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What lessons are there to learn from the COVID-19 pandemic – a study assessing the impact of COVID-19 on Dutch surgical health care

Authors: Michelle R. de Graaff*, Rianne N.M. Hogenbirk*, Yester F. Janssen*, David J. Heineman, Michel W.J.M. Wouters Schelto Kruijff, on behalf of the Dutch CovidSurg Collaborative Study Group * M.R. de Graaff, R.N.M. Hogenbirk, and Y.F. Janssen share first authorship and contributed equally to this work
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Disruption of health care due to COVID-19

The COVID-19 pandemic has caused a significant disruption in regular healthcare with serious consequences for patients with, but certainly also without COVID-19. To meet the increased demand for COVID-19-related intensive care unit (ICU) capacity, hospitals were forced to reduce and adjust their regular level of healthcare. Especially in 2020, during the first pandemic year, surgical theatres and post-anaesthesia care unit were repurposed as ICUs, hospital attendances were reduced, screening programmes were paused, and health care personnel was reallocated.1,2

Although the COVID-19 pandemic affected multiple facets of healthcare, elective surgery was one of the fields that was affected mostly by the pandemic, resulting in a weekly decrease of 2.4 million elective surgical procedures globally.3 The Dutch COVIDSurg Collaborative publishes a study in BJS that covers the impact of COVID-19 on surgical care in the Netherlands, expressed in the number of procedures performed, the proportion of altered treatment plans, and changes in surgical outcomes during 2020. These data are compared with a two year pre-COVID historical cohort.

Dutch Institute of Clinical Auditing

A nationwide prospective cohort study was performed in collaboration with the Dutch Institute for Clinical Auditing (DICA). DICA is an organisation that facilitates clinical auditing using a validated process of systematic analysis of the quality of care.4

During 2020, eight surgical audits were expanded with an additional COVID-19 survey aiming to assess alterations in scheduling and treatment plans during the first pandemic year. This included the audits for hepatobiliary- and upper gastro-intestinal surgery, for lung-, pancreatic- and colorectal cancer surgery, hip fracture-, aortic aneurysm- and bariatric surgery. A historical cohort consisting of similar patients operated in the participating hospitals during the two years prior to the pandemic (2018-2019) were included as control group.

A total of 50 Dutch hospitals participated in the Dutch COVIDSurg Snapshot Study, whereafter a total of 40 296 patients were included in this study. Of these 40 296 patients, 13 985 (34.7%) were surgically treated in 2018, 14 157 (35.1%) in 2019, and 12 154 (30.2%) in 2020.

Patterns of surgical care during the pandemic

Surgeons stated that reduced capacity caused a delay in surgery in almost 10% of the surgical procedures performed in 2020. As hypothesized, the total number of surgical procedures decreased, and especially the number of elective non-oncological procedures was mainly affected during the first and second COVID-19 waves. However, contrary to what one might expect, the weekly number of performed acute surgical procedures remained stable throughout the entire first year of the pandemic. It was also observed that the proportion of performed oncological procedures remained unchanged and we even observed a decrease in overall waiting time to surgery in 2020 due to prioritization of oncological procedures. Remarkably, the length of stay for these procedures decreased in 2020, while complication and readmission rates did not differ between 2020 and the historical reference cohorts.

Lessons learned from the COVID-19 pandemic

The first lesson learned is that although the downscaling of healthcare was inevitable, it did not result in an increased volume of acute surgical care or an increase in dismal elective surgical outcomes in the year 2020 for those who were surgically treated. However, for patients who still have to undergo elective non-oncological surgery, the aftermath of the pandemic, reflected by increased waiting lists, has already become apparent.

The second lesson is that although there was a decreased length of hospital stay due to COVID-19 circumstances in patients who underwent an oncological surgical procedure, this did not lead to an increase in readmission rates. A significant decrease in ICU admissions for major oncological procedures was also observed. With the current shortage of ICU capacity, this may represent an important lesson: apparently it is possible to reconsider the indications for standardized post-operative ICU admission for major surgical procedures and to create more medium care or post-anaesthesia care units to decrease the pressure on ICU facilities for potential new COVID-19 waves.

In the upcoming years the Dutch COVIDSurg initiative will perform more research on the aftermath of the pandemic such as increased waiting lists, the effect of triage decisions that were made, and experiences by physicians and patients.


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