The economic and psychological impact of cancellations of elective spinal surgeries in the COVID-19 era

COVID-19 and the forgone health benefits of elective operations

BACKGROUND AND AIM

The first SARS-CoV-2 pandemic wave in Germany involved a tradeoff between saving the lives of COVID-19 patients by providing sufficient intensive care unit (ICU) capacity and foregoing the health benefits of elective procedures. This study aims to quantify this tradeoff.

METHODS

The analysis is conducted at both the individual and population levels. The analysis calculates quality-adjusted life years (QALYs) to facilitate a comparison between the health gains from saving the lives of COVID-19 patients in the ICU and the health losses associated with postponing operative procedures. The QALYs gained from saving the lives of COVID-19 patients are calculated based on both the real-world ICU admissions and deaths averted from flattening the first wave. Scenario analysis was used to account for variation in input factors.

RESULTS

At the individual level, the resource-adjusted QALY gain of saving one COVID-19 life is predicted to be 3 to 15 times larger than the QALY loss of deferring one operation (the average multiplier is 9). The real-world QALY gain at the population level is estimated to fall within the range of the QALY loss due to delayed procedures. The modeled QALY gain by flattening the first wave is 3 to 31 times larger than the QALY loss due to delayed procedures (the average multiplier is 17).

CONCLUSION

During the first wave of the pandemic, the resource-adjusted health gain from treating one COVID-19 patient in the ICU was found to be much larger than the health loss from deferring one operation. At the population level, flattening the first wave led to a much larger health gain than the health loss from delaying operative procedures.

Elective surgeries during and after the COVID-19 pandemic: Case burden and physician shortage concerns

The COVID-19 pandemic had a significant impact on several aspects of global healthcare systems, particularly surgical services. New guidelines, resource scarcity, and an ever-increasing demand for care have posed challenges to healthcare professionals, resulting in the cancellation of many surgeries, with short and long-term consequences for surgical care and patient outcomes. As the pandemic subsides and the healthcare system attempts to reestablish a sense of normalcy, surgical recommendations and advisories will shift. These changes, combined with a growing case backlog (postponed surgeries + regularly scheduled surgeries) and a physician shortage, can have serious consequences for physician health and, as a result, surgical care. Several initiatives are already being implemented by governments to ensure a smooth transition as surgeries resume. Newer and more efficient steps aimed at providing adequate surgical care while preventing physician burnout, on the other hand, necessitate a collaborative effort from governments, national medical boards, institutions, and healthcare professionals. This perspective aims to highlight alterations in surgical recommendations over the course of the pandemic and how these changes continue to influence surgical care and patient outcomes as the pandemic begins to soften its grip.

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The COVID-19 pandemic had a significant impact on several aspects of surgical care.

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New surgical recommendations amidst an ever-increasing demand for care pose, short and long-term consequences for surgical care and patient outcomes.

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As the pandemic subsides, these changes, combined with a growing case backlog and a physician shortage, can have serious consequences for physician health and, as a result, surgical care.

Patients awaiting surgery for neurosurgical diseases during the first wave of the COVID-19 pandemic in Spain: a multicentre cohort study

OBJECTIVES

The large number of infected patients requiring mechanical ventilation has led to the postponement of scheduled neurosurgical procedures during the first wave of the COVID-19 pandemic. The aims of this study were to investigate the factors that influence the decision to postpone scheduled neurosurgical procedures and to evaluate the effect of the restriction in scheduled surgery adopted to deal with the first outbreak of the COVID-19 pandemic in Spain on the outcome of patients awaiting surgery.

DESIGN

This was an observational retrospective study.

SETTINGS

A tertiary-level multicentre study of neurosurgery activity between 1 March and 30 June 2020.

PARTICIPANTS

A total of 680 patients awaiting any scheduled neurosurgical procedure were enrolled. 470 patients (69.1%) were awaiting surgery because of spine degenerative disease, 86 patients (12.6%) due to functional disorders, 58 patients (8.5%) due to brain or spine tumours, 25 patients (3.7%) due to cerebrospinal fluid (CSF) disorders and 17 patients (2.5%) due to cerebrovascular disease.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was mortality due to any reason and any deterioration of the specific neurosurgical condition. Second, we analysed the rate of confirmed SARS-CoV-2 infection.

RESULTS

More than one-quarter of patients experienced clinical or radiological deterioration. The rate of worsening was higher among patients with functional (39.5%) or CSF disorders (40%). Two patients died (0.4%) during the waiting period, both because of a concurrent disease. We performed a multivariate logistic regression analysis to determine independent covariates associated with maintaining the surgical indication. We found that community SARS-CoV-2 incidence (OR=1.011, p<0.001), degenerative spine (OR=0.296, p=0.027) and expedited indications (OR=6.095, p<0.001) were independent factors for being operated on during the pandemic.

CONCLUSIONS

Patients awaiting neurosurgery experienced significant collateral damage even when they were considered for scheduled procedures.

COVID-19-related cancellation of elective orthopaedic surgery caused increased pain and psychosocial distress levels

PURPOSE

Health care systems in most European countries were temporarily restructured to provide as much capacity as possible for the treatment of coronavirus disease 2019 (COVID-19) patients. Subsequently, all elective surgeries had to be cancelled and postponed for months. The aim of the present study was to assess the pretreatment health status before and after COVID-19-related cancellation and the psychosocial distress caused by the cancellation.

METHODS

For this study, a questionnaire was developed collecting sociodemographic data and information on health status before and after the cancellation. To assess psychosocial distress, the validated depression module of the Patient Health Questionnaire (PHQ-9), was implemented. PHQ-9-Scores of 10 and above were considered to indicate moderate or severe depressive symptoms. In total, 119 patients whose elective orthopaedic surgery was postponed due to the COVID-19 pandemic were surveyed once at least 8 weeks after the cancellation.

RESULTS

Seventy-seven patients (65%; 34 female, 43 male) completed the questionnaire and were included. The predominant procedures were total knee arthroplasty (TKA), hip arthroscopy and foot and ankle surgery. The mean pain level significantly increased from 5.5 ± 2.2 at the time of the initially scheduled surgery to 6.2 ± 2.5 at the time of the survey (p < 0.0001). The pain level before cancellation of the surgery was significantly higher in female patients (p = 0.029). An increased analgetic consumption was identified in 46% of all patients. A mean PHQ-9 score of 6.1 ± 4.9 was found after cancellation. PHQ-9 scores of 10 or above were found in 14% of patients, and 8% exhibited scores of 15 points or above. Significantly higher PHQ-9 scores were seen in female patients (p = 0.046). No significant differences in PHQ-9 scores were found among age groups, procedures or reasons for cancellation.

CONCLUSION

Cancellation of elective orthopaedic surgery resulted in pain levels that were significantly higher than when the surgery was scheduled, leading to increased analgesic use. Additionally, significant psychosocial distress due to the cancellation was identified in some patients, particularly middle-aged women. Despite these results, confidence in the national health care system and in the treating orthopaedic surgeons was not affected.

LEVEL OF EVIDENCE

Level III.