key: cord-0836321-jlz5t04n
authors: Earp, Brandon E.; Zhang, Dafang; Benavent, Kyra A.; Byrne, Laura; Blazar, Philip E.
title: The Impact Of COVID-19 Restrictions on an Academic Hand Surgery Practice
date: 2021-11-15
journal: J Hand Surg Glob Online
DOI: 10.1016/j.jhsg.2021.10.008
sha: 68d1dee0d070c72dacf21f6595cced1800523816
doc_id: 836321
cord_uid: jlz5t04n

Purpose The impact of the SARS-CoV-2 (COVID-19) coronavirus has been felt worldwide, impacting all aspects of healthcare. We examined the quantitative impact during the first four weeks of hospital system and state-mandated restrictions on elective healthcare on an academic urban hand surgery practice. We hypothesized that the volume of overall ambulatory clinic encounters, office procedures, and surgical procedures and cases would dramatically decrease during this time and that the volume of non-elective care would remain unchanged. Methods We retrospectively reviewed all patient encounters in a 4-week time period from March 16, 2020 through April 12, 2020 for an academic orthopedic hand surgery practice and compared those to two control 4-week time periods: February 17, 2020 through March 15, 2020 and March 16, 2019 through April 12, 2019. Weekly encounter volumes and work relative value units (RVUs) were obtained for ambulatory clinic encounters, office procedures, and surgical procedures and cases. The type of ambulatory visit, in-person or telemedicine was also identified. Surgical cases were categorized into four types: fracture or dislocation, acute soft tissue or nerve injury, infection, or elective/non-urgent for the two most recent time periods. T-tests were performed to compare weekly volume and RVUs between time periods. Results After the implementation of mandated restrictions on elective healthcare, ambulatory hand surgery clinic encounters decreased 72-73%, clinic procedures decreased by 87-90%, and surgical cases decreased by 87-88%. The percentage of ambulatory visits performed via telemedicine increased from 0.06% to 74%. Similar impacts on RVUs were seen. All elective surgery was deferred. Surgeries for fractures and dislocations declined by 58% and those for acute soft tissue or nerve injury declined by 40%; the number of surgical procedures for infection remained unchanged. Conclusions The COVID-19 restrictions on elective healthcare led to an immediate, substantial impact on hand surgery practice. There was a significant decrease in ambulatory encounter volume, office procedures, and surgical cases. Non-elective surgical case volume also decreased by 47%. The long-term financial impact of this change in practice on providers, practices, patients and hospitals is still to be determined but based on the quantitative impacts seen, is likely to be substantial.

The SARS-CoV-2 (COVID-19) pandemic has created significant strain on the United 34 States healthcare system, as rapid disease transmission through a disease-naïve population has 35 led to a public health crisis. In some areas of the country, the needs of the infected population 36 exceed the normal capacity of the system to care for these patients. Efforts have been made to 37 decrease disease transmission by using "social distancing" and personal protective equipment issued an order that required the deferral of non-essential elective procedures as part of a 44 governmental effort to address the SARS-CoV-2 (COVID-19) pandemic. 4 Some of the expected 45 benefits of this policy were to limit the exposure of patients who would otherwise come to the 46 J o u r n a l P r e -p r o o f hospital, to limit the exposure of healthcare workers to those patients, to preserve the supply of infected with COVID-19. The state also mandated that insurers compensate providers for 50 performing medically necessary telehealth visits, which had not been mandatory prior to that 51 time. 5

On the following day, March 16, 2020, our hospital system enacted the state policy and 53 extended the restrictions to also include ambulatory clinic patient encounters and office 54 procedures. Providers were required to immediately postpone non-urgent clinic visits and 55 surgical procedures. Urgent clinic visits for issues which could not be addressed remotely by a 56 video and/or audio visit were allowed. Urgent and emergent surgical procedures were not 57 restricted. The guidelines allowed for individual practitioners to determine the urgency of 58 ambulatory visits but required divisional or departmental review and approval of all surgical 59 cases to ensure compliance.

The objective of this study was to determine the impact of these elective healthcare The utilization of telemedicine as a modality for completing these visits increased 104 dramatically. During the IPreM period, only one video telemedicine encounter and no telephone 105 telemedicine encounters were performed out of 1,623, total (0.06%). In the PostM period, 106 telemedicine visits accounted for 74% of the visits (of which 39% were telephone and 61% were 107 video) (Table 1) . The categorization of surgical cases was performed for the PostM and IPreM periods 128 ( Table 2) . As elective surgery ceased, the mixture of case type changed to predominantly Our telemedicine ambulatory clinic system, which had been available but was infrequently used, 154 was rapidly expanded to all providers, aided by a state mandate requiring insurers to compensate 155 for telephone and video telehealth visits. 5

Our study reveals the rapidity with which compliance was achieved. Ambulatory clinic http://dhss.alaska.gov/News/Documents/press/2020/SOA_03192020_HealthMandate005 J o u r n a l P r e -p r o o f 

Office of the Governor and Lt. Governor of Alaska. COVID-19 Health Mandate 5