key: cord-0998487-sohaqmom authors: Rao, Saieesh A.; Ravi, Mohan S.; Zhao, Jeffrey W.; Sturgeon, Cord; Bilimoria, Karl Y. title: Social Media Responses to Elective Surgery Cancellations in the Wake of COVID-19 date: 2020-06-02 journal: Ann Surg DOI: 10.1097/sla.0000000000004106 sha: cbb7efa2172edd1643eb031f7fe26418422a4d87 doc_id: 998487 cord_uid: sohaqmom nan On Friday, March 13 th , 2020 the American College of Surgeons (ACS) recommended halting elective surgery nationwide to prepare for the COVID-19 pandemic. 1 This recommendation was endorsed the following day by the U.S. Surgeon General. 2 A recently published national health survey revealed that "not being able to get medical care," such as elective surgery, was the second highest concern among respondents besides "getting sick because of COVID-19." 3 In light of this concern, we aimed to investigate public sentiment regarding the recommendations from the ACS and Surgeon General. We queried online posts from Reddit, a social media platform and the fifth most popular website in the United States with 21 billion screen-views per month. 4 Several discussion forums on the site, known as "subreddits," are dedicated to topics of medical interest. We examined the subreddits r/medicine, r/surgery, and r/coronavirus, which together claim over 2.3 million members. Reddit is an ideal platform of study because (1) all posts are public, (2) user anonymity encourages reporting noncompliance with the recommendations, and (3) narrative content is encouraged through which to express sentiment. We used the Reddit PushShift API 5 in Python to identify comments containing the keyword "elective" that were archived between December 31, 2019 (when the first COVID-19 cases were reported in China) and April 15, 2020. Each comment was manually reviewed by three admission as such either in their comment or post history; otherwise, non-HCW status was presumed. Comments were grouped by date before or after the ACS announcement. Sentiment analysis of comment text was performed in Python using the Valence Aware Dictionary for sEntiment Reasoning (VADER), a validated natural language processing tool that has previously been used to study health behaviors with social media. 6,7 VADER is optimized for social media text, accounting for elements of the online lexicon such as slang, emoticons, "all caps," and redundant punctuation (e.g., multiple exclamation points). Furthermore, VADER calculates sentiment in a context-aware manner, using textual clues to interpret negation and disambiguate multiple word meanings. Two measures, scores for negativity and sentiment, were calculated by VADER for each comment. Negativity scores ranging from 0 to 1 quantify the intensity-weighted proportion of text expressing negative sentiment; whereas, sentiment scores ranging from -1 to 1 quantify overall negative to positive sentiment. Comments with non-zero sentiment scores (implying the text included subjective viewpoints) were included for subgroup comparisons using Wilcoxon rank-sum, Kruskal-Wallis, and chi-squared tests. Significance was determined using α=0.05. Scores are reported as medians. Data analysis and visualization were performed in R 3.6.1. This study was deemed non-human subjects research. A total of 1777 comments were identified and manually reviewed. Of these, 1387 (78.1%) were specific to elective surgery and procedures in the United States during the COVID-19 pandemic, of which 1272 (91.7%) had a non-zero sentiment score; these were included for Among the 1272 included comments, overall sentiment did not significantly differ between HCWs and non-HCWs in the period on or prior to March 13 (-0.08 versus -0.10, p=0.98). However, sentiment among non-HCWs became significantly more negative after March 13 compared with before (-0.25 versus -0.10, p=0.037). In contrast, no statistically significant change in sentiment was observed among HCWs (-0.08 versus -0.18, p=0.71) between time periods. Furthermore, overall sentiment after March 13 was significantly more negative among non-HCWs than among HCWs (-0.25 versus -0.18, p=0.027). Negativity scores were also higher among non-HCWs than HCWs (0.10 versus 0.08, p<0.001; Figure 1A ) after March 13. Sentiment and negativity scores did not significantly differ based on whether comments described cancellations, expected cancellations, or ongoing elective cases (961 total comments; Figure 1B) . However, negativity scores of the 690 comments reporting cancellation were significantly worse among non-HCWs than HCWs (0.10 versus 0.08, p=0.028). Reports of ongoing elective cases were more likely to be reported by HCWs (OR 2.30, p<0.001); whereas, non-HCWs were more likely to report cancellations (OR 1.24, p=0.005) and expected cancellations (OR 1.58, p=0.03). Copyright © 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. To our knowledge, this is the first study to measure emotional responses to cancellation of elective surgeries and procedures in the wake of COVID-19. Sentiment regarding cancellations, gauged through social media activity, was significantly more negative among non-HCWs than HCWs. Sentiment among non-HCWs also became significantly more negative following March 13 when the ACS recommendations were published, whereas sentiment among HCWs did not change. These results highlight the importance of elective surgery to patients' emotional well-being. Study limitations should be acknowledged. First, Reddit users may not be representative of the general public; 8 however, this limitation is inherent to research on all social media platforms. 9 Traditional polling methodologies may be helpful, but analyzing social media gives a unique perspective because doing so avoids Hawthorne effects and recall bias regarding sentiment before and after March 13. Second, sample sizes for discussion of elective surgery and coronavirus were limited prior to March 13, which reduces statistical power. Third, we used restrictive criteria to identify HCWs from social media posts; hence, it's possible that some HCWs were not identified as such due to intentional anonymity. The same limitation applies to our identification of non-U.S. users for exclusion from the analysis. Lack of timely access to elective surgery and procedures may have profound consequences for patients' emotional well-being. This study sheds light on the emotional importance of access to elective surgeries and procedures and highlights the emotional burden of cancelling such surgeries. It is not known if there is a similar emotional impact from the loss of access to other forms of medical care during the COVID-19 crisis. Further research may evaluate how to better measure and mitigate the emotional burden of loss of healthcare access to patients and those who treat them. Copyright © 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. COVID-19: Recommendations for Management of Elective Surgical Procedures. American College of Surgeons Surgeon General advises hospitals to cancel elective surgeries US Public Concerns About the COVID-19 Pandemic From Results of a Survey Given via Social Media VADER: A Parsimonious Rule-based Model for Sentiment Analysis of Social Media Text Twitter-based measures of neighborhood sentiment as predictors of residential population health 6% of online adults are reddit users Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited The Demographics of Social Media Users -2012 Figure 1. Negativity scores over time for comments relating to elective cases during the COVID-19 pandemic (A) for healthcare workers vs. non-healthcare workers and (B) for ongoing cases A) Negativity scores generated by VADER for comments relating to elective cases in the United States during the global COVID-19 pandemic. Negativity scores were significantly greater in comments posted by non-HCWs compared with those posted by HCWs (p<0.001). (B) Negativity scores for comments describing prospective cancellations, actual cancellations, or ongoing elective cases. Negativity scores did not significantly differ across the three groups