key: cord-1026393-fus0f7p5
authors: Wells, Michael; Jella, Tarun K.; Zheng, David X.; Chang, Irene A.; Gerber, Alexandria L.; Jella, Taral; Gatherwright, James R.
title: Impact of COVID-19 geographic distribution on advanced age plastic surgeons: A cross-sectional analysis
date: 2020-12-26
journal: J Plast Reconstr Aesthet Surg
DOI: 10.1016/j.bjps.2020.12.049
sha: ec2c118a60fa01ac1f371a489553199032db60e4
doc_id: 1026393
cord_uid: fus0f7p5

nan

Dear Sir, The outbreak of severe acute respiratory syndrome coronavirus 2, responsible for coronavirus disease 2019 (COVID-19), was first identified in Wuhan, China, and has since spread worldwide. Among countries struggling to contain the spread of COVID-19, the United States (U.S.) has been particularly heavily affected. Since recording a new singleday peak of 83,010 cases on October 23, 2020, 1 the U.S. has continued to experience record highs in daily confirmed COVID-19 cases and hospitalizations. Increased susceptibility to severe COVID-19 has been noted in certain populations (e.g., individuals over age 60). 2 Advanced age patients are at increased risk of COVID-19 morbidity and mortality, and represent a potential for nosocomial transmission to healthcare providers. 3 Figure 1 Geospatial distribution of cumulative COVID-19 cases and plastic surgeons age ≥ 60 in the United States. States were grouped into color-coordinated quintiles based on relative proportion of older plastic surgeons, and cumulative COVID-19 case volumes were adjusted via logarithmic scale to create proportionally-sized data points.

Plastic surgeons are at especially high risk of COVID-19 nosocomial infection. Many head and neck procedures involve exposure to oral and nasal passages. Indications for surgery include traumatic/urgent (e.g., facial fractures) and cosmetic (e.g., rhinoplasty) reasons, and both physical examination and subsequent procedures expose plastic surgeons to the patient's airway, with potential transmission of COVID-19 via respiratory and aerosol droplets. 3 Given the surge in COVID-19 cases across the U.S., identifying geographic regions with susceptible physicians may allow for risk stratification, and provide guidelines for predicting and reducing transmission and mortality. 3 In this study, we compared the geographic distribution of US plastic surgeons ≥ 60 years of age to cumulative COVID-19 cases to better inform clinical guidelines.

Demographic data regarding practicing U.S. plastic surgeons age ≥ 60 were obtained from the most recent American Association of Medical Colleges (AAMC) State Physician Workforce Reports (2018). 4 COVID-19 latitude and longitude data on cumulative cases (as of November 15, 2020) were gathered from the Environmental Systems Research Institute. 5 The two data collections were superimposed in QGIS geospatial mapping software (version 3.12.1), onto state boundary files provided by the U.S. Census Bureau. States were grouped into color-coordinated quintiles based on relative proportion of plastic surgeons age ≥ 60, and case volumes were adjusted via logarithmic scale to create proportionally-sized data points, resulting in a heatmap representing the COVID-19 risk faced by older plastic surgeons across the country ( Figure 1 ). States with fewer than 10 plastic surgeons age ≥ 60 were excluded as, due to privacy reasons, greater than 10 physicians for a given category was the threshold for data publication by the AAMC. The COVID-provider ratio (CPR) was calculated by dividing cumulative COVID-19 cases by the number of plastic surgeons age ≥ 60, providing a more granular determina-tion of risk for each state. This study was considered IRB exempt. There were 7205 clinically-active U.S. plastic surgeons in 2018, of whom 2781 (38.6%) were ≥ 60 years of age. The five states with the highest percentage of plastic surgeons age ≥ 60 were South Dakota (71.4%), Hawaii (66.7%), Montana (65.0%), Alabama (55.4%), and New Mexico (54.2%), while the five states with the highest CPRs were Iowa (12,089), Wisconsin (10,439), Arkansas (10,167), Oklahoma (9388), and Nevada (7934). The proportion of plastic surgeons age ≥ 60 ranged from 30.3% in Arizona to 71.4% in South Dakota ( Table 1 ) .

In this study, we provide a cross-sectional analysis of the risk faced by older U.S. plastic surgeons during the COVID-19 pandemic. We identified several states with a particularly high CPR (Iowa, Wisconsin, Arkansas, Oklahoma, and Nevada), indicating both a high proportion of plastic surgeons age ≥ 60 and high COVID-19 disease burden. While South Dakota (6418) is among only the top 10 in CPR values, we remain concerned by this state having both the highest percentage of plastic surgeons age ≥ 60 (71.4%) and the highest COVID-19 test positivity rate (22.4%, as of November 15, 2020) in the nation. 1 These findings, along with the nearly 2.5-fold difference in proportion of older plastic surgeons across states (30.3% to 71.4%), provide justification for prioritization of PPE supply toward plastic surgeons in "higher risk" states.

We recommend that local entities (e.g., state plastic surgery societies) encourage hospital/university systems and private practices to take appropriate measures to guarantee the safety of the older plastic surgery workforce. These measures might include transitioning plastic surgeons age ≥ 60 to telemedicine services and modifying operating room protocol to minimize aerosolization and droplet transmission. 3 Moreover, we suggest that plastic surgeons be overly cautious in PPE usage (e.g., wearing a N95 respirator and eye protection, at minimum) when treating urgent cases asymptomatic for COVID-19. Limitations to this study include not exploring individual factors associated with COVID-19 severity (e.g., comorbidities, smoking history) and region-specific data (e.g., differing institutional practices) being unavailable for analysis. Regardless, we hope that our findings will assist in workforce management and continued assessment of safety guidelines. Plastic surgeons in higher-risk states, especially those over age 60 and/or with additional comorbidities, should strictly adhere to Centers for Disease Control and hospital guidelines, and consider delaying elective surgeries whenever possible.

JID: PRAS [m6+

National analysis of COVID-19 and older emergency physicians

Da Lio A . The COVID-19 pandemic and plastic surgery: literature review, ethical analysis, and proposed guidelines

AAMC. State Physician Workforce Data Report

An interactive web-based dashboard to track COVID-19 in real time

The authors report no funding sources relevant to this work.

The authors report no conflicts of interest relevant to this work.

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