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Millions of cancelled operations due to COVID and high death risk – UK study

The first nationwide study of the impact of COVID-19 on surgery at NHS hospitals in the United Kingdom has revealed that more than 1.5 million operations were cancelled or postponed during the pandemic and surgical patients who became infected with COVID were five times more likely to die.

The analysis, led by Queen Mary University of London and Swansea University Medical School, and funded by Barts Charity, comes at a time when NHS England has paused the collection and publication of official statistics on cancelled operations.

The research is the first to provide operational detail on surgical activity, and to gauge the true reduction in procedures that occurred across all NHS hospitals during the pandemic.

In the first of two papers published in the British Journal of Anaesthesia, the researchers calculate that the overall shortfall will increase to 2.4 million cancelled operations by the end of 2021 with millions more patients feeling the impact for years to come.

Key findings of study into surgical activity

The investigation used hospital and patient data, describing every episode of NHS hospital care in England and Wales during 2020. These statistics were then compared to the surgical activity during the four years prior to the study period.

Across all categories of surgery, there was an overall drop of 33.6% in surgical activity over the year. The largest number of cancelled or postponed operations occurred in semi-urgent surgery with over 900,000 cancelled procedures.

The greatest decrease in surgical activity was seen in elective surgery with nearly half a million fewer admissions and more than one in two procedures cancelled.

The researchers calculate the recovery of surgical activity has to date been incomplete, hampered by increased hospital staff sickness, reduced operating room capacity and an enhanced regime of infection controls. This will mean a cumulative shortfall of 2.4 million procedures by the end of the year, the equivalent of more than six months of pre-pandemic surgical activity.

High risk of death in surgery patients with COVID-19

In a separate study, led by Queen Mary and also published in the British Journal of Anaesthesia, the England-wide survey of all NHS surgery patients reveals the high risk of death among patients who acquire COVID-19 during or immediately after their hospital stay.

The analysis found that while only 1.1% of patients acquired the infection at the time of their operation, where patients did succumb to the virus, the mortality rate was extremely high.

Overall, surgical patients who became infected with COVID were five times more likely to die within 90 days of their operation.

Patients undergoing elective surgery who became infected were 25 times more likely to die.

The authors say these statistics indicate that current infection prevention and control policies are highly effective – but cannot be relaxed.

Co-lead author Dr Tom Abbott from Queen Mary’s William Harvey Research Institute said: “Our study reveals the true impact of the COVID-19 pandemic on surgical care in England and Wales, including both emergency and elective care.

“The long-term consequence of the disruption is unclear, but we anticipate that for many patients their quality of life will be severely affected.

“The backlog of surgery is likely to take many years to clear, particularly as the speed with which surgical treatments can be delivered is now slowed by infection control procedures.

“As highlighted by our research, the high mortality amongst patients who acquire COVID-19 at the time of their surgery, indicates that the current procedures and precautions must remain in place to safeguard our patients.”

Co-lead author Dr Tom Dobbs of Swansea University Medical School said: “The interruption of surgical treatment detailed in our research will be felt by millions of patients for many years to come.

“Delays in the diagnosis and surgical management of cancer patients will lead to an increase in deaths, while those waiting for semi-urgent and elective surgery are likely to experience a worsening of their condition, with some procedures made more problematic and less likely to succeed.

“Our research highlights the urgent need for a major re-organisation of hospital surgical services. We need more financial commitment from central government and tough decisions to be made about which patients should be prioritised for NHS treatment over the coming weeks, months and years.”

 

Study 1 details

Surgical activity in England and Wales during the COVID-19 pandemic: a nationwide observational cohort study

Thomas D Dobbs, John AG Gibson, Alex J Fowler, Tom E Abbott, Tasnin Shahid, Fatemeh Torabi, Rowena Griffiths, Ronan A Lyons, Rupert M Pearse and Iain S Whitaker.

Author affiliations: Swansea University Medical School, Welsh Centre for Burns and Plastics at Morriston Hospital in Swansea, and Queen Mary University of London, United Kingdom.

Published in the British Journal of Anaesthesia on 17 June 2021.

 

Abstract

A significant proportion of healthcare resource has been diverted to the care of those with COVID-19. This study reports on the volume of surgical activity and the number of cancelled surgical procedures during the COVID-19 pandemic.
Methods

We used hospital episode statistics for all adult patients undergoing surgery between 1 January 2020 and 31 December 2020 in England and Wales. We identified surgical procedures using a previously published list of procedure codes.

Procedures were stratified by urgency of surgery as defined by NHS England. We calculated the deficit of surgical activity by comparing the expected number of procedures from 2016 to 2019 with the actual number of procedures in 2020.

Using a linear regression model, we calculated the expected cumulative number of cancelled procedures by December 31, 2021.

Results

The total number of surgical procedures carried out in England and Wales in 2020 was 3 102 674 compared with the predicted number of 4 671 338 (95% confidence interval [CI]: 4 218 740e5 123 932). This represents a 33.6% reduction in the national volume of surgical activity.

There were 763 730 emergency surgical procedures (13.4% reduction) compared with 2 338 944 elective surgical procedures (38.6% reduction). The cumulative number of cancelled or postponed pro- cedures was 1 568 664 (95% CI: 1 116 066e2 021 258).

We estimate that this will increase to 2 358 420 (95% CI: 1 667 587e3 100 808) up to 31 December 2021.

Conclusions

The volume of surgical activity in England and Wales was reduced by 33.6% in 2020, resulting in more than 1.5 million cancelled operations. This deficit will continue to grow in 2021.

 

Study 2 details

Mortality after surgery with SARS-CoV-2 infection in England: A population-wide epidemiological study

Tom E Abbott, Alex J Fowler, Thomas D Dobbs, John AG Gibson, Tasnin Shahid, P Dias, A Akbari, Iain S Whitaker and Rupert M Pearse.

Author affiliations: Swansea University Medical School, Welsh Centre for Burns and Plastics at Morriston Hospital in Swansea, and Queen Mary University of London, United Kingdom.

Published in the British Journal of Anaesthesia on 10 June 2021.

 

Abstract

The COVID-19 pandemic has heavily impacted elective and emergency surgery around the world. We aimed to confirm the incidence of perioperative severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and associated mortality after surgery.
Methods

Analysis of routine electronic health record data from NHS hospitals in England. We extracted data from Hospital Episode Statistics in England describing adult patients undergoing surgery between 1 January 2020 and 28 February 2021. The exposure was SARS-CoV-2 infection defined by International Classification of Diseases (ICD)-10 codes.

The primary outcome measure was 90 day in-hospital mortality. Data were analysed using multivariable logistic regression adjusted for age, sex, Charlson Comorbidity Index, Index of Multiple Deprivation, presence of cancer, surgical procedure type and admission acuity.

Results are presented as n (%) and odds ratios (OR) with 95% confidence intervals (CI). Results

We identified 2 666 978 patients undergoing surgery of whom 28 777 (1.1%) had SARS-CoV-2 infection. In total, 26 364 (1.0%) patients died in hospital. SARS-CoV-2 infection was associated with a much greater risk of death (SARS-CoV-2: 6153/28 777 [21.4%] vs no SARS-CoV-2: 20 211/2 638 201 [0.8%]; OR1⁄45.7 [95% CI, 5.5e5.9]; P<0.001).

Amongst patients undergoing elective surgery, 2412/1 857 586 (0.1%) had SARS-CoV-2, of whom 172/2412 (7.1%) died, compared with 1414/1 857 586 (0.1%) patients without SARS-CoV-2 (OR1⁄425.8 [95% CI, 21.7e30.9]; P<0.001).

Amongst patients undergoing emergency surgery, 22 918/582 292 (3.9%) patients had SARS-CoV-2, of whom 5752/22 918 (25.1%) died, compared with 18 060/559 374 (3.4%) patients without SARS-CoV-2 (OR1⁄45.5 [95% CI, 5.3e5.7]; P<0.001).

Conclusions

The low incidence of SARS-CoV-2 infection in NHS surgical pathways suggests current infection prevention and control policies are highly effective. However, the high mortality amongst patients with SARS-CoV-2 suggests these precautions cannot be safely relaxed.

 

Queen Mary University of London article – First nationwide study reveals millions of cancelled operations due to COVID-19 and high risk of death (Open access)

British Journal of Anaesthesia article – Surgical activity in England and Wales during the COVID-19 pandemic: a nationwide observational cohort study (Open access)

British Journal of Anaesthesia article – Mortality after surgery with SARS-CoV-2 infection in England: A population-wide epidemiological study (Open access)

 

See also from the MedicalBrief archives

 

COVID-19's long-term impact on surgery in SA

COVID-19 patients undergoing surgery at increased risk of post-operative death — NIHR

Delays in cancer surgery caused by COVID-19 may cost UK thousands of lives — Institute of Cancer Research

Elective surgery during the COVID-19 pandemic may increase complications — small China study

 

 

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