).
Weekly office procedure volume.
Weekly office procedure work RVUs.
During the PM period, 197 surgical procedures (CPT codes) were performed, compared with 1206 during the IPM period and 1155 during the OYPM period. The mean weekly volume of surgical procedures decreased by 83% to 84%, with 49.2 performed during the PM period and 301.5 performed during the IPM period and 288.8 performed during the OYPM period (P=.0006 and P<.0001, respectively) (Figure E, available in the online version of the article). The volume of weekly surgical cases (individual encounters) showed a similar statistically significant 88% decrease, from 160.5 (IPM) and 156.25 (OYPM) to 19.2 (PM) (P=.0002 and P<.0001, respectively) (Figure F, available in the online version of the article). The mean weekly work RVUs also decreased significantly from 3274.0 (IPM) and 3096.7 (OYPM) to 541.9 (PM) (P=.0004 and P<.0001, respectively) (Figure G, available in the online version of the article).
Weekly surgical procedure volume by CPT.
Weekly surgical case volume by encounter.
Weekly surgical work RVUs.
During the PM period, surgical volume by CPT decreased over time, with 83 procedures performed during the first week of restrictions on elective surgery and 10 procedures completed in week 4 (Figure H, available in the online version of the article). Similarly, the surgical case volume decreased significantly over time, with 32 cases performed in the first week and 8 performed in the fourth week (Figure I, available in the online version of the article).
Weekly surgical volume by CPT during the PM time period.
Weekly surgical volume by case number during the PM time period.
Surgical cases performed during the PM and IPM periods (Table 2) were classified into 5 categories: (1) fracture or dislocation, (2) acute soft tissue or nerve injury, (3) infection, (4) oncology, and (5) elective or nonurgent. As elective surgery ceased, the mixture of case types changed to predominantly fractures and dislocations (58.4%, an increase from 14.5%). The total number of nonelective cases decreased by 51%. The number of procedures performed for fracture or dislocation decreased by 52%, the number performed for acute soft tissue or nerve injury declined by 39%, the number performed for infection declined by 43%, and the number performed for oncology decreased by 85%.
Classification of Surgical Cases During the IPM and PM Periods
The COVID-19 pandemic has had a variable but substantial effect on health care around the world. In the United States, health care systems and institutions have adapted rapidly to meet the current and anticipated health care needs of their local communities while incorporating the guidelines, recommendations, and mandates from federal and state government bodies and professional societies. Limiting disease transmission has been a major focus through allowing fewer in-person interactions, maintaining social distancing both within and outside of the hospital, and using personal protective equipment.6,7
As part of this dynamic process, state and federal agencies have variably issued recommendations and orders to limit elective surgical procedures.1,3–5,8–10 Restrictions on elective surgery allow for fewer interactions between patients and providers and limit the number of patients presenting to hospital systems for nonurgent conditions. These restrictions allow hospital systems to conserve resources, such as personal protective equipment, ventilators, hospital beds, and personnel, to meet the current and future requirements of patients infected with COVID-19.
States have responded with varying degrees of restriction. The Commonwealth of Massachusetts issued an order on March 15, 2020, that required the postponement of nonessential elective procedures as part of a governmental effort to address the COVID-19 pandemic.1 A definition of elective surgery was provided as invasive procedures “scheduled in advance because the procedure does not involve a medical emergency,” and examples were provided. Alaska provided more vague guidance and allowed hospital systems to determine their own definition of “elective.”8 Maryland went beyond recommendations and put forth an order allowing the state to “control, restrict, and regulate facilities” for elective procedures, and failure to comply was punishable by fines or even incarceration.9
Working in parallel to enact best known practices and incorporate the state mandate, on March 16, 2020, the authors' health care system instituted restrictions on elective surgical procedures, office procedures, and ambulatory clinic patient encounters. All nonurgent and nonemergent encounters were deferred. Throughout the system, the use of telemedicine was expanded exponentially to quickly include all providers; this rapid adoption of a previously lightly used modality was significantly bolstered by a state mandate requiring insurers to compensate for telemedicine visits.2
Clinic compliance was achieved virtually overnight. Ambulatory clinic visit volume decreased by 74% to 77% overall, with the number of in-person visits decreasing by 95.2%. Similar findings were seen with office procedures. The relative proportion of telemedicine visits increased from 0.3% to 81.2% of total visits.
Surgical compliance also was immediate; no elective surgeries were performed during the PM period. Close monitoring of the operative schedule by the institution, with division oversight and vetting of all scheduled cases, led to 100% compliance. In the authors' practice, nonelective surgery accounted for 24.4% of cases during the IPM period but 100% of cases during the PM period. Across all nonelective categories, the total number of nonelective cases decreased by 51% from the IPM period to the PM period, and the weekly number of nonelective cases decreased during the 4 weeks (75%). A potential explanation for this finding could be that fewer injuries occurred as a result of behavioral changes caused by social distancing requirements and stay-at-home orders. In other words, people may be engaging in fewer higher-risk activities, such as the use of motor vehicles and participation in outdoor and sporting activities. Alternatively, as has been a concern in other areas of medicine,11 patients may be delaying care because of concerns about putting themselves at risk for COVID by presenting to emergency departments or urgent care centers.
The effects of COVID-19 on the future delivery of orthopedic care are still unknown but are likely to be profound and lasting. The short-term financial effect of a decrease in the volume of ambulatory encounters and surgical cases by 74% to 77% and 88%, respectively, is likely to be substantial. In 2017, Blue Cross Blue Shield estimated that 47% of the total expenditure on orthopedic care was for elective procedures.12 Further, in a 2016 study of health care expenditure by condition, orthopedic conditions accounted for more than $354 billion in health care spending, or more than 11% of total health care spending.13 At the time of this study, it is unclear when and at what rate elective orthopedic surgery will be able to resume. Nevertheless, this sudden financial shock is likely to have major and lasting effects on individual practices and the overall health care system. At the same time, orthopedic surgeons and patients have rapidly incorporated telemedicine encounters, by telephone and video, into their practices and their expectations. In an increasingly digital age, telemedicine will surely persist as an adjunct modality for the delivery of orthopedic care. The ultimate financial effects of COVID-19 are still to be determined, but the lasting effect on orthopedic providers, practices, patients, and the overall health care system will likely be great.
This study had some limitations. First, the patient population of this orthopedic department may not be representative of the wider orthopedic surgery patient population. Trauma and urgent conditions may account for a different proportion of patients in other practice settings, and this difference may produce varying results. Second, the authors' department has had minor fluctuations in the number of surgeons and nonoperative providers during the past year. Some of the variation between OYPM and IPM volume is likely related to these staff changes. Third, state governmental regulatory mandates differ across the country and may contribute to different effects elsewhere. Fourth, weekly variations in the volume of clinical encounters, office procedures, and surgical procedures can have many causes, and the differences could have other explanations. The authors attempted to address this effect by using 2 control periods: the 4 weeks immediately before the COVID restrictions were placed on elective care (IPM) and the 4-week period 1 year before the restrictions (OYPM). Finally, this study evaluated only the initial period after COVID-related restrictions were enacted in the authors' health care system, and the longer-term effects of these restrictions are unknown.
The significant effect of the response of the authors' health system to COVID-19, incorporating and expanding on state-mandated restrictions on elective health care, was noted immediately. The volume of ambulatory clinic encounters, office procedures, and surgical cases significantly decreased compared with both earlier periods. To continue providing remote ambulatory care, the department responded rapidly by increasing patient and provider access to telemedicine.
Deferral of elective health care in Massachusetts in response to COVID-19 led to a dramatic reduction of in-person patient encounters for orthopedic ambulatory clinics and surgical procedures. This decrease helped the hospital system to achieve the goals of decreasing in-person interactions between patients and providers, limiting the number of patients presenting to hospital sites, and repurposing resources such as personal protective equipment, medications, equipment, and staffing from elective surgical care to the treatment of the rising state population of patients requiring hospitalization for COVID-related morbidity. The longer-term financial effects on hospitals, providers, practices, and the overall health care system will not be determined for some time.
- Commonwealth of Massachusetts Department of Public Health. Order of the Commissioner of Public Health on elective procedures. https://www.mass.gov/doc/march-15-2020-elective-procedures-order/download. Accessed April 2, 2020.
- Office of the Governor and Lt. Governor of the Commonwealth of Massachusetts. Order expanding access to telehealth services and to protect health care providers. https://www.mass.gov/doc/march-15-2020-telehealth-order/download. Accessed April 2, 2020.
- Centers for Medicare & Medicaid Services. Press release: CMS releases recommendations on adult elective surgeries, non-essential medical, surgical, and dental procedures during COVID-19 response. https://www.cms.gov/newsroom/press-releases/cms-releases-recommendations-adult-elective-surgeries-non-essential-medical-surgical-and-dental. Accessed April 3, 2020.
- American College of Surgeons. COVID-19: elective case triage guidelines for surgical care. https://www.facs.org/covid-19/clinical-guidance/elective-case. Accessed April 4, 2020.
- Guy DK, Bosco JA, Savoie FH. AAOS guidelines for elective surgery during the COVID-19 pandemic. https://www.aaos.org/about/covid-19-information-for-our-members/aaos-guidelines-for-elective-surgery. Accessed April 11, 2020.
- Wilder-Smith A, Freedman DO. Isolation, quarantine, social distancing and community containment: pivotal role for old-style public health measures in the novel corona-virus (2019-nCoV) outbreak. J Travel Med. 2020;27(2):taaa020. doi:10.1093/jtm/taaa020 [CrossRef] PMID:32052841
- Chavez S, Long B, Koyfman A, Liang SY. Coronavirus disease (COVID-19): a primer for emergency physicians. Am J Emerg Med. 2020;pii:S0735–6757(20)30178–9.
- Office of the Governor and Lt. Governor of Alaska. COVID-19 health mandate 5.1. http://dhss.alaska.gov/News/Documents/press/2020/SOA_03192020_HealthMandate005_ElectiveMedProcedures.pdf. Accessed April 18, 2020.
- Maryland Department of Health. Directive and order regarding various healthcare matters. https://governor.maryland.gov/wp-content/uploads/2020/03/03.23.2020-Sec-Neall-Healthcare-Matters-Order.pdf. Accessed April 18, 2020.
- Diaz A, Sarac BA, Schoenbrunner AR, Janis JE, Pawlik TM. Elective surgery in the time of COVID-19. Am J Surg. 2020;S0002-9610(20)30218-X. doi:10.1016/j.amjsurg.2020.04.014 [CrossRef]. PMID:32312477
- American Heart Association. Press release. The new pandemic threat: people may die because they're not calling 911. https://news-room.heart.org/news/the-new-pandemic-threat-people-may-die-because-theyre-not-calling-911. Accessed April 23, 2020.
- Blue Cross Blue Shield. Report: planned knee and hip replacement surgeries are on the rise in the U.S. https://www.bcbs.com/the-health-of-america/reports/planned-knee-and-hip-replacement-surgeries-are-the-rise-the-us. Accessed April 23, 2020.
- Dieleman JL, Cao J, Chapin A, et al. US health care spending by payer and health condition, 1996–2016. JAMA. 2020;323(9):863–884. doi:10.1001/jama.2020.0734 [CrossRef] PMID:32125402
Classification of Clinic Visits
|3/16/19–4/12/19 (OYPM)||2/17/20–3/15/20 (IPM)||3/16/20–4/12/20 (PM)|
|Telephone telemedicine encounter||0||1||850|
|Video telemedicine encounter||0||17||609|
Classification of Surgical Cases During the IPM and PM Periods
|2/17/20–3/15/20 (IPM)||3/16/20–4/12/20 (PM)|
|Fracture or dislocation||93 (14.5%)||45 (58.4%)|
|Acute soft tissue or nerve injury||28 (4.4%)||17 (22.1%)|
|Infection||23 (3.6%)||13 (16.9%)|
|Oncology||13 (2.0%)||2 (2.6%)|
|Elective or nonurgent||485 (75.5%)||0 (0%)|