Indirect effects of peaks in COVID admissions on access to surgery in the English NHS, differential effects by operation type, ethnicity and socio-economic status: a database study

  1. Sandra C Remsing
  2. Felicity Evison
  3. Ravinder S Vohra
  4. Dion Morton
  5. Peter Chilton
  6. Kamlesh Khunti
  7. Richard J Lilford

Reviewed by

Read the full article

Listed in

Log in to save this article

Abstract

Objectives

During the COVID pandemic the UK saw two peaks in the prevalence of hospital admissions resulting in disruption of routine hospital services in the English National Health Service. This study aimed to track the effect of these peaks on various types of surgery representing differences in urgency, importance, and complexity.

Design

Database study using the Hospital Episode Statistics database and surgical operations selected purposively, to represent different combinations of urgency, importance and complexity.

Setting

All hospitals within England that carried out procedures funded by the National Health Service.

Main Outcome Measures

Number of emergency routine surgeries; cancer-removal surgeries; transplant surgeries; renal transplants Deceased and living donors); and elective routine surgeries carried out prior to and during the COVID pandemic.

Results

While all surgeries declined, emergency or urgent operations held up better than elective cases. There was rapid rebound between peaks. Among emergency cases, coronary angioplasty for acute myocardial infarction held up well in contrast to appendectomy, where indications for surgery are more elastic. Among urgent cancer and transplant operations, those with the most complex pathways were the most severely affected. The pandemic affected socio-economic and ethnic groups similarly. Disruption during the second peak was slightly less than during the first peak despite even greater COVID admission rates.

Conclusion

The NHS titrated its response appropriately to the pandemic by prioritising emergency and urgent cases over elective cases. However, complex time critical conditions like organ transplants and certain cancers are also disrupted with implications for third peaks in hospital admissions that many countries are experiencing.

Article activity feed

  1. ScreenIT

    SciScore for 10.1101/2021.09.09.21262542: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    Ethicsnot detected.
    Sex as a biological variablenot detected.
    Randomizationnot detected.
    Blindingnot detected.
    Power Analysisnot detected.

    Table 2: Resources

    No key resources detected.

    Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).

    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
    Strengths and limitations: This is the first comprehensive study using a national dataset of all hospital admissions in England examining disruptions in a number of areas including routine, complex, emergency and elective procedures. Previous studies have been limited by examining disruptions in surgical care of people from single centres or regions and mainly related to cancers,14 patient experiences,15 and single routine or emergency procedures.16-18 Our study is limited to a particular range of surgical procedures because we wanted to see how the system had been able to cope with procedures of different types. However, these types do not serve as a classification system for two reasons. First, they overlap. For example, cancer operations are urgent because they are time critical. Second, they are hard to define or categorise in much the same way as a tree and a bush. Thus, our criteria simply illustrate features of different surgeries that act as barriers (e.g. complexity) or facilitators (e.g. degree of urgency) to access to surgery during an acute rise in hospital admissions. We think our findings show that when an operation is complex, not just technically but in terms of the pathway patients follow, then this acts as a barrier even if surgery is time-critical. This study does not seek to identify where on the patient pathway barriers occur databases. Implications: While reductions in surgery were attenuated in the second peak compared to the first peak, it would be unw...

    Results from TrialIdentifier: No clinical trial numbers were referenced.

    Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

    Results from JetFighter: We did not find any issues relating to colormaps.

    Results from rtransparent:
    • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
    • Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
    • No protocol registration statement was detected.

    Results from scite Reference Check: We found no unreliable references.

    About SciScore

    SciScore is an automated tool that is designed to assist expert reviewers by finding and presenting formulaic information scattered throughout a paper in a standard, easy to digest format. SciScore checks for the presence and correctness of RRIDs (research resource identifiers), and for rigor criteria such as sex and investigator blinding. For details on the theoretical underpinning of rigor criteria and the tools shown here, including references cited, please follow this link.

  2. Version published to 10.1101/2021.09.09.21262542v1 on medRxiv