Undoubtedly, the COVID-19 crisis has had a very tangible impact on healthcare systems around the globe. The National Bureau of Economic Research predicted that the pandemic would have “pronounced effects on local economic conditions and households’ expectations” [1]. Most of the discussion about the effects of COVID-19 have focused on the long-term outcomes of the pandemic, whether this be fiscal, medical, or organizational. But what effect has the pandemic had on the quality of healthcare currently, particularly when it comes to procedures like surgery? In order to answer this question, authors Milán et al. retrospectively investigated the impact of the COVID-19 pandemic on the morbidity and mortality risk of patients undergoing surgery [2].
Given the constraints posed by the COVID-19 pandemic, the authors note significant reason for concern that surgical outcomes may be compromised. For example, in Spain, where the study was conducted, many hospital beds and other resources had been allocated for patients infected with COVID-19. These novel constraints understandably called into question the ability for surgeons to maintain the standard of care established pre-pandemic. In their paper, Milán et al. list a number of organizational changes which occurred in their hospital in response to the pandemic: for example, designation of a non-COVID area, preoperative COVID screening, different entry and exit routes, and adjustments to triage of elective surgery.
The authors included a total of 2,412 patients in their study: 1,649 in the pre-pandemic group, and 763 patients in the COVID-19 group. Each patient was given a severity of illness rating according to their Diagnosis-Related Groups (DRG) score. Using the Clavien-Dindo classification, the authors set up non-inferiority at a ten percent difference for grade III to V complications and two percent difference in mortality. Patients in the two groups were matched by DRG severity score and then comparative analyses were conducted, using Chi-square tests, parametric and non-parametric tests, and bilateral tests.
The authors found that, although patients in the COVID group tended to present with greater severity/higher DRG risks and had a higher frequency of Clavien III-V outcomes, this difference was not significant. Moreover, there was no significant difference in length of hospital stay nor in-hospital mortality. In fact, frequency of death and disability was reduced in the COVID-19 group, though again, this difference was not significant. A larger predictor for mortality was age, a finding supported by previous studies [3]. Finally, reoperation rates in the higher severity groups of both the pre-COVID and post-COVID groups were also comparable.
Although the authors noted several limitations to their study – for example, the fact that it was performed retrospectively, as well as the heterogeneity of the included patient population – they concluded that elective surgery did not carry higher risk in the pandemic period as it was before COVID-19. Their recommendation was therefore that – assuming the replicability of their findings for other facilities – hospitals might consider resuming elective surgeries within the adjusted capacities posed by COVID-related organizational changes. Research on this topic is crucial as the pandemic continues and normal hospital operations continue to be disrupted by additional waves of infection.
References
1 Coibion, O., Gorodnichenko, Y., & Weber, M. (2020, May 11). The Cost of the Covid-19 Crisis: Lockdowns, Macroeconomic Expectations, and Consumer Spending. Retrieved from https://www.nber.org/papers/w27141
2 Caballero-Milán, M., Colomina, M. J., Marin-Carcey, L. A., Viguera-Fernandez, L., Bayona-Domenge, R., Garcia-Ballester, S., López-Farre, A., Ruiz-Buera, L., Sanz-Iturbe, M., Álvarez-Villegas, D., Jenssen-Paz, E. C., Puig-Sanz, G., Arcos-Terrones, A., Belmonte-Cuenca, C., Perelada-Alonso, E., Blasco-Blasco, F., & Sabaté, A. (2021). Impact of the SARS-CoV-2 (COVID19) pandemic on the morbidity and mortality of high-risk patients undergoing surgery: a non-inferiority retrospective observational study. BMC Anesthesiology, 21(1), 295. https://doi.org/10.1186/s12871-021-01495-3
3 Turrentine, F. E., Wang, H., Simpson, V. B., & Jones, R. S. (2006). Surgical risk factors, morbidity, and mortality in elderly patients. Journal of the American College of Surgeons, 203(6), 865–877. https://doi.org/10.1016/j.jamcollsurg.2006.08.026
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