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Amit Jain and Shruti Aggarwal: COVID-19 created a surgery backlog that’s only going to get worse

Amit Jain and Shruti Aggarwal Baltimore Sun

When can I get my surgery? Is it safe to get surgery? Should I hold off? Am I going to get worse? These are questions that have been on many patients’ minds since the COVID-19 crisis began.

Starting mid-March, elective surgeries were halted in many parts of the country, though “elective” is a misnomer. While it implies optional or unnecessary, that is rarely the case. The problem is that disease progression does not take a break and continues to adversely affect people’s quality of life — think increasing pain from spinal stenosis and decreased vision from worsening cataracts. A major consequence in the aftermath of the pandemic is that the waiting times for surgeries are bound to get worse.

COVID-19 has resulted in a large surgical backlog. First, there are those patients who were supposed to get surgery during the surgical suspension period. Second, there are patients who are not getting surgery due to limited capability while health care systems are still ramping up. As long as we are not operating at 100 percent capacity, we will continue to add to the backlog and the waiting lists.

A recent study we conducted found the number of backlogged total joint replacement and spine surgery cases may exceed 1 million in the United States by mid-2022. While suspensions are being lifted across the country, there are a number of factors that prevent reverting back to pre-COVID surgical volumes.

Many hospitals are still struggling with COVID-19 cases. There is just not enough room to put on a full load of elective surgeries requiring hospital beds and intensive care units. Key personnel such as anesthesiologists and critical care nurses are overwhelmed.

Even when hospitals have availability, it may be difficult to get patients on the schedule due to requirements for universal COVID-19 testing, and appropriate medical and financial clearances. Yes, surgical demand may dampen due to changing patient preferences and fears of uncertainty, yet substantial backlog would likely remain.

Experience from countries such as England and Australia, where waiting lists for elective operations have long existed, shows that patients generally do not forego surgery once recommended for it despite the wait. And the queues could certainly get worse if there are any future COVID-19 surges or additional surgical suspensions.

The other major issue is ethical dilemmas in prioritizing surgeries. The potential harm from delaying surgery due to worsening disease needs to be balanced against the potential harm with proceeding due to high-risk for the patient and resource consumption issues.

Any missteps may further marginalize already disadvantaged patient groups and worsen existing health disparities.

Unless significant investments are made in expansion of surgical capacity, the future will be challenging. Some strategies for recovery include: shifting surgeries from inpatient to outpatient settings when appropriate, cutting red-tape around financial clearances, leveraging technologies such as telemedicine to make health care more efficient, and developing ethical and transparent frameworks for surgical triage. Time for action is now.

Dr. Amit Jain ( is associate professor of orthopedic surgery at Johns Hopkins andDr. Shruti Aggarwal ( is an ophthalmologist at Katzen Eye Group.