Spine Surgery and COVID-19: The Influence of Practice Type on Preparedness,Response,and Economic Impact

Study Design

The AO Spine COVID-19 and Spine Surgeon Global Impact Survey was developed by an international working group of spine surgeons, epidemiologists and surgical trainees who are experts in spinal disorders. Question selection was based on a Delphi methodology^24,25 to achieve consensus through numerous rounds of review. Domains of the survey included surgeon demographics, location of practice, type of practice, COVID-19 perceptions, institutional preparedness and response, personal and practice impact, and future perceptions. Specific demographics obtained include age, gender, country of practice, region of practice, population of city of practice, specialty, fellowship experience, year in practice, and practice type. For the purpose of this study, practice type was either private, academic, privademic, or public. Privademic refers to a hybrid practice model whereby physicians work within a private practice at an academic institution enabling them to contribute to high-quality literature, discoveries, and innovation. ²⁶

Survey Distribution

The 73-item, English language survey was distributed via email to the AO Spine membership who previously agreed to receive surveys for research purposes (n = 3805). AO Spine provided the largest available international network of spine surgeons (www.aospine.org). The survey recipients were asked to complete the questionnaire during a predefined 9-day period (March 27, 2020 to April 4, 2020). Respondents were informed that their participation was voluntary, that they could end their participation at any time, and that all data would be kept confidential. Participants were informed that findings from the study would be disseminated in peer-reviewed journals, websites, and social media.

Statistical Analyses

All statistical analyses were performed with SAS (SAS Institute). Graphical representation of survey responses was performed using Excel (Microsoft Inc). Percentages and means were made for count data and rank-order questions, respectively. All means were presented with standard deviations (mean ± standard deviation). Respondents were not required to answer all questions, thus, the number of responses for each question varies. Statistical analyses were performed to assess significant differences in count data using a combination of Fisher’s exact and chi-square tests, where applicable. For variables with significance on 4-way chi-square tests, post hoc 2-way chi-square was performed for direct comparison between groups. Differences in continuous variables between groups were assessed using analysis of variance (ANOVA).

A nominal multivariate regression analysis was performed to control for baseline demographic differences between the groups (gender, home city population, region, fellowship training, and practice breakdown). Outcome variables with P < .200 on univariate analysis were assessed in the multivariate model. Variables with dichotomous categorical outcomes are presented as odds ratios (ORs) and 95% confidence intervals (CIs) were also noted. An OR > 1 indicated increased occurrence of outcome. An OR < 1 indicated decreased occurrence of outcome. Variables with numerous categorical outcomes were presented as likelihood ratios (LRs). The threshold for statistical significance for all tests was P < .05.

Preparedness by Practice Type

The World Health Organization (WHO) and the global health community made pandemic preparedness one of their main missions,^27,28 and research on pandemic preparedness is abundant.^9,29-31 However, it remains unknown how surgeons in various practice settings interpret these guidelines and prepare for global health crises.

Limitations in access and availability of testing have been cited as a major shortcoming in the media.^32,33 Our results indicate that access to testing is no longer a major limitation for surgeons, with over 82% of surgeons reporting access to a COVID-19 test. Furthermore, there were no differences in testing availability reported by surgeons at academic, privademic, private, or public institutions. While the overall availability of testing for surgeons is encouraging, prior studies reported that health care workers have accounted for anywhere between 10% and 30% of total positive COVID-19 tests in various regions.^34,35 Surgeons in all practice settings need to improve testing availability and guarantee testing is accessible for their staff and patients before a return to normal operations.

Unsurprisingly, practice setting was independently associated with the availability of personal protective equipment. Across all practice settings, access to personal protective equipment was concerningly low, at 49%. The media in the United States and across the world has highlighted the critical lack of PPE that frontline health care workers faced in the early days of the COVID-19 outbreak.^7,8,36-38 Our results indicate that public and privademic hospitals face worse PPE shortages than academic medical centers. The issues with PPE availability for public hospitals are likely driven by public safety-net hospitals in the United States, where resource and funding shortages were well established before COVID-19.^39,40 Further research is needed to elucidate the reason for PPE shortages among privademic practices.

Along with PPE shortages, physicians faced the possibility of difficult decisions surrounding allocation of ventilators,^41,42 and operating room anesthesia machines were reallocated to intensive care units, closing operating rooms for surgeon use. ⁴³ A disturbingly low 41% of respondents reported adequate ventilator supplies during the COVID-19 pandemic. While there was a significant difference in ventilator availability on univariate analysis, this was likely confounded by regional differences, as only privademic practice setting was independently associated with ventilator availability on multivariate analysis. Once again, further research into the shortcomings of privademic practice preparedness is needed.

Despite numerous health departments across of the world recommending formal institutional guidelines for pandemic preparedness,^44-46 an unexpectedly low 60% of respondents reported guidelines in place at their institutions prior to COVID-19. We postulate that countries with prior infectious disease epidemics likely had guidelines in place or were quick to adopt formal guidelines while countries with little infectious disease experience were slow to respond. Also, surgeons in academic institutions reported formal guidelines at a greater rate than private practice surgeons; however, practice setting alone was not associated with the presence of guidelines. Future guidelines for crisis preparedness need to be applicable and adaptable to all practice settings to maximize adoption.

COVID-19 Response by Practice Type

As COVID-19 continued to spread despite numerous interventions, there were a variety of responses to the growing threat. Many of the variations in response have been attributed to geopolitical differences between nations around the world.^47-51 However, our results indicate that independent of global region, spine surgeons in different practice types experienced distinctive responses to COVID-19.

Surgeons in practice settings more reliant on clinical productivity for income (eg, private practice, privademic practice) were more worried about the impact of COVID-19. This likely stemmed from private and privademic surgeons increased stress around economic issues. The high level of stress among surgeons at public hospitals likely stems from their concerns about resource availability and ability to adequately care for COVID-19 patients.

Based on our survey results, academic institutions appeared to respond more robustly to COVID-19 compared with private, privademic, and public institutions. Academic respondents reported more domestic travels bans, cancellation of educational activities, and more work-from-home orders compared with surgeons at private, privademic, and public institutions. Overall, a disappointing 61.4% of respondents rated their hospital responses as “acceptable,” while 27.7% rate their hospital’s action as “not enough.” Surgeons in academic institutions were satisfied at a higher rate compared to other practice settings.

These large academic institutions tend to have the infrastructure and human resources in place to respond to new guidelines. Smaller private practices and privademic institutions operate with less ancillary staff and possibly lack the resources to develop comprehensive response plans that can be quickly disseminated to their staff. This presents an opportunity for leadership in the spine community to develop crisis guidelines that are easily adaptable to all practice settings. A comprehensive preparedness and response plan could be developed that applies to all practice settings with more individualized plans then developed for each practice setting to specifically address unique concerns by practice type. Given the enormous public health impact of COVID-19, a multidisciplinary effort is needed to develop these guidelines to minimize the impact of future outbreaks.

Economic Impact by Practice Type

COVID-19 occurred during a period of major changes in healthcare economics. Alongside the swift shift in practice types, is the transition away from fee-for-service reimbursement toward alternative payment models.^21,22 These models were designed to shift financial risk from insurers to providers in an attempt to improve quality and outcomes.^52,53 However, these models still require clinical productivity to generate revenue.

Prior research across numerous specialties has compared the compensation of surgeons in academic practices versus private practices.^19,54,55 Private practice surgeons tend to be compensated based on clinical productivity, and tend to have higher overall income.^19,54 Academic surgeons tend to have inputs into their income, including base salary, clinical productivity, and academic productivity. ⁵⁶ Surgeons at public or government-run hospitals tend to be salaried employees. ⁵⁷ Therefore, providers in various practice settings have differing incentives on clinical productivity.

Despite the guidance issued by professional societies and spine leadership, our survey indicates that a small percent of surgeons continued to perform elective spine surgeries throughout the pandemic.^10,16,58 However, contrary to what we predicted, private and privademic surgeons performed elective spine surgeries at a lower rate compared with surgeons in academic or public hospitals. Thus, despite increased monetary incentive to continue elective surgeries, private and privademic surgeons heeded the governmental recommendations and stopped operating during the pandemic. We postulate that perhaps the greater resource availability and multidisciplinary approach of academic and public hospitals allowed them to continue some elective cases at a greater rate. Because of the fact that private practice models exist only in some countries, it is also conceivable that the result is confounded by unequal distribution of practice types around the world.

With the drastic reduction in elective case volume occurring during COVID-19, surgeons who rely on clinical productivity as a major source of revenue are reporting a decrease in revenue and income. Our survey further outlines that surgeons in private and privademic practices are reporting that their hospitals are experiencing greater financial hardship compared to academic and public hospitals. The American Medical Association issued guidance on how private medical practices could adapt to financial and logistical stresses of this global pandemic. ²³ However, surgeons may be even more affected. The American Academy of Orthopaedic Surgeons recently released guidance to support private practice surgeons during COVID-19 and is lobbying congress for specific government programs to assist private practice surgeons. ⁵⁹ While our survey results echo the sentiment that private and privademic surgeons are at risk for the greatest financial impact, the Department of Health and Human Services is obligated to assist all spine providers in surviving this pandemic so we can continue to ensure care is accessible to all patients.

Long-Term Impacts

While the COVID-19 pandemic is ongoing, we must start looking toward the future. Spine practices must adapt to the post-COVID-19 era in order to keep patients and providers safe while ensuring the survival of all practice types. Our respondents identified heightened awareness of hygiene, increased PPE use, and a rise in digital communication options as changes to patient care over the next year. However, many questions remain. Over the past several years, private equity firms have started to see private surgical practices as potential investment opportunities. ⁶⁰ These firms specialize in improving the financial performance of struggling or unprofitable companies, and selling them for a profit. This raises concern that practices facing financial difficulty in the post-COVID-19 era will be bought up by private equity firms, accelerating the transition away from surgeon-controlled practices.

We believe spine surgeons and spine societies must lead our healthcare system into the post-COVID-19 era. We must ensure that governments do not use COVID-19 as an opportunity to transition away from private or privademic practice. COVID-19 highlighted the need for future formal guidelines to consider the stresses that pandemics cause for different practice types.

Limitations

As with many survey-based studies, there are clear limitations. The survey distribution was limited to the current AO Spine surgeon members network. The survey was sent out to 3,805 spine surgeons worldwide; however, only 902 surgeons responded (23.7%). This likely introduces a response bias as subjects with strong opinions are more inclined to respond. Previous studies have described that low response rate is a risk factor for low validity, but does not dictate low validity. ⁶¹ Response rates are important to assess, but should not be considered a proxy for study validity.

Our study relied on respondents’ self-classification of practice type. Given that our study included international respondents, there may be different definitions of private, privademic, academic, and public around the world. Furthermore, we attempted to control for differences in the distribution of practice types throughout the world by including geographic region in our multivariate model, however, we lacked sufficient power to control for individual countries. Given the limit of survey length due to fatigue, we were not able to explore all the possible domains related to COVID-19.

Finally, our targeted demographic was spine surgeons that are members associated with AO Spine. This is one group of subspecialty surgeons and the results may not be generalizable to other medical specialties. Despite these limitations, this survey remains the largest, international effort to assess multiple domains of the impact of COVID-19 on spine surgeons.