key: cord-0754603-qs40g1fz
authors: Jella, Tarun K.; Desai, Ansh; Jella, Taral; Steinmetz, Michael; Kimmell, Kristopher; Wright, James; Wright, Christina Huang
title: Geospatial Distribution of Neurosurgeons Age 60 and Above Relative to the Spread of COVID-19
date: 2020-10-14
journal: World Neurosurg
DOI: 10.1016/j.wneu.2020.10.037
sha: 59208c649e5c262fe3039cda884d6fb9b661bb09
doc_id: 754603
cord_uid: qs40g1fz

Objective To perform an ecological study in order to analyze the geospatial distribution of neurosurgeons ≥ 60 years old and compare these data with the spread of COVID-19 across the; U.S. Methods Data regarding the distribution of COVID-19 cases was collected from the Environmental Systems Research Institute and demographic statistics from the American Association of Medical Colleges 2019State Workforce Reports. These figures were analyzed using geospatial mapping software. Results As of July 5, 2020, the 10 states with the highest number of COVID-19 cases showed older neurosurgical workforce proportions (the proportion of active surgeons aged 60 years or older) ranging from 20.6% to 38.9%. Among states with the highest number of COVID-19 deaths, the older workforce proportion ranged from 25.0% to 43.4%. Connecticut demonstrated the highest with 43.4% of neurosurgeons 60 years or older. Conclusions Regional COVID-19 hotspots may coincide with areas where a substantial proportion of the neurosurgical workforce is ≥ 60 years of age. Continuous evaluation and adjustment of local and national clinical practice guidelines are warranted throughout the; pandemic era.

Despite local and national attempts to contain the novel coronavirus (COVID-19), it has 64 continued to spread, with 32 states reporting re-opening related surges throughout the United 65

States as of July 1, 2020. 1 The continued prevalence of the disease and wide fluctuations in 66 hospital resources have forced many healthcare institutions, including neurosurgical 67 departments, to repeatedly amend departmental practices. 2,3 The pandemic has disrupted and 68 reconfigured supply chains on local and international levels. Most notable and most publicized 69 was the unreliability in available personal protective equipment (PPE) for the healthcare 70 workforce. The fluctuations in both COVID case numbers and PPE availability could prove 71 dangerous especially as states enter into various phases of reopening. It is important to 72 conscientiously assess the risks faced by the neurosurgical workforce and identify the most 73 vulnerable populations within the specialty. 74 75 Numerous risk factors have been found to contribute to COVID-19 disease severity and 76 mortality. However, age independently has been reported as one of the most significant risk 77 factors for death due to COVID-19. 4-8 Characterization of the geospatial patterns between 78 COVID-19 and the most at-risk neurosurgeons will help to determine regions that must optimize 79 resources and commit to safety precautions in order to safeguard the neurosurgical workforce. As 80 a result, this study was performed in order to establish first the geographical distribution of 81 neurosurgeons aged 60 years or older and, secondly, to compare this data to the distribution of 82 COVID-19 cases across the country. Recent publications have analyzed similar distributions 83 with respect to orthopedic surgeons and otolaryngologists, but a specific focus on the 84 neurosurgical workforce is vital because it would allow for protective precautions to be taken 85 more strategically. 9,10 86 Data collected included the total number of neurosurgeons in each state, the number and 94

proportion of neurosurgeons aged 60 years or older per state, and the total state population. Next, 95 geospatial data describing the spread and severity of COVID-19 were gathered from the 96 Environmental Systems Research Institute (ESRI). 12 To compile and display all of this data, the 97 QGIS geospatial analysis software (version 3.12.1) was used, creating a map of all 50 states that 98 displayed the coordinates of active COVID-19 cases and deaths as of July 5, 2020. Based on the 99 distribution of the neurosurgeon ages, states were grouped into quintiles and a graduated color 100 scheme was established to visualize and compare with regional COVID-19 statistics. Finally, 101 temporal data regarding the daily and cumulative incidence of confirmed COVID-19 cases were 102 extracted from the New York Times online data repository and graphed in order to visualize the 103 national trajectory of the pandemic over the past six months. 13 104 105

In the five states with the highest number of active COVID-19 cases as of July 5, 2020, 107 the percentage of neurosurgeons 60 years or older ranged from 28.7% to 38.9% (Figure 1 , Table  108 1). Similarly, in the five states with the largest number of COVID-19 related deaths as of July 5, 109 the percentage of neurosurgeons 60 years or older was as high as 35% (Figure 2 , Table 2 (Table 1, Table 2 ). Overall, the states in the highest quintile of neurosurgical workforce 115 age showed between 35% and 43.4% of actively practicing neurosurgeons to be aged 60 years or 116 above (Table 3) . Additionally, of this quintile, Florida, Alabama, and Montana are in the top five 117 for the oldest average physician workforce (Figure 3) . 118 119 It is also important to note that, when comparing state workforce age proportions across 120 specialties, neurosurgery has a higher proportion of the workforce 60 years or older than only 121 vascular surgery, obstetrics & gynecology, and emergency medicine (Figure 4) . 122 downtrend in COVID-deaths occurred in mid-April, which simultaneously marked the return to 126 elective surgeries authorized by the American College of Surgeons (ACS) on April 17 th . The 127 number of daily COVID-19 deaths has continued to decrease from this original peak of over 128 2,000 deaths per day. 13 A second peak occurred in mid July at 66,000 daily confirmed cases 129 followed by a valley that leveled off at 43,000 cases daily as of September 29, 2020 and now again 130 appears to be increasing. 14 131 132

This study performed an overlay of cross-sectional data to understand more intimately the 134 risks to the neurosurgical workforce by geographical region and age. This study found that, as of 135

July 5, 2020, certain states, specifically Florida, Massachusetts, Georgia, Alabama and 136

Connecticut, have been significantly affected by COVID-19, have some of the highest average 137 physician workforce ages, and report the largest proportion of neurosurgeons aged 60 years or 138 above. As suggested in this paper and by most news sources across the country, the number of 139 COVID-19 cases in the United States continues to increase, but, as emergent, urgent, and even 140 elective neurosurgical procedures are cleared to proceed, it is important that local entities, such 141 as state neurosurgical societies, encourage hospitals, particularly those in states with the highest 142 proportion of practicing neurosurgeons aged 60 years and above, to take proper steps to 143 guarantee the safety and security of the neurosurgical workforce. 144 145 Age is a known independent risk factor for poor outcomes and higher rates of mortality in 146 both the general and the physician populations infected with COVID-19. One study reported a 147

Google search of physician deaths as of April 15, 2020, and found 278 physicians worldwide had 148 died from COVID-19 and their average and median age was 63.7 and 66 years respectively. 15 149 Additionally, as of June 2 nd , 19 neurosurgeons across the world have died from COVID-19, with 150 the average and median age at death being 61 and 62, respectively. 16 The case fatality 151 rate in Italy, as of March 17, for individuals 60 years or older was nearly three times higher than 152 that of individuals younger than 60 years of age. 17 Given that this analysis is performed with state-level data, we cannot distinguish age 197 distributions or COVID-19 cases by urban or rural regions, academic or private hospitals, or 198 hospital networks. Furthermore, states where less than 10 neurosurgeons are above 60 years old 199 did not report data for this metric due to privacy reasons and were thus excluded from our study. 200 A total of states 9 states (AK, AZ, ME, NE, ND, NH, SD, VT, WY) did not provide data on age 201 of neurosurgeons. Our data also could not distinguish whether providers were practicing full-202 time or part-time and/or the age distribution of neurosurgeons by subspecialty. Also, the data 203 provided regarding the neurosurgeon workforce is also from December 2018 and more recent 204 data is not available, so recent changes in the workforce demographics are not reflected. 205 206 This is a cross-sectional evaluation that is unable to accurately capture the rapid undulation in 207 COVID-19 rates, and it furthermore does not report this data as a true rate. In other words, the 208 data presented provides a relatively broad overview that will continue to change as time passes. The 209 data that is provided with regards to the number of COVID-19 cases or deaths by state is relatively 210 general information that is likely not novel for many readers. Since this study's data 211 was acquired on July 5, the daily surge in cases has peaked at 75,600, rather than 50,000, as 212 reported above. Further, determining an accurate point estimate of COVID-19 incidence has 213 proven to be an national epidemiological challenge. It is undermined by the significant variance 214 in proportion of state populations that actually receive testing, the range of sensitivity of tests spread, hospitals have strengthened their policies with regards to PPE usage and testing, which 217 has both mitigated the risk that providers faced early on during the pandemic and also minimized 218 the spread of COVID-19 in hospitals. 219 220

In addition to the importance of PPE availability, numerous COVID-19 related guidelines 222 and consensus recommendations already have been published for a host of neurosurgical 223 subspecialties. 25,27-30 Armed with this increased awareness of regional hotspots in the United 224

States, it is our hope that state associations, hospitals, neurosurgery departments, and 225 neurosurgeons, will apply and improve these guidelines in order to ensure that the most at-risk 

ESRI: GIS Mapping Software, Location Intelligence & Spatial Analytics Technology

GitHub. nytimes/covid-19-data: An ongoing repository of data on coronavirus cases and 262 deaths in the U

Accessed 14

New Cases of COVID-19

Memoriam: A Memoir for Our Fallen 268 "Heroes

Case-Fatality Rate and Characteristics of Patients Dying 270 in Relation to COVID-19 in Italy

Workforce in the USA During the Coronavirus Disease-19 Pandemic

Licensed Physicians in the United States

Survey of COVID-19 Disease Among Orthopaedic Surgeons 279 in Wuhan, People's Republic of China