DOI: https://doi.org/10.21203/rs.3.rs-1638451/v1
Background: COVID-19 pandemic has reduced healthcare utilization worldwide and no sufficient studies were published from resource-limited countries. This study aimed to quantify and characterize the changes in service utilization within years 2020–2021 in one of the Egyptian university hospitals, with special emphasis on oncology services.
Methods: Data were longitudinally collected for various services and categorized as for all-hospital patients and for oncology patients. Percentage reduction was calculated compared to year 2019.
Results: For all-hospital patients, the overall utilization reduced by –23.2% in 2020 and –3.6% in 2021. Also, emergency room visits were reduced (–22.7% in 2020; –17.5% in 2021). For oncology patients, greater reduction was recorded in overall services (–43.7% in 2020; –37.4% in 2021). Reduction, that showed fluctuation according to COVID-19 waves in Egypt, was larger in diagnostic (–44.8% in 2020; –45.4% in 2021) and screening services (–71.2% in 2020; –58.2% in 2021) than therapeutic (–36.2% in 2020; –31.4% in 2021). Despite its much reduction in 2020 (–31.5%), surgeries were the fastest to approach its pre-pandemic level (–1.4%) in 2021. Still lagging services were admissions, outpatient visits, radiotherapy, diagnostics, and screening.
Conclusion: With marked utilization reduction, a higher disease burden, stage migration, and premature death is anticipated. Reduction of emergency visits may raise questions for redefining what constitutes an “actual” emergency; or conversely, whether late presentations and/or preventable deaths have occurred. Preparation for, and evaluation of the impact of such experience are needed from policy/decision makers and researchers as well.
Since the declaration of the novel coronavirus disease as a pandemic on March 11, 2020, Egypt, like many other countries, has scaled up its preventive measures to minimize the spread of the virus in the community and to preserve the healthcare system capacity. Partial lockdown, stay-at-home orders, and reduction of non-emergency healthcare services were among the measures taken [1]. In addition, more than 300 public hospitals in Egypt—including some cancer care institutes—were turned into isolation hospitals for COVID-19 patients [2]. Similarly, most healthcare systems worldwide have reduced non-emergency services and rapidly switched to and expanded the use of virtual care [3]. The reduced availability and the fear of infection have resulted in reduction in non-COVID healthcare utilization. Figures reported showed substantial reduction in utilization worldwide [4]. For instance, the median [and interquartile range (IQR)] of percentage reduction was 42% (IQR − 53% to − 32%) in patients’ visits, 28% (IQR − 40% to − 17%) in admissions, 31% (IQR − 53% to − 24%) in diagnostics, 30% (IQR − 57% to − 19%) in therapeutics, and 37% (IQR − 51% to − 20%) in overall services [5]. This situation could be perceived as a universal natural experiment of “less care”.
Oncology patients have faced an increased challenge in accessing their needed care. Considering patients’ vulnerability as immunocompromised, the reduced service availability, and the potential risk of delaying treatment, oncologists are obliged to take the undesirable task of weighing up the benefit of the planned cancer treatment versus the threat of morbidity and mortality associated with COVID-19 [6]. Professional societies have released amendments to care guidelines to cope with these new challenges [7]. Consequently, marked utilization reduction in oncology services up to 60–75% was observed at the peak of pandemic [8].
Given this unique “less care” experience, important questions should be raised. For instance, what is the impact of this “less care” on the health outcome, future disease burden, and healthcare costs? What is the expected number of cancer patients that will present in a more advanced stage and what is the anticipated increase in the cancer mortality? How can we help those who became short of sufficient healthcare? The first step to answer such questions is to quantify and characterize this reduction in terms of services, settings, disease categories, and time trend. This knowledge is important to inform mathematical models and also, to help gain an insight into the potential alternatives for supporting patients. To my knowledge, no study has published figuring out the COVID-19 associated changes in healthcare utilization in resource-limited countries. Hence, this work aimed to quantify and characterize the changes in the service utilization over the years 2020 and 2021 in one of the Egyptian university hospitals, with special emphasis on oncology services.
Study Setting, Design, and Period
This study was conducted in one of the largest Egyptian university hospitals with ~2300 beds capacity. It consists of a medical city campus encompassing 12 hospitals and specialized centres, each of which is dedicated for certain medical speciality. These hospitals were not included as isolation facilities for COVID-19 patients. The discovered COVID-19 cases during medical care were normally referred to another hospital outside the main campus and dedicated for isolation. The number of patients utilized each service were longitudinally collected from all hospitals and centres, excluding the isolation hospital, over the calendar years 2020 and 2021.
Study data:
Data were comprehensively collected for various diagnostic and therapeutic services provided in all hospitals/centres and categorized as those for all-hospital patients’ services and those for oncology patients’ services. The services for all-hospital patients were outpatient clinic visits, emergency room visits, admissions for total hospital and intensive care unit (ICU), surgeries, dialysis and chemo/radiotherapy sessions, and diagnostic procedures. For oncology patients, services were outpatient clinic visits, number of chemotherapy and external beam radiotherapy sessions and patients, total admissions, surgeries, the diagnostic imaging [mammography and Positron Emission Tomography-Computed Tomography scan (PET-CT)], and the breast cancer screening activities: clinical examination and mammographic imaging. Breast cancer screening has been launched as a national campaign for universal screening of Egyptian women and the study hospitals have participated in these services in July 2019.
Data analysis
Considering data of the year 2019 as the pre-COVID-19 reference points, percentage change of utilization was calculated for each service. Trends of change were illustrated yearly for data of all-hospitals patients, and additionally on a quarterly basis—compared with the 2019 equivalent quarter—for data of oncology patients. Because the study hospitals began breast cancer screening services in July 2019, the pre-COVID-19 reference data points for quarterly comparison were calculated based on the sum of a three-month period of established screening services before the appearance of the first COVID-19 case in Egypt (November, December 2019, and January 2020). For all data and services, percentage change was calculated as the [post-COVID-19 numbers – pre-COVID-19 numbers] ∕ pre-COVID-19 numbers. Being a descriptive analysis for a longitudinal data of the whole study population rather than a sample, inferential statistical tests were not used in this study.
Ethics statement: Ethics committee approval was not required, as in this study a use of aggregate data was done with no collection of identifying or personal information at any point.
Compared to year 2019, the overall service utilization was reduced by − 23.2% with reduction in the therapeutic (–34.3%) more than the diagnostic (–16.1%) services in 2020. This reduction was less observed in 2021 to record − 3.6% in overall services and − 23.9% in therapeutic services. Diagnostic services, however, exceeded the pre-COVID-19 pandemic level by + 9.4% in 2021 [Figure 1 and Additional table 1 (see Additional file 1)].
Ordered by the magnitude of reduction, therapeutic services that markedly reduced in 2020 were the outpatient visits (–42.5%), surgeries (–39.4%), number of chemo/radiotherapy sessions (–37.6%), and admissions (–28.5%). In 2021, the order changed to become outpatient visits (–32.6%), number of chemo/radiotherapy sessions (–32.3%), surgeries (–21.5%), and emergency visits (–17.5%) while admissions recorded much improvement (only − 9.8%). Laboratory testing was the least reduced diagnostic service in 2020 (–10.3%) and in 2021, it exceeded its pre-pandemic level (+ 18.1%) [Figure 2 and Additional table 1 (see Additional file 1)].
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.
COVID-19 pandemic has markedly impacted utilization of healthcare services in 2020 with some improvement in 2021. Utilization by oncology patients recorded greater reduction (2020= –43.7% and 2021= –37.4% for overall services) than all-hospital patients (2020= –23.2% and 2021= –3.6% for overall services). Utilization reduction by all-hospital patients was larger in therapeutic than diagnostic services, while the opposite was expressed by oncology patients for whom the diagnostic and screening services were more reduced and showed slower improvement than therapeutic.
Generally, utilization by oncology patients demonstrated fluctuation in accordance with the reported COVID-19 infection waves in Egypt. Therapeutic service that recorded the largest reduction was the number of admissions; while the smallest reduction, with a relatively rapid improvement, was recorded with the number of patients receiving chemotherapy. Despite its much reduction in the beginning of pandemic, surgical service was the fastest to approach its pre-pandemic level. Services that were still lagging by the end of 2021 were admissions, outpatient visits, radiotherapy, diagnostics, and screening services.
Emergency room visits reduction of almost a quarter should raise a question about redefining the emergency situations that require physical existence of patients and finding alternative solutions for fulfilling the less urgent patients’ needs. Conversely, it is still difficult to judge whether this reduction has resulted in a late patients’ presentation or even caused deterioration and/or preventable patients’ deaths. For the non-communicable diseases in general and for cancer patients in particular, a higher disease burden, stage migration, and premature death could be anticipated in the near future. Preparation for, and evaluation of the impact of this “less care” natural experiment on the population health, healthcare policies and finance, and the social and economic aspects are urgently required from policy and decision makers, and from researchers as well.
COVID-19: coronavirus disease of 2019
IQR: interquartile range
ICU: Intensive Care Unit
PET-CT: Positron Emission Tomography-Computed Tomography scan
Funding:
None declared
Conflicts of interest:
The authors have no conflicts of interest to declare
Ethics approval:
Ethics committee approval was not required, as in this study a use of aggregate data was done with no collection of identifying or personal information at any point.
Consent to participate:
Not applicable as no participants were included.
Consent for publication:
Not applicable as no participants were included.
Availability of data and material:
All data generated or analysed during this study are included in this published article and its Additional information file.
Code availability:
Not applicable
Author’s contributions:
Conceptualization, data curation, methodology, formal analysis, visualization, and writing of original draft; then reviewing, editing and approval of the final manuscript: Sahar K. Kandil
Acknowledgment:
The author acknowledges all members of Statistics and Medical Record Department in Ain Shams University Hospitals for their efforts in data collection. Special thanks to Mrs. Bothaina Nomaan for her excellent coordination of data collection team and the preliminary organization of data.