Original Research Article|Articles in Press

Impact of COVID on surgical case volume at military treatment facilities with surgical residencies

Published:February 06, 2023DOI:


      • Bariatric case volume decreased 84% at MTFs vs 20% in adjacent civilian centers during the initial response to the pandemic.
      • Major colorectal surgical case volume at both MTFs and adjacent civilian facilities was minimally affected by the pandemic.
      • MTF bariatric case volume has been slow to recover with a greater percentage of cases now being done in civilian centers.



      The Military Health System (MHS) is tasked with the dual mission of providing medical care to beneficiaries while ensuring medical readiness. MHS provides care through a combination of military treatment facilities (MTF) (“direct care”; DC) & off-base civilian facilities (“purchased care”; PC). Given recent concerns regarding low surgical volume at MTFs, we sought to evaluate COVID's impact on elective and non-elective case volume at MTFs with surgical residencies.


      Retrospective review of 2017–2021 M2 database was performed on Tricare beneficiaries who underwent bariatric surgery or major colorectal surgery in the DC or PC market at, or, surrounding MTFs with surgical residencies. Procedures were identified using ICD-10 procedure codes and Medicare severity-diagnosis related groups. A detailed analysis was then performed on changes in case volume in the DC and PC markets.


      5,698 bariatric and 5,517 major colorectal procedures were performed during the study period. There was an 84% vs 20% quarterly decrease in elective bariatric surgeries completed in the DC and PC markets from Q1 to Q2 2020. Pre to post-COVID (Q1 2017 – Q1 2020 vs Q3 2020 – Q4 2021) there was a decrease in the percentage of bariatric surgeries completed in the DC market (74.1% vs 55.0%, p = 0.001). Meanwhile, major colorectal surgery quarterly case volume remained unchanged in the DC (137 vs 125, p = 0.18) and PC (146 v 137, p = 0.13) markets, pre- and post-COVID.


      Bariatric surgical case volume at MTFs disproportionately decreased during COVID when compared to the PC market and major colorectal cases. Bariatric case volume has rebounded in PC markets surpassing pre-COVID levels while DC case volume remains depressed. Further attention is warranted regarding decreased elective surgical case volume at MTFs.


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      1. Evaluation of the TRICARE Program: Fiscal Year 2021 Report to Congress. 2021
      2. DoD Instruction 6000.11 Patient Movement (PM). June 22, 2018
      3. DoD Instruction 6000.22 National Defense Medical System (NDMS). April 14, 2016
        • Hall A.B.
        • Davis E.
        • Vasquez M.
        • et al.
        Current challenges in military trauma readiness: insufficient relevant surgical case volumes in military treatment facilities.
        J Trauma Acute Care Surg. 2020; 89: 1054-1060
        • Dossett L.A.
        • Dimick J.B.
        Surgical volumes and Readiness–Challenges of declining cases for the military surgeon.
        JAMA Surg. 2022; 157: 50-51
        • Haag A.
        • Cone E.B.
        • Wun J.
        • et al.
        Trends in surgical volume in the military health system–a potential threat to mission readiness.
        Mil Med. 2021; 186: 646-650
        • Hall A.B.
        • Krzyzaniak M.
        • Qureshi I.
        • et al.
        Declining military surgical cases and the impact on military surgical graduate medical education.
        Am Surg. 2022; 31348221109451
      4. Center MAM. General Surgery Residency Program. Accessed 15 July 2022, 2022.

      5. Kime P. Plans for Hospital Closures as Part of Military Health System Reform Forging Ahead After Pause. Military News. Accessed 26 August, 2022.

      6. Report to The Congressional Defense Committees Section 703 of the National Defense Authorization Act For Fiscal Year 2017, (PUBLIC LAW vols. 114-328) (2017).

        • Defense Do
        CORNAVIRUS: Timeline.
        31 August 2022 (Accessed)
        • Command USN
        DoD support to operations allies welcome.
        Date accessed: September 4, 2022
        • Defense Do
        Fact sheet: elective surgery and procecdures.
        • Services CfMM
        Non-emergent, elective medical services, and treatment recommendations.
        • Surgeons ACo
        COVID-19: guidance for triage of non-emergent surgical procedures.
      7. Interpretive Statement Related to Proclamation by the Governor 20-24, Restrictions on Non-urgent Medical Procedures. 2022
        • Holt D.B.
        • Hueman M.T.
        • Jaffin J.
        • et al.
        Clinical readiness program: refocusing the military health system.
        Mil Med. 2021; 186: 32-39
        • Glance L.G.
        • Chandrasekar E.K.
        • Shippey E.
        • et al.
        Association between the COVID-19 pandemic and disparities in access to major surgery in the US.
        JAMA Netw Open. 2022; 5 (e2213527-e2213527)
        • Prasad N.K.
        • Englum B.R.
        • Turner D.J.
        • et al.
        A nation-wide review of elective surgery and COVID-surge capacity.
        J Surg Res. 2021; 267: 211-216
        • Johnson J.C.
        • Morey B.L.
        • Carroll A.M.
        • et al.
        Cardiothoracic surgical volume within the military health system: fiscal years 2007 to 2017.
        Ann Thorac Surg. 2021; 111: 1071-1076
        • Defense Do
        More active troops to help take COVID-related pressure off civilian hospitals.
        • Lopez V.
        • Anderson J.
        • West S.
        • Cleary M.
        Does the COVID-19 pandemic further impact nursing shortages?.
        Issues Ment Health Nurs. 2022; 43: 293-295
        • Lin Y.
        • Hu Z.
        • Danaee M.
        • Alias H.
        • Wong L.P.
        The impact of the COVID-19 pandemic on future nursing career turnover intention among nursing students.
        Risk Manag Healthc Pol. 2021; 14: 3605
      8. Temin T. How COVID-19 impacted staffing at the military’s hospitals and clinics. Federal News Network. Accessed 25 August, 2022.

        • Groeber G.
        • Mayberry P.W.
        • Crosby B.
        • et al.
        Federal Civilian Workforce Hiring, Recruitment, and Related Compensation Practices for the Twenty-First Century.
      9. General Surgery Clinical Readiness Dashboard –– Methodology Document V3.vol. 1 (2019).