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Trends in US Surgical Procedures and Health Care System Response to Policies Curtailing Elective Surgical Operations During the COVID-19 Pandemic

Educational Objective
To identify the key insights or developments described in this article
1 Credit CME
Key Points

Question  Were 2 separate COVID-19 crises, one policy driven during the initial shutdown and the other occurring during the highest burden of infections, associated with changes in surgical procedure volume in the US surgical health system?

Findings  In this cohort study of more than 13 million US surgical procedures from January 1, 2019, through January 30, 2021, there was a 48.0% decrease in total surgical procedure volume immediately after the March 2020 recommendation to cancel elective surgical procedures. Surgical volume returned to 2019 rates in all surgical specialties except otolaryngology, a rate maintained during the COVID-19 peak surge in fall and winter.

Meaning  These findings suggest that health systems learned to adapt and were able to self-regulate, maintaining surgical procedure volume during the largest peak in volume of patients with COVID-19.


Importance  The COVID-19 pandemic has affected every aspect of medical care, including surgical treatment. It is critical to understand the association of government policies and infection burden with surgical access across the United States.

Objective  To describe the change in surgical procedure volume in the US after the government-suggested shutdown and subsequent peak surge in volume of patients with COVID-19.

Design, Setting, and Participants  This retrospective cohort study was conducted using administrative claims from a nationwide health care technology clearinghouse. Claims from pediatric and adult patients undergoing surgical procedures in 49 US states within the Change Healthcare network of health care institutions were used. Surgical procedure volume during the 2020 initial COVID-19–related shutdown and subsequent fall and winter infection surge were compared with volume in 2019. Data were analyzed from November 2020 through July 2021.

Exposures  2020 policies to curtail elective surgical procedures and the incidence rate of patients with COVID-19.

Main Outcomes and Measures  Incidence rate ratios (IRRs) were estimated from a Poisson regression comparing total procedure counts during the initial shutdown (March 15 to May 2, 2020) and subsequent COVID-19 surge (October 22, 2020-January 31, 2021) with corresponding 2019 dates. Surgical procedures were analyzed by 11 major procedure categories, 25 subcategories, and 12 exemplar operative procedures along a spectrum of elective to emergency indications.

Results  A total of 13 108 567 surgical procedures were identified from January 1, 2019, through January 30, 2021, based on 3498 Current Procedural Terminology (CPT) codes. This included 6 651 921 procedures in 2019 (3 516 569 procedures among women [52.9%]; 613 192 procedures among children [9.2%]; and 1 987 397 procedures among patients aged ≥65 years [29.9%]) and 5 973 573 procedures in 2020 (3 156 240 procedures among women [52.8%]; 482 637 procedures among children [8.1%]; and 1 806 074 procedures among patients aged ≥65 years [30.2%]). The total number of procedures during the initial shutdown period and its corresponding period in 2019 (ie, epidemiological weeks 12-18) decreased from 905 444 procedures in 2019 to 458 469 procedures in 2020, for an IRR of 0.52 (95% CI, 0.44 to 0.60; P < .001) with a decrease of 48.0%. There was a decrease in surgical procedure volume across all major categories compared with corresponding weeks in 2019. During the initial shutdown, otolaryngology (ENT) procedures (IRR, 0.30; 95% CI, 0.13 to 0.46; P < .001) and cataract procedures (IRR, 0.11; 95% CI, −0.11 to 0.32; P = .03) decreased the most among major categories. Organ transplants and cesarean deliveries did not differ from the 2019 baseline. After the initial shutdown, during the ensuing COVID-19 surge, surgical procedure volumes rebounded to 2019 levels (IRR, 0.97; 95% CI, 0.95 to 1.00; P = .10) except for ENT procedures (IRR, 0.70; 95% CI, 0.65 to 0.75; P < .001). There was a correlation between state volumes of patients with COVID-19 and surgical procedure volume during the initial shutdown (r = −0.00025; 95% CI, −0.0042 to −0.0009; P = .003), but there was no correlation during the COVID-19 surge (r = −0.00034; 95% CI, −0.0075 to 0.00007; P = .11).

Conclusions and Relevance  This study found that the initial shutdown period in March through April 2020, was associated with a decrease in surgical procedure volume to nearly half of baseline rates. After the reopening, the rate of surgical procedures rebounded to 2019 levels, and this trend was maintained throughout the peak burden of patients with COVID-19 in fall and winter; these findings suggest that after initial adaptation, health systems appeared to be able to self-regulate and function at prepandemic capacity.

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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

Accepted for Publication: October 12, 2021.

Published: December 8, 2021. doi:10.1001/jamanetworkopen.2021.38038

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Mattingly AS et al. JAMA Network Open.

Corresponding Author: Sherry M. Wren, MD, Department of Surgery, Stanford University School of Medicine, G112 3801 Miranda Ave, Palo Alto, CA 94304 (

Author Contributions: Dr Rose had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Mattingly, Rose, Trickey, Cullen, Morris, Wren.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Mattingly, Eddington, Trickey, Wren.

Critical revision of the manuscript for important intellectual content: Rose, Eddington, Trickey, Cullen, Morris, Wren.

Statistical analysis: Rose, Eddington, Trickey, Cullen.

Obtained funding: Wren.

Administrative, technical, or material support: Mattingly, Rose, Cullen, Morris.

Supervision: Rose, Trickey, Cullen, Wren.

Conflict of Interest Disclosures: None reported.

Funding/Support: This study was funded by a seed grant from the Stanford University School of Medicine Department of Surgery.

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The opinions expressed herein are those of the authors and do not represent views of Change Healthcare.

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