COVID-19 pandemic has greatly impacted healthcare utilization. Findings of this study presented a trend of utilization of healthcare services that reflected what has been reported globally [4,5]. It revealed marked utilization reduction in almost all services within the two years of pandemic; including oncology services that exhibited an overall yearly reduction despite the temporary quarterly improvement in some services within year 2021. The exception of this reduction occurred in 2021 with the ICU admissions and laboratory diagnostics. The increased laboratory services may reflect the additional COVID-19 screening tests that have been required routinely for all triaged and admitted patients, and periodically for healthcare workers. As an essential lifelong service, renal dialysis sessions showed almost no reduction in 2020; while the observed increase in 2021 was due to increasing the number of dialysis machines that has occurred in the hospitals this year.
Like what was found in this study, reduction of emergency room visits was reported in some healthcare settings [10,11]. Noteworthy that the reduction of almost a quarter that occurred in 2020 may reveal the magnitude of unnecessary emergency visits in this study setting. A question here may be raised for the possible redefining of what constitutes an emergency condition. It may also provide an opportunity for finding alternative solutions to fulfill the needs for those who are not “actually” required to visit emergency room, which can help conserve these precious resources for the more needy patients. Such a solution may rely on the technology of telemedicine that showed rapid expansion in the era of pandemic [12]—despite being still in its early steps of implementation in this study setting.
Cancer patients’ management has been modified during COVID-19 pandemic according to many proposed guidelines [13–15]. In Egypt, many cancer care facilities have changed their management plan—including this study hospitals—aiming to continue treatment within the available resources and to minimize the risk of patients’ exposure to infection whenever possible. Wider spacing in the schedule of systemic chemotherapy, adopting a shorter course, and switching to oral treatment when possible were performed. Also, shorter courses and delayed adjuvant radiotherapy and delayed elective surgeries were selected when suitable for patients’ conditions [16]. These changes were clearly demonstrated in this study results. The greater reduction of outpatient visits for the established compared to the new patients may be due to the replacement of routine checkup and prescription refill visits by the available virtual methods of consultation that were implemented for patients’ follow-up. Much uncertainty about the long-term consequences of the recommended modifications is present and the issue is still controversial and requires further studies [17].
The relatively less reduction in the therapeutic than the diagnostic and screening services for oncology patients may denote that the already diagnosed patients were not much impacted as those who were not, which may be left behind undiagnosed. Screening services in this study setting were totally performed under the national breast cancer screening campaign. This campaign was economically justified according to a return-on-investment analysis for facility-based screening, which displayed a positive value of 133%—indicating an overall cost-savings—caused by downstaging of detected cases [18]. Suspended campaign activities have occurred during the peak of epidemic (April to July 2020) to limit the spread of infection and to conserve healthcare capacity needed for COVID-19 patients. Screening activities have been resumed thereafter with taking adaptive measures to ensure infection prevention and control. The improvement in mammographic screening seen in 2021 was not accompanied by similar improvement in the clinical examination visits, which is the first step in the screening process. This might indicate that this improvement was a catch-up phase for the backlog accumulated in the previous months and not screening for new patients. The unmet diagnostic and screening services for oncology patients may have great impact on cancer morbidity and mortality. Delay in the diagnosis allow cancer patients to present in more advanced stages with higher probability of less favorable treatment outcome, more treatment costs, and higher incidence of mortality. This stage migration is anticipated to be seen in the subsequent years that may reveal a higher burden on the cancer care facilities, required cost of care, and patients’ response. Also, a risk-based approach [19] may be required to deal with the accumulated women with delayed screening.
Strength and limitations
This study is the first to document and measure the changes in the healthcare utilization during a two-years period of COVID-19 pandemic in Egypt. Data were comprehensively and longitudinally collected from all the study hospitals and their departments within this period to illustrate, as much as possible, the complete picture of the effect of pandemic on non-COVID-19 services; particularly those provided for oncology patients. Although presenting only a descriptive picture of this unique pandemic period, this information is essential to inform modeling for further prediction of the indirect effect of the pandemic on healthcare provision, costs, and outcome particularly in resource-limited countries.
The choice of year 2019 as the pre-pandemic reference point rather than the average of multiple previous years was done because in the older years, the hospital capacity was gradually increasing with extensions in many departments and services that completely established by the end of year 2018. Therefore, year 2019 is reflecting what is expected for the services to be in the subsequent years and hence, it is more suitable for comparison.
Despite being a single center study, this hospital represents one of the largest university hospitals that collectively contribute by 23.2% of the total national inpatients’ bed capacity. Hence, the results obtained could be generalized for many of the similar healthcare settings.