Using Health Services Research to Address the Unique Challenges of the COVID-19 Pandemic | Research, Methods, Statistics | JAMA Surgery | JAMA Network
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Surgical Outcomes Club
May 21, 2021

Using Health Services Research to Address the Unique Challenges of the COVID-19 Pandemic

Author Affiliations
  • 1Emory Health Services Research Center, Departments of Medicine and Surgery, Emory University School of Medicine, Atlanta, Georgia
  • 2Department of Surgery, Duke University School of Medicine, Durham, North Carolina
  • 3Department of Surgery, Center for Surgery and Health Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
JAMA Surg. 2021;156(10):903-904. doi:10.1001/jamasurg.2021.2597

Introduction

The COVID-19 pandemic has had profound effects on the health care workforce; more than 130 million cases of COVID-19 and nearly 3 million deaths have been recorded worldwide as of April 1, 2021.1 To reduce health care resource utilization and increase the expected need for critical care capacity as COVID-19 cases surged, surgical care was dramatically interrupted, with more than 28 million elective surgeries canceled worldwide.2 In response to the major disruptions of surgical care, the Surgical Outcomes Club assembled a 3-part panel to highlight key ways in which the surgical health services research community responded. This Viewpoint serves to disseminate mechanisms for how surgical outcomes researchers can contribute to (1) safely delivering evidence-based surgical care during the pandemic, (2) accelerating the path to health equity in the wake of disparities provoked by the pandemic, and (3) using the unique conditions of the pandemic as a natural experiment to define the future of surgical care delivery.

COVIDSurg Collaborative: Data-Driven Risk Stratification During a Pandemic

The need for timely access to population-specific data is critical to the attainment of optimal surgical outcomes and conducting research that can be used to quickly inform surgical care. Leveraging an existing network of collaborating surgeons and anesthetists across more than 80 countries, the COVIDSurg collaborative was quickly launched to provide evidence to guide the delivery of safe surgery in patients with COVID-19. This sophisticated collaborative has been able to stand up multicenter studies, including cohort and pragmatic randomized clinical trials, to address surgical care delivery using patient-level and system-level data, and to facilitate timely dissemination of study findings.3

Aneel Bhangu, MBChB, PhD, and Joana Simões, MBChB, from the University of Birmingham (UK) presented examples of how the COVIDSurg collaborative has informed guidance on optimal use of preoperative severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing to prevent poor outcomes in surgical patients and inform guidelines about the timing of surgery. For example, an early cohort study conducted among COVIDSurg collaborative partners in 235 hospitals across 24 countries studied all patients undergoing surgery who had SARS-CoV-2 infection confirmed within 7 days before or 30 days after surgery and demonstrated high rates of 30-day mortality (23.8%) and the presence of pulmonary complications in more than half of the surgical patients.2 These results helped to inform policies to delay nonurgent surgeries for these patients. Surgical outcomes researchers could and should do more to leverage large, population-based, collaborative data such as these to continue to answer important and timely questions remaining about the effects of COVID on access to and outcomes of surgical care and use this opportunity to examine variation in these important outcomes across health systems to inform clinical decision-making.

Surgical Reentry After COVID-19: The Potential for Provoking Existing Disparities

The COVID-19 pandemic has altered trajectories of care and shifted research priorities while simultaneously exacerbating existing disparities in surgical care. While the effects of the pandemic on access and outcomes of surgical care for racial/ethnic minority groups are not entirely known, it is well established that minorities have experienced a disproportionate burden of COVID-19 infection, poorer outcomes, and had lower COVID-19 vaccination rates. In the past year, we have seen increased attention on health equity and health disparities research with the inequities exposed by COVID-19, although much work for surgical outcomes researchers remains.

Panelist Oluwadamilola “Lola” Fayanju, MD, MA, MPHS, of Duke University described the effects of the COVID-19 pandemic on racial/ethnic minority communities, using an example of women with breast cancer. It has been well established that Black women with breast cancer experience greater delays in accessing treatment compared with White patients,4 and the COVID-19 pandemic is expected to increase these disparities. For example, it is likely that the pandemic has increased loss to follow-up among women undergoing screening mammography and may result in higher rates of late-stage breast cancer. Challenges remain in the reengagement of these women in health care, given competing priorities (eg, loss of insurance, unemployment, and uncertain childcare), all of which represent opportunities for researchers of surgical outcomes to study and intervene on these inequities.

While the surgical literature has documented examples of health inequities exacerbated by COVID-19, we see fewer examples of interventions to address these inequities in surgical care. This represents an important opportunity for surgical outcomes researchers to do more to not only describe these inequities in surgical care and outcomes but also combat these inequities in surgical practice. Rather than focusing surgical research and professional guidelines on simply estimating the association of COVID-19 with the logistical challenges of treating surgical disease, a multifaceted approach to providing care and conducting research that will involve partnerships between surgeons, primary care professionals, public health experts, and social scientists, as well as use of new sources of patient data (eg, the National COVID Cohort Collaborative) is needed to address the important inequities heightened by COVID-19.5

The Role of Telehealth in Improving the Value of Surgical Care

In March 2020, because of the COVID-19 pandemic and stay-at-home orders throughout many regions, in-person medical visits declined by roughly two-thirds of prepandemic levels.6 Rapid regulatory changes implemented in the US pushed telehealth forward in a paradigm shift that allowed some patients to connect to their clinicians more safely from home than a clinic or hospital for nonurgent medical issues. While national data on trends in telehealth across surgical specialties are limited, evidence from Michigan7 suggests that the use of telehealth use for preoperative and postoperative follow-up visits is substantially higher across all surgical specialties compared with prepandemic levels and substantial variation exists in the use of this care approach across surgical specialties. The major shift to telehealth in the health care system represents another important opportunity for surgical outcomes researchers to study.

Panelist Chad Ellimoottil, MD, MS, of the University of Michigan offered context on several critical questions that must still be answered in the field as the use of telemedicine in surgical care extends through and ultimately beyond the pandemic. For example, it is not yet known the extent to which telemedicine will reduce or exacerbate disparities across race/ethnicity, socioeconomic status, age, urban/rural residence, English language proficiency level, and surgical specialties, particularly for populations that lack access to high-speed internet, a computer, or a smartphone and may have limited technological comfort with telehealth. There remains uncertainty as to whether the use of telehealth will lead to changes in the costs of care as experienced by patients, clinicians, and payers. For example, in a recent study of 2 outpatient surgical clinics in an academic medical center, physician-led video visits used the same amount of time as in-person visits but only resulted in cost savings when the call was led by a physician assistant.8 Furthermore, the cost and feasibility of successful telehealth implementation will likely vary significantly across surgical populations, but this remains understudied. Finally, there are few population-level studies on how the increasing use of telehealth may affect health outcomes and health care utilization across diverse surgical populations over time. These unanswered questions offer important opportunities for surgical outcomes researchers to answer to provide guidance to the surgical communities on how best to apply telemedicine in practice.

Conclusions

During this unprecedented time, surgical outcomes research has continued, as it must. For trainees and other researchers starting their careers and looking to help improve surgical care delivery, reduce inequity, and ensure good patient outcomes among diverse patients, there are numerous opportunities to answer the many questions that remain about how COVID-19 has influenced surgical care. In addition to the important topics of using collaborative outcomes data and studying topics of surgical health inequities and telehealth, researchers can also use health services methods to answer remaining questions critical to the field. For example, by leveraging the natural experiment of the pause in elective surgeries, we can examine the factors associated with effectiveness of surgical vs nonsurgical treatments on a population health level. In addition, it is also critical that we strive to not only study how the pandemic has affected care and outcomes but also move the field forward by implementing evidence-based interventions to improve health.

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Article Information

Corresponding Author: Rachel E. Patzer, PhD, MPH, Health Services Research Center, Departments of Medicine and Surgery, Emory University School of Medicine, 101 Woodruff Cir, Atlanta, GA 30322 (rpatzer@emory.edu).

Published Online: May 21, 2021. doi:10.1001/jamasurg.2021.2597

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the panel members Aneel Bhangu, MBChB, PhD, and Joana Simões, MBChB, University of Birmingham (UK), Oluwadamilola Fayanju, MD, MA, MPHS, Duke University School of Medicine, and Chad Ellimoottil, MD, MS, University of Michigan, for participating and allowing us to present their views in this article. They were not compensated for their contributions.

References
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Johns Hopkins University. Coronavirus resource center. Published February 1, 2021. Accessed May 3, 2021. https://coronavirus.jhu.edu/
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COVIDSurg Collaborative.  Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study.   Lancet. 2020;396(10243):27-38. doi:10.1016/S0140-6736(20)31182-XPubMedGoogle ScholarCrossref
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NIHR Global Health Research Unit on Global Surgery. About CovidSurg. Published 2021. Accessed March 30, 2021. https://globalsurg.org/covidsurg
4.
Prakash  I, Thomas  SM, Greenup  RA,  et al.  Time to surgery among women treated with neoadjuvant systemic therapy and upfront surgery for breast cancer.   Breast Cancer Res Treat. 2021;186(2):535-550. doi:10.1007/s10549-020-06012-7PubMedGoogle ScholarCrossref
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National Institutes for Health. National COVID Cohort Collaborative (N3C). Published 2021. Accessed May 3, 2021. https://ncats.nih.gov/n3c
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Patel  SY, Mehrotra  A, Huskamp  HA, Uscher-Pines  L, Ganguli  I, Barnett  ML.  Trends in outpatient care delivery and telemedicine during the COVID-19 pandemic in the US.   JAMA Intern Med. 2021;181(3):388-391. doi:10.1001/jamainternmed.2020.5928PubMedGoogle ScholarCrossref
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Chao  GF, Li  KY, Zhu  Z,  et al.  Use of telehealth by surgical specialties during the COVID-19 pandemic.   JAMA Surg. Published March 26, 2021;e210979. doi:10.1001/jamasurg.2021.0979PubMedGoogle Scholar
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Portney  DS, Ved  R, Nikolian  V,  et al.  Understanding the cost savings of video visits in outpatient surgical clinics.   Mhealth. 2020;6:32. doi:10.21037/mhealth-20-33PubMedGoogle ScholarCrossref
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