Real-time assessment of COVID-19 impact on global surgical case volumes

  1. Vikas N. O’Reilly-Shah
  2. Wil Van Cleve
  3. Dustin R. Long
  4. Vanessa Moll
  5. Faye M. Evans
  6. Jacob E. Sunshine
  7. Nicholas J. Kassebaum
  8. Ewen M Harrison
  9. Craig S. Jabaley

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Abstract

Importance

The COVID-19 pandemic has disrupted global surgical capacity. The impact of the pandemic in low and middle income countries has the potential to worsen already strained access to surgical care. Timely assessment of surgical volumes in these countries remains challenging.

Objective

To determine whether usage data from a globally used anesthesiology calculator mobile application can serve as a proxy for global surgical case volume and contribute to monitoring of the impact of the COVID-19 pandemic, particularly in World Bank low income countries where official data collection is not currently practical.

Design

Subset of data from an ongoing observational cohort study of users of the application collected from October 1, 2018 to April 18, 2020.

Setting

The mobile application is available from public sources; users download and use the application per their own clinical needs on personal mobile devices.

Participants

No user data was excluded from the study.

Exposure(s)

Events with impacts on surgical case volumes, including weekends, holidays, and the COVID-19 pandemic.

Main Outcome(s) and Measure(s)

It was previously noted that application usage was decreased on weekends and during winter holidays. We subsequently hypothesized that more detailed analysis would reveal impacts of country-specific or region-specific holidays on the volume of app use.

Results

4,300,975 data points from 92,878 unique users were analyzed. Physicians and other anesthesia providers comprised 85.8% of the study population. Application use was reduced on holidays and weekends and correlated with fluctuations in surgical volume. The COVID-19 pandemic was associated with substantial reductions in app use globally and regionally. There was strong cross correlation between COVID-19 case count and reductions in app use. By country, there was a median global reduction in app use to 58% of baseline (interquartile range, 46%-75%). Application use in low-income continues to decline but in high-income countries has stabilized.

Conclusions and Relevance

Application usage metadata provides a real-time indicator of surgical volume. This data may be used to identify impacted regions where disruptions to surgical care are disproportionate or prolonged. A dashboard for continuous visualization of these data has been deployed.

Key Points

Question

Can usage data from a globally used anesthesiology calculator mobile application contribute to monitoring of the impacts to global surgical case volume caused by the COVID-19 pandemic, particularly in resource-limited environments such as World Bank low income countries?

Findings

In this ongoing observational cohort study, application usage data from 92,878 unique users in 221 countries was found to serve well as a qualitative proxy for surgical case volume, with clear impacts to app use during weekend, holidays, and during the COVID-19 pandemic.

Meaning

This proxy of surgical volume will provide insight into the impact of and recovery from the COVID-19 pandemic where official data collection is not currently practical. A real time dashboard tracking this proxy of global surgical volume is live and under continued development.

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  1. ScreenIT

    SciScore for 10.1101/2020.05.03.20086819: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    Institutional Review Board StatementIRB: Ethics Approval and Manuscript Preparation: The study was reviewed and approved by the Emory University Institutional Review Board (study number 00082571), and there is a reliance agreement in place with the University of Washington Institutional Review Board.
    Consent: The approval includes a waiver of written informed consent.
    Randomizationnot detected.
    Blindingnot detected.
    Power Analysisnot detected.
    Sex as a biological variablenot detected.

    Table 2: Resources

    Software and Algorithms
    SentencesResources
    Statistical Methods: Raw data were downloaded and analyzed in R using RStudio
    RStudio
    suggested: (RStudio, RRID:SCR_000432)
    The choropleth in Online Supplement, Figure S4 was generated using the tmap package for R.24
    tmap
    suggested: (TMAP, RRID:SCR_000687)

    Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).

    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
    This same stochasticity highlights a limitation of the work, namely that data from individual regions or countries with a small user base reduces the confidence we can assign to the association between app use time series data and surgical case volume. Fortunately for global health purposes, our previous work demonstrates that, in LMIC, the app has greater frequency of use as compared to HIC.27 Another important limitation of the present work is the qualitative nature of the interpretation that can be made of shifts in app use. The app is used primarily for the care of pediatric cases (~75% of app uses are for patients age 12 and younger), and users also consult the app during emergencies.34 Thus, the pattern of app use is greater on weekends (when a greater proportion of cases are emergencies) than would be expected based on the actual proportion of surgical case volumes comparing weekdays to weekends. This pediatric clinical predominance may drive greater use of the app in LMIC where (a) subspecialty training in pediatric anesthesia is less prevalent compared to HIC and (b) as high as 50% of the population may be under the age of 16. Patterns in app use will additionally be biased towards impacts specifically on pediatric case volumes. Notably, these needs in LMIC are not trivial: 1.7 billion children lack adequate access to surgical care and an estimated 85% of children in LMIC will need surgical care by age 16.35 Conversely, app utilization patterns may be relatively less...

    Results from TrialIdentifier: No clinical trial numbers were referenced.

    Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

    Results from JetFighter: We did not find any issues relating to colormaps.

    Results from rtransparent:
    • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
    • No funding statement was detected.
    • No protocol registration statement was detected.

    About SciScore

    SciScore is an automated tool that is designed to assist expert reviewers by finding and presenting formulaic information scattered throughout a paper in a standard, easy to digest format. SciScore checks for the presence and correctness of RRIDs (research resource identifiers), and for rigor criteria such as sex and investigator blinding. For details on the theoretical underpinning of rigor criteria and the tools shown here, including references cited, please follow this link.

  2. Version published to 10.1101/2020.05.03.20086819 on medRxiv