key: cord-1006947-sebzbijm
authors: Quereshy, Humzah A.; Jella, Tarun; Ruthberg, Jeremy S.; Kocharyan, Armine; D'Anza, Brian; Maronian, Nicole; Otteson, Todd D.
title: “Hot zones” for otolaryngologists: Assessing the geographic distribution of aerosol-generating procedures amidst the COVID-19 pandemic
date: 2020-05-27
journal: Am J Otolaryngol
DOI: 10.1016/j.amjoto.2020.102550
sha: 188675e517763c227232fe3fda5cfb481a643c1e
doc_id: 1006947
cord_uid: sebzbijm

OBJECTIVE: Given high COVID-19 viral load and aerosolization in the head and neck, otolaryngologists are subject to uniquely elevated viral exposure in most of their inpatient and outpatient procedures and interventions. While elective activity has halted across the board nationally, the slow plateau of COVID-19 case rates is prompting the question of timing of resumption of clinical activity. We sought to prospectively predict geographical “hot zones” for otolaryngological exposure to COVID-19 based on procedural volumes data from 2013 to 2017. METHODS: Otolaryngologic CPT codes were stratified based on risk-level, according to recently published specialty-specific guidelines. Using the Medicare POSPUF database, aerosol-generating procedures (AGPs) were mapped based on hospital referral regions, against up-to-date COVID-19 case distribution data, as of April 24, 2020. RESULTS: The most common AGPs were diagnostic flexible laryngoscopy, diagnostic nasal endoscopy, and flexible laryngoscopy with stroboscopy. The regions with the most AGPs per otolaryngologist were Iowa City, IA, Detroit, MI, and Burlington, VT, while the states with the most COVID-19 cases as of April 24th are New York, New Jersey, and Massachusetts. CONCLUSIONS: Our study provides a model for predicting possible “hot zones” for otolaryngologic exposure based on both COVID-19 case density and AGP-density. As the focus shifts to resuming elective procedures, these potential “hot zones” need to be evaluated for appropriate risk-based decision-making, such as “reopening strategies” and allocation of resources.

J o u r n a l P r e -p r o o f

With the majority of the country now in social isolation, Coronavirus disease 2019 has rendered essential healthcare workers disproportionately susceptible to persistently elevated viral exposure. Viral RNA exposure and load correlate highly with severity of clinical manifestations, namely requiring ICU admission 1 procedures to the clinicians were aerosol-generating interventional procedures, including but not limited to intubation, extubation, tracheostomy care, drainage of peritonsillar abscesses, and nasal packing 3 . For these procedures, guidelines demand surgeons don N95 masks or powered air-purifying respirators (PAPR) regardless of patient presentation. This is juxtaposed with guidelines for soft tissue surgery, which recommend standard operating room personal protective equipment (PPE), such as mask, face shield, gown, and gloves. Protocols differentiating these two procedure categories have been corroborated by academic otolaryngologic societies have not yet wholly adapted to procedural exposure risk. For example, recommendations for preoperative testing and PPE requirements have been variable 3,6, .

In light of recommendations from the Centers for Disease Control and Prevention to prioritize urgent and emergency visits, the American Academy of Otolaryngology-Head and Neck Surgery has temporarily recommended the provision of only "time-sensitive" or "emergent" care 7 .

Accordingly, at the hands of local governments, many elective procedures have ceased for weeks in an effort to limit exposure risk and preserve resources such as PPE and hospital beds for dire circumstances 8, 9, 10 . Following the interim cancellation of elective surgical procedures, the American College of Surgeons suggested that, in order to reopen elective surgeries, geographic areas should see sustained reductions in rates of new COVID-19 cases and have adequate hospital resources to take care of all patients sufficiently 11 . In this way, as case numbers have begun to plateau, the resumption of clinical activity for hospital systems nationally is on the horizon. Therefore, we sought to geographically characterize the predicted burden of aerosolgenerating otolaryngology procedures based on previously reported procedural volumes to predict areas of high-risk to otolaryngologists as recovery plans are implemented and elective procedures resume in the near future.

We utilized the Medicare Physician and Other Supplier Public Use File (POSPUF), including annual aggregated claims data from over one million physicians to identify all services billed by otolaryngologists between 2013 and 2017. Data were filtered by current procedural terminology (CPT) code and geography. Based on recently published specialty safety guidelines, we stratified CPT codes based on risk: non-aerosol-generating procedures versus aerosol-generating procedures 3 . POSPUF data within the study period were imported into the geospatial mapping software QGIS (version 3.12.1) and joined with a shapefile of hospital referral regions (HRR) from the Dartmouth Atlas of Healthcare 12 . Procedural volume data were then grouped into quintiles by HRR, which approximate the local market for tertiary healthcare services, appropriately reflecting specialized otolaryngologic care, whose patients travel outside county boundaries for treatment. In addition, COVID-19 case volume distribution as of April 24, 2020 was mapped, using up-to-date geospatial mapping by the New York Times 13 . The present study was approved for exemption status by our institution's Institutional Review Board (STUDY20200432).

Based on our risk stratification, approximately 1.3 million aerosol-generating procedures (AGPs) were performed per year nationally in the Medicare population between 2013 and 2017. The most common were diagnostic flexible laryngoscopy (43.5%), diagnostic nasal endoscopy (37.3%), and flexible laryngoscopy with stroboscopy (4.8%) ( Table 1) 

Our study demonstrates that otolaryngologists are at risk of transmission not only in COVID-19dense regions, but also in areas with uniquely high AGP case burden per otolaryngologist. These additional "hot zones" do not correlate with population density, but rather with low otolaryngologist per capita rates. The regions deemed potentially at the highest risk with both high COVID-19 density and elevated AGP-density reflect regions with major academic centers with high procedural volumes, coupled with high population density and subsequent high COVID-19 growth rates. While the provided data only represent a snapshot of time in this pandemic, this mapping analysis can serve as a dynamic tool that is adaptable to constantly changing procedural volumes and COVID-19 case rates for resource allocation nationwide.

As the focus shifts to resuming elective procedures in hospitals, ambulatory surgery centers, and outpatient clinics, we must appreciate that otolaryngologists remain at very high risk of exposure due to their unique susceptibility of aerosol-generating procedures. With over 85% of otolaryngologic AGPs accounted for by outpatient ambulatory endoscopy, appropriate risk management of elective activity in both inpatient and outpatient settings is paramount 3 . In this J o u r n a l P r e -p r o o f way, while health systems across the country have instituted changes to their approach to these procedures during the pandemic, it is critical for all institutions to re-evaluate the risk of certain procedures involving high viral load based on predicted procedural volumes to establish appropriate clinical protocols as we look to restore surgical practices to normalcy.

With elective activity halted over the last six weeks, health systems have experienced significant financial ramifications. For instance, among other surgical subspecialties, otolaryngology ambulatory visits saw up to a 75% drop during the pandemic 14 . Similar effects have been seen in the operating rooms, with significant reductions in operating room productivity due to widespread procedure cancellations. Accordingly, given the backdrop of lost revenues and increased costs associated with pandemic, there has been fiscal pressure to resume scheduled procedures as soon as circumstances are deemed "safe enough" to proceed 8 . It is expected that, as return-to-work practices are established, hospital throughput will accelerate, with operating rooms flooded with little to no vacancy in schedules for months 11 . Although our analysis uses retrospective data from prior years to estimate anticipated procedural volume, we expect that volumes may be even greater than predicted, given recent policies cancelling elective procedures for a prolonged amount of time. Unfortunately, it is difficult to quantify that relative increase in volume from baseline activity. However, qualitatively, case burden for all physicians, including otolaryngologists, will increase significantly, as hospitals strive to make up for lost revenue.

Accordingly, healthcare institutions must make appropriate risk-based decisions when approaching the resumption of clinical practice to protect the health and safety of their surgeons.

Our findings have important implications on the resumption of clinical activities, for which otolaryngology committees globally have published guidelines and proposed solutions. Those solutions and guidelines are further supported by our data, and decision-making on a regional level ought to account for past volumes of aerosol-generating procedures in designing individual "reopening" strategies. For example, rather than complete and simultaneous resumption of all procedures, a tiered approach to ramp up procedural volume based on risk-level and patient need could be employed. As many of their procedures are aerosol-generating, it is important to consider the persistent high-risk for otolaryngologists, as we resume these procedures. This could entail reinitiating non-aerosol generating procedures first, followed by aerosol-generating procedures, reintroduced based on acuity and urgency. This tiered approach will allow for the ability to treat patients who have had their care postponed, while still prioritizing our clinicians' safety from high-risk procedures. Alternatively, in a recent statement by The American College of Surgeons identifying 10 key issues for health institutions to address prior to ramping up elective clinical activity, they identified additional considerations and strategies for prioritizing cases for the near future 11, 15 . These include increased operating room workforce to support higher volume, increased operating room availability with extended hours or weekend OR time, phased opening of operating rooms, and COVID-19-related surgical outcomes data -all of which will have important implications on how we return back to our baseline clinical activity.

Another recommendation to be considered prior to resuming procedures is targeted preoperative COVID-19 testing for patients undergoing aerosol-generating procedures. In the setting of conservative testing, a risk-based utilization of resources should include prioritization of diagnostics for all patients in "hot zones." Similarly, personal protective equipment (PPE) has J o u r n a l P r e -p r o o f been at the forefront of appropriate resource allocation discussions. With surgeon exposure to high-risk patients in high-risk procedures, extra attention ought to be paid to "hot-zones." It is important that we not ignore the highly trained workforce that has been one of our most valuable "resources" in this pandemic. In order to prioritize our patients, we must first prioritize our healthcare providers.

The present study utilized a Medicare claims dataset from 2013-2017, which does not precisely quantify volumes and distributions of procedures in 2020. However, by examining volume trends over a five-year period, the data provide a predictive model for approximating case distributions preceding the COVID-19 pandemic. Additionally, by adhering to recent clinical guidelines for stratifying CPTs based on risk category, we hoped to mitigate the deficiency of CPT procedure codes in comprehensively reflecting case risk and clinical severity. Furthermore, our model cannot account for geographic variability in PPE availability, screening practices, and hospitalspecific procedural policies, all of which play significant roles in nosocomial transmission during this pandemic. Moreover, our study provides a snapshot of the most recent data of COVID-19 case rates for each state. Given the rapidly changing landscape of COVID-19 case volumes, this is subject to change. Subsequent analysis ought to retrospectively assess and validate whether the hot zones identified herein reflect true "hot zones." Table 1 

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