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      Equity in the recovery of elective and oncological surgery volumes after the COVID-19 lockdown: a multicentre cohort study in Italy

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          Abstract

          Background

          The COVID-19 pandemic has had, and still has, a profound impact on national health systems, altering trajectories of care and exacerbating existing inequalities in health. Postponement of surgeries and cancellation of elective surgical procedures have been reported worldwide. In Italy, the lock-down measures following the COVID-19 pandemic caused cancellations of surgical procedures and important backlogs; little is known about potential social inequalities in the recovery process that occurred during the post-lockdown period. This study aims at evaluating whether all population social strata benefited equally from the surgical volumes’ recovery in four large Italian regions.

          Methods

          This multicentre cohort study covers a population of approximately 11 million people. To assess if social inequalities exist in the recovery of eight indicators of elective and oncological surgery, we estimated Risk Ratios (RR) through Poisson models, comparing the incidence proportions of events recorded during COVID-19 (2020-21) with those in pre-pandemic years (2018-19) for each pandemic period and educational level.

          Results

          Compared to 2018-19, volumes of elective surgery showed a U-shape with the most significant drops during the second wave or the vaccination phase. The recovery was socially unequal. At the end of 2021, incidence proportions among highly educated people generally exceeded the expected ones; RRs were 1.31 (95%CI 1.21–1.42), 1.24 (95%CI 1.17–1.23), 1.17 (95%CI 1.08–1.26) for knee and hip replacement and prostatic surgery, respectively. Among low educated patients, RR remained always < 1. Oncological surgery indicators showed a similar social gradient. Whereas volumes were preserved among the highly educated, the low educated were still lagging behind at the end of 2021.

          Conclusions

          Surgical procedures generally returned to pre-pandemic levels but the low educated experienced the slowest recovery. An equity-oriented appraisal of trends in healthcare provision should be included in pandemic preparedness plans, to ensure that social inequalities are promptly recognised and tackled.

          Supplementary Information

          The online version contains supplementary material available at 10.1186/s12939-024-02127-1.

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          Most cited references26

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          Elective surgery cancellations due to the COVID ‐19 pandemic: global predictive modelling to inform surgical recovery plans

          Dmitri Nepogodiev, Aneel Bhangu, Savino Spadaro … (2020)
          Background The COVID‐19 pandemic has disrupted routine hospital services globally. This study estimated the total number of adult elective operations that would be cancelled worldwide during the 12 weeks of peak disruption due to COVID‐19. Methods A global expert‐response study was conducted to elicit projections for the proportion of elective surgery that would be cancelled or postponed during the 12 weeks of peak disruption. A Bayesian beta‐regression model was used to estimate 12‐week cancellation rates for 190 countries. Elective surgical case‐mix data, stratified by specialty and indication (cancer versus benign surgery), was determined. This case‐mix was applied to country‐level surgical volumes. The 12‐week cancellation rates were then applied to these figures to calculate total cancelled operations. Results The best estimate was that 28,404,603 operations would be cancelled or postponed during the peak 12 weeks of disruption due to COVID‐19 (2,367,050 operations per week). Most would be operations for benign disease (90.2%, 25,638,922/28,404,603). The overall 12‐week cancellation rate would be 72.3%. Globally, 81.7% (25,638,921/31,378,062) of benign surgery, 37.7% (2,324,069/6,162,311) of cancer surgery, and 25.4% (441,611/1,735,483) of elective Caesarean sections would be cancelled or postponed. If countries increase their normal surgical volume by 20% post‐pandemic, it would take a median 45 weeks to clear the backlog of operations resulting from COVID‐19 disruption. Conclusions A very large number of operations will be cancelled or postponed due to disruption caused by COVID‐19. Governments should mitigate against this major burden on patients by developing recovery plans and implementing strategies to safely restore surgical activity. This article is protected by copyright. All rights reserved.
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            Indicators of socioeconomic position (part 1).

            B Galobardes, George Davey Smith (2006)
            This glossary presents a comprehensive list of indicators of socioeconomic position used in health research. A description of what they intend to measure is given together with how data are elicited and the advantages and limitation of the indicators. The glossary is divided into two parts for journal publication but the intention is that it should be used as one piece. The second part highlights a life course approach and will be published in the next issue of the journal.
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              Mortality due to cancer treatment delay: systematic review and meta-analysis

              Timothy Hanna, Will King, Stephane Thibodeau … (2020)
              Abstract Objective To quantify the association of cancer treatment delay and mortality for each four week increase in delay to inform cancer treatment pathways. Design Systematic review and meta-analysis. Data sources Published studies in Medline from 1 January 2000 to 10 April 2020. Eligibility criteria for selecting studies Curative, neoadjuvant, and adjuvant indications for surgery, systemic treatment, or radiotherapy for cancers of the bladder, breast, colon, rectum, lung, cervix, and head and neck were included. The main outcome measure was the hazard ratio for overall survival for each four week delay for each indication. Delay was measured from diagnosis to first treatment, or from the completion of one treatment to the start of the next. The primary analysis only included high validity studies controlling for major prognostic factors. Hazard ratios were assumed to be log linear in relation to overall survival and were converted to an effect for each four week delay. Pooled effects were estimated using DerSimonian and Laird random effect models. Results The review included 34 studies for 17 indications (n=1 272 681 patients). No high validity data were found for five of the radiotherapy indications or for cervical cancer surgery. The association between delay and increased mortality was significant (P<0.05) for 13 of 17 indications. Surgery findings were consistent, with a mortality risk for each four week delay of 1.06-1.08 (eg, colectomy 1.06, 95% confidence interval 1.01 to 1.12; breast surgery 1.08, 1.03 to 1.13). Estimates for systemic treatment varied (hazard ratio range 1.01-1.28). Radiotherapy estimates were for radical radiotherapy for head and neck cancer (hazard ratio 1.09, 95% confidence interval 1.05 to 1.14), adjuvant radiotherapy after breast conserving surgery (0.98, 0.88 to 1.09), and cervix cancer adjuvant radiotherapy (1.23, 1.00 to 1.50). A sensitivity analysis of studies that had been excluded because of lack of information on comorbidities or functional status did not change the findings. Conclusions Cancer treatment delay is a problem in health systems worldwide. The impact of delay on mortality can now be quantified for prioritisation and modelling. Even a four week delay of cancer treatment is associated with increased mortality across surgical, systemic treatment, and radiotherapy indications for seven cancers. Policies focused on minimising system level delays to cancer treatment initiation could improve population level survival outcomes.
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                Author and article information

                Contributors
                Chiara Di Girolamo: chiara.digirolamo@unito.it
                Journal
                Journal ID (nlm-ta): Int J Equity Health
                Journal ID (iso-abbrev): Int J Equity Health
                Title: International Journal for Equity in Health
                Publisher: BioMed Central (London )
                ISSN (Electronic): 1475-9276
                Publication date (Electronic): 15 March 2024
                Publication date PMC-release: 15 March 2024
                Publication date Collection: 2024
                Volume: 23
                Electronic Location Identifier: 57
                Affiliations
                [1 ]Department of Clinical and Biological Sciences, University of Turin, ( https://ror.org/048tbm396) Regione Gonzole, 10, Orbassano (Turin), Italy
                [2 ]Regional Health and Social Care Agency Emilia-Romagna Region, Viale Aldo Moro, 21, Bologna, Italy
                [3 ]Epidemiology Unit, ASL TO3 Piedmont Region, Viale Sabaudia, 164, Grugliasco (Turin), Italy
                [4 ]Department of Epidemiology, Regional Health Service Lazio, Via Cristoforo Colombo, Rome, 112 Italy
                [5 ]Regional Healthcare Agency of Puglia Region, Lungomare Nazario Sauro, Bari, 33 Italy
                Article
                Publisher ID: 2127
                DOI: 10.1186/s12939-024-02127-1
                PMC ID: 10943780
                PubMed ID: 38491445
                SO-VID: 726bfa84-f0be-480d-8464-ad96d1830ba4
                Copyright © © The Author(s) 2024
                License:

                Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

                History
                Date received : 10 November 2023
                Date accepted : 10 February 2024
                Categories
                Subject: Research
                Custom metadata
                issue-copyright-statement © BioMed Central Ltd., part of Springer Nature 2024

                ScienceOpen disciplines: Health & Social care
                Keywords: covid-19,social inequalities,surgery,italy
                Data availability:
                ScienceOpen disciplines: Health & Social care
                Keywords: covid-19, social inequalities, surgery, italy

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