New research, published in the British Journal of Surgery, into the impact of COVID-19 on mortality in surgical patients has found that despite a reduction in cases, and a higher mortality rate in those patients infected with COVID-19, the overall national risk of death for patients in England undergoing major emergency and elective surgery was the same as that in 2019.
The careful analysis from the Dr Foster Unit at Imperial College and surgical colleagues found that during the first wave of the pandemic (February to August 2020), there was a 15% reduction in the volume of high-risk emergency general surgical cases and a 38% reduction in major elective surgery cases compared with the previous year.
The research also found the prevalence of COVID-19 infection in emergency surgical patients was just 2%. However, these patients had around double the risk of death (30-day mortality, casemix adjusted) compared with patients without infection. For elective surgery, just under 1% of patients were infected with COVID-19, but they had a mortality rate of 15.5%. This was significantly higher than those patients without infection (1%).
Despite the reduction in cases, and the higher mortality rates in those patients infected with COVID-19, the overall national risk of death for English patients undergoing major emergency and elective surgery was the same as that in 2019.
The analysis used a range of high-risk diagnoses (defined by a greater than 5% in-hospital mortality) that are usually managed surgically as well as a range of procedures carried out as planned admissions across several surgical subspecialties to identify the group of surgical patients admitted to hospitals in England between February and August 2020. Outcomes were compared with similar patients admitted in the previous year.
Hospital Episode Statistics, collected nationally, are the only single source of data that cover such a wide group of patients with these diagnoses and procedures, as well as providing comparison data on historical performance. Further information within the records allowed comparisons to be made taking into account differences in risk factors such as age, sex, ethnicity and comorbidity.
Given the limitations to these data, such as the way COVID-19 is recorded in hospital admissions, it is difficult to know whether patients acquired COVID-19 either prior or during their time in hospital. However, the key findings are still valid, and the significant reduction in surgical activity is concerning. This is because it raises the possibility that patients needing surgery may have put off seeing a doctor about their symptoms or that referrals to specialists may have been deferred.
Reassuringly, the overall COVID-19 infection rates in this patient population for the first wave were low. However, patterns of care had changed for the second wave, and acute trusts were expected to continue with elective surgery while also treating patients acutely ill with COVID-19.
The implications of the analysis are significant. Data up to the end of the second wave are now coming through and, looking ahead, surgical services will need to be reconfigured to deal with the backlog of surgical cases. Challenges such as the retention of an expanded workforce, combined with illness, fatigue and social and other factors, will have to be overcome to meet the increase in surgical activity required. This means it will be more important than ever to monitor outcomes such as mortality, emergency readmissions, length of stay, as well as specialty-specific indicators, to ensure that that services remain safe and effective.
Dr Foster has always supported high-quality academic research through the Dr Foster Unit, which encourages collaboration between statisticians, epidemiologists, data scientists and clinicians working on timely national sources of data. The insight that Dr Foster can provide to acute hospital trusts, working alongside academics and developing robust methodology, contributes to the unique value of the Dr Foster’s analytics offering.
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M Deputy, C Rao, G Worley, V Balinskaite, A Bottle, P Aylin, E M Burns, O Faiz. Effect of the SARS-CoV-2 pandemic on mortality related to high-risk emergency and major elective surgery. British Journal of Surgery 2021; znab029: https://doi.org/10.1093/bjs/znab029