key: cord-0767524-2x9bb6ap
authors: Cimba, Michael J.; Day, Saxon; Rose, Matthew J.; Lee, Kevin C.; Chuang, Sung-Kiang; Giannakopoulos, Helen E.; Ford, Brian P.
title: How has the COVID Pandemic Impacted the Clinical Volume and Variety of an Academic Oral and Maxillofacial Surgery Program?
date: 2021-11-30
journal: J Oral Maxillofac Surg
DOI: 10.1016/j.joms.2021.06.033
sha: e30ccef30214b1a727248f1e093bfb806451b821
doc_id: 767524
cord_uid: 2x9bb6ap

PURPOSE: Attempts to mitigate the coronavirus disease of 2019 (COVID) have disrupted the delivery of non–pandemic care. The purpose of this study was to evaluate the effects of the COVID pandemic on surgical volume and variety at an academic oral and maxillofacial surgery program. MATERIALS AND METHODS: A retrospective cohort study was conducted using the surgical logs of the University of Pennsylvania, Department of Oral and Maxillofacial Surgery from January 2012 through January 2021. Each record identified patient demographics and case classifications. The study predictor was timing of care, which was divided into pre-pandemic, peak pandemic, or post-peak pandemic. The primary study outcomes were the monthly procedure count and the procedure categories. The secondary dependent variables were patient age and race. Multivariate and univariate analyses of variance were used to determine whether pandemic effects existed within outcome groups. RESULTS: The final sample included 64,709 surgical procedures. Before, during, and after the pandemic peak, there were means of 691.0, 209.0, and 789.4 procedures per time period, respectively (P < .01). There was significantly more infection (baseline 2.2%, peak 6.0%, post-peak 2.0%, P < .01) and trauma (baseline 5.3%, peak 26.7%, post-peak 3.9%, P < .01) cases during the pandemic peak. The mean percentage of pediatric patients increased during the peak and post-peak periods (baseline 2.4%, peak 12.9%, post-peak 10.2%, P < .01). No differences were observed among the mean percentage of White (P = .12), Black (P = .21), and Hispanic (P = .25) patients treated. CONCLUSIONS: Along with a predictable decline in surgical numbers, a greater proportion of infection and trauma procedures were performed at the pandemic's peak. Despite these changes, surgery volume normalized and case variety returned to pre-pandemic levels in the post-peak period. Our study suggests that the addition of COVID restrictions did not change the case volume or variety in the months’ after the initial crisis.

Conclusions: Along with a predictable decline in surgical numbers, a greater proportion of infection and trauma procedures were performed at the pandemic's peak. Despite these changes, surgery volume normalized and case variety returned to pre-pandemic levels in the post-peak period. Our study suggests that the addition of COVID restrictions did not change the case volume or variety in the months' after the initial crisis. The novel coronavirus disease of 2019 (COVID) has contributed to multiple shifts in healthcare utilization. On March 18, 2020, the Centers for Medicare and Medicaid Services (CMS) made recommendations to postpone elective medical, surgical, and dental procedures in order to mitigate the spread of COVID and preserve scarce healthcare resources. 1 Following these expert guidelines, Pennsylvania quickly issued an executive order to restrict all procedures that were non−emergent. 2 This statewide pause lasted until April 27, 2020 when non−emergent and elective surgeries were permitted to resume. 3 Many other states likewise implemented similar preventive guidelines during this period, and every major hospital system has had to adapt to new pandemic policies.

Despite the liberalization of constraints at the end of April 2020, by mid-June, global decreases in the number of hospitalized non−COVID patients were still commonplace. 1, 4 Not only were there changes in healthcare utilization at the pandemic's peak, but there also appear to be sustained changes in the aftermath of the initial COVID crisis. This investigation sought to determine how the COVID pandemic impacted the practice patterns at a major urban academic oral and maxillofacial surgery program. The purpose of this study was to evaluate the effects of the pandemic on the volume and types of surgical cases performed. To achieve this aim, we compared both peak and post-peak periods to a pre-pandemic baseline. We hypothesized the surgical volume and case variety would be significantly different across all 3 time points.

This retrospective cohort study was composed of oral-maxillofacial surgical encounters at the University of Pennsylvania from January 2012 through January 2021. We classified this study as an open, dynamic cohort study because this is not a traditional cohort study that follows a single sample of patients over time with repeated measures. Emergency department treatments were not included in the final study sample. From each surgical encounter, the following information was recorded: date of service, patient age, self-reported race, International Classification of Diseases (ICD) diagnosis code, and Current Procedural Terminology (CPT) code. In order to assess the effect of the COVID pandemic, 3 time points (prepandemic, peak pandemic, and post-peak pandemic) were delineated. Pre-pandemic was defined as any time before March 2020. Peak pandemic was defined as the months of March 2020, April 2020, and May 2020. Post-peak pandemic was defined as any time after the pandemic peak and included dates from June 2020 through January 2021. Patient age was classified as pediatric (<18 years), younger adult (18 to 65 years), and older adult (65 years and older). Patients identifying with multiple ethnicities were classified as "other". Using billing codes, each surgery was classified as either cancer/reconstruction, benign pathology, craniofacial, orthognathic, temporomandibular joint, cosmetic, dentoalveolar, sedation, odontogenic infection, or facial trauma. Surgical encounters that were ambiguous or that could not be grouped into 1 of the aforementioned categories were excluded from the analysis. Multiple procedures that were performed and coded for during the same visit were each considered separately. For example, a dentoalveolar surgery performed under sedation was counted both as a dentoalveolar case and a sedation case in this study.

The predictor variable was the timing of surgery relative to the pandemic. The primary study outcomes were the monthly procedure count and distribution of procedure categories. Procedural variety was defined as having a significantly different distribution of cases across clinical categories. The secondary study outcomes were the patient characteristics of age and race. For the primary outcome of monthly case counts, an analysis of variance (ANOVA) was performed to determine whether the mean number of cases were significantly different across all time periods. For all of the remaining multilevel study outcomes, multivariate analyses of variance (MANOVAs) were conducted to determine whether timing of surgery had a significant association with each outcome group. Significance in each MAN-OVA test, as determined using Wilks's lambda statistics, was followed by post hoc ANOVAs to determine which specific factors within each outcome category experienced pandemic changes. All statistical analyses were performed with SAS, version 9.4 (SAS Institute, Cary, NC). This study was granted exemption by the University of Pennsylvania Institutional Review Board.

A total of 64,709 surgical procedures were included in the final sample. The descriptive statistics of the samples are presented in Table 1 . There were statistically significant differences in the mean monthly case volume before, during, and after the COVID pandemic peak (F(2,109) = 8.96, P < .01) ( Table 2) . Before the pandemic, an average of 691.0 cases (SD: 212.9) were performed per month. During the peak of the pandemic, the case volume declined to 209.0 cases (SD:163.8) per month. After the peak, the case volume increased above pre-pandemic levels to 789.4 cases (SD: 120.2) per month.

The pandemic was associated with significant differences in the distributions of procedure types (F (10,210) = 5.99, Wilks' lambda = 0.61, P < .01), patient age (F(6,214) = 10.86, Wilks' lambda = 0.59, P < .01), and patient race (F(10,210) = 3.13, Wilks' lambda = 0.76, P < .01). In the post-hoc analysis (Table 3) , the mean percentage of pediatric patients sustained an increase during the peak and post-peak periods (P < .01). There were no significant differences in the proportion of older adults over 65 years that were treated (P = .34). With respect to race, no differences were observed among the mean percentage of White (P = .12), Black (P = .21), and Hispanic (P = .25) patients. During the pandemic months, there were higher rates of Asian (P < .01) and lower rates of other/multiracial (P < .01) patients. For procedure categories, the mean proportions of cancer/ pathology/reconstruction (P = .73) and craniofacial/ orthognathic/TMJ/cosmetic (P = .06) cases were maintained at pre-pandemic levels during the entire study period. There were significantly more infection (P < .01) and trauma (P < .01) cases during the pandemic peak; however, this surge appeared to normalize to baseline in the ensuing months after the peak. Similarly, the share of dentoalveolar (P < .01) cases decreased during the height of the pandemic, but returned to pre-pandemic levels afterward.

The study sought to determine how the COVID pandemic affected case volume and variety at an academic oral and maxillofacial surgery program, and we found that the pandemic was associated with statistically significant changes in these outcomes. On closer examination of the data, there was a clinically relevant increase in the share of infection and trauma cases treated by the Penn oral and maxillofacial surgery service during the pandemic peak. This likely stemmed from the statewide restrictions on elective procedures at that time. Once the restrictions were lifted, the number and variety of surgical cases were restored to pre-pandemic levels. Mandatory social distancing and pre-operative COVID testing did not appear to lead to a protracted pandemic effect on our institution's clinical practice. The normalization of the post-peak period also argues against the presence of a second wave phenomenon at our institution. Furthermore, this finding is reassuring as it suggests that oral and maxillofacial surgery training programs can adapt to new guidelines and preserve the resident surgical experience.

The surgical volume did not appear to return to a normal steady state until July 2020. This brief period of delay may have had multiple contributions including both limited availability of hospital beds and COVID testing, a public fear of contagion, or a general decreased ability to afford elective services secondary to financial strain from the pandemic. Fear of contagion refers to public hesitancy to obtain medical care due to the prevalence of COVID in the healthcare setting. It is important to note that this concern of transmission does solely impact high-risk specialties with aerosol generating procedures. There have been reports across multiple specialties confirming the role of fear in causing public reluctance to seek out medical attention. 5 To combat this sentiment, health systems have issued communications reinforcing the importance of seeking healthcare during the post-pandemic period. 6 Fortunately, any fear of contagion phenomenon or other barrier to care did not appear to have a sustained post-peak effect on surgical volume in our oral and maxillofacial surgery practice. Given the mandatory pause on elective surgeries, there was a predictable increase in the share of infection and trauma cases treated during the peak of the COVID crisis. We suspect that there were also other driving factors that contributed to an increased number of infection and trauma cases during that time. Of note, our sample only included emergency department encounters that were treated in the operating room. Because outpatient dental services were inaccessible at the time, patients with odontogenic infections had limited care options. Furthermore, because most patients were avoiding local emergency departments that were overwhelmed with COVID, it is probable that certain mild infections that otherwise could be treated in-office may have transformed into more severe airway threatening conditions that required operating room drainage. Trauma accounted for over a quarter of surgical cases during the peak months of the pandemic. Pennsylvania issued a stayat-home order for Philadelphia county from March 23 until May 8, 2020. 7 With the stay-at-home order, certain areas found that there was a dramatic decline in the total incidence of traumatic injuries. 8 According to Abdallah et al, there was a regional decrease in the overall volume of trauma at the University of Pennsylvania. 5 This was largely driven by parallel decreases in the number of unintentional injury mechanisms such as motor vehicle collisions. 5 Interestingly, in the same sample, there was a paradoxical increase in the number of intentional interpersonal injuries. 5 The rise in domestic violence with the stay-at-home order has been documented elsewhere. Firearm violence in Philadelphia saw an increase with social distancing and home sheltering. 9 Nationally, the number of domestic assault cases grew by at least 5% during this time. 10 Interestingly, our study found that the proportion of pediatric patients increased significantly during the peak and post-peak periods. Many school systems adopted distance learning for the 2020 academic year. The lack of in person instruction may have allowed teenage patients the flexibility to pursue oralmaxillofacial surgery treatments such as third molar removal and orthognathic surgery. Although there was some statistically significant variance in patient race, we did not identify any obvious clinically significant differences. Past studies have reported that the Black population is less likely to present for medical care during the pandemic when compared with the White population. 11 It has been hypothesized that this disparity may be secondary to the socioeconomic and geographic challenges that affect much of the Black population. 12, 13 Almost half of surveyed Black participants self-reported economic hardships during the pandemic, whereas during the same timeframe, only 21% of their White counterparts provided a similar response. In our sample, there were more Black patients treated during the peak months even though the mean percentage was not significantly different across time periods. This finding, although counter to prior reports, is reassuring.

There are a variety of strengths and weaknesses to our study that warrant acknowledgement. Because of annual variation in surgical volume, it would be poor sampling to simply use 1-or 2-years of surgical logs to serve as a pre-pandemic baseline. We pooled 8-years of surgical procedures in order to obtain an accurate depiction of our pre-pandemic operative experience. Although we identified certain trends over time, this study was largely observational and descriptive. Therefore, we could only speculate the underlying causes and were unable to prove that external factors, such as dental neglect or domestic violence, contributed to our results. Finally, this was a single-institution experience and, therefore, our findings may not be generalizable to other dissimilar programs.

In conclusion, our study found that although the surgical case logs were skewed toward infection and trauma cases during the pandemic's peak, both the case volume and variety normalized in the post-peak period. With widespread vaccination, lower transmission rates, and liberalization of COVID restriction, we assume that normalcy will continue to be maintained in our academic oral and maxillofacial surgery practice. Lessons learned during the COVID pandemic will increase preparedness and guide the management of future public health crises.

How the COVID-19 pandemic has affected provision of elective services: the challenges ahead

Ambulatory Surgery Center Association and ASCA Foundation. State guidance on elective surgeries

COVID-19: executive orders by state on dental, medical, and surgical procedures

State governors' "stay-at-home" and prohibition on elective procedure orders

Increased firearm injury during the COVID-19 pandemic: a hidden urban burden

Coronavirus and cardiovascular disease: don't ignore heart symptoms

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