Real-Time Assessment of COVID-19 Impact on Global Surgical Case Volumes

Background:: The COVID-19 pandemic has disrupted global surgical capacity. The impact of the pandemic in low and middle income countries (LMIC) has the potential to worsen already strained access to surgical care. However, timely assessment of surgical volumes in LMIC remains challenging. Methods: Data from a globally available anesthesia mobile application were examined to assess utilization as a real-time qualitative proxy for surgical case volume. Users consent to cloud-based data collection for an ongoing app utilization study. These data were analyzed to identify temporal and geographic trends indicative of COVID-19-associated changes in surgical volume. Findings: Between 1 October 2018 and 18 April 2020, data from 92,878 unique users in 221 countries were collected. App use was reduced on major holidays and weekends, strongly correlated with known fluctuations in surgical volume. The COVID-19 pandemic was associated with substantial reductions in app use globally and regionally. In individual countries and regions, 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 54% of baseline (interquartile range, 42%-64%). Overall app use in LMIC continues to decline but in high-income countries has stabilized.  Interpretation: The metadata from this app offers an inexpensive 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 will be deployed to ensure access to this proxy for global surgical volumes. Funding Statement: No funding to declare in support of the present work. Declaration of Interests: All authors declare: no financial relationships with any organizations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work. The Anesthesiologist app was initially released in 2011 by Vikas O'Reilly-Shah with advertising in the free version and a paid companion app to remove the ads. The app intellectual property was transferred to Emory University in 2015 and advertisements were subsequently removed, and the companion app to remove ads made freely available for legacy users not updating to the ad-free version. Following review by the Emory University Research Conflict of Interest Committee, Vikas O'Reilly-Shah was released from any conflict of interest management plan or oversight. Ethics Approval Statement: 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. The approval includes a waiver of written informed consent. Participants anonymously gave electronic consent before participating in any data collection.