Summary of main findings
Compared to 2018-19, volumes of total elective surgical procedures and orthopaedic, prostatic hyperplasia, and laparoscopic cholecystectomy surgery showed a U-shape with the most significant drop recorded during the second wave (October 2020-January 2021) or the population vaccination phase (February-April 2021). The afterward recovery was faster among the highly educated than among the low educated. Among the former, surgical volumes returned to and, at times, outnumbered the pre-pandemic ones, whereas among the latter volumes never returned to the pre-pandemic levels.
Oncological surgery underwent less dramatic average reductions and the overall recovery was less appreciable. However, significant social differences emerged: low educated people paid the highest toll in volume reductions and by the end of 2021 they had not caught up with pre-pandemic levels yet.
Interpretation and comparison with other studies
During the early stages of the pandemic, routine hospital services were severely disrupted and elective planned surgeries were cancelled or postponed, resulting in a variety of potential short and mid-term effects on patient care. Early predictions estimated a weekly decrease of 2.4 million elective surgical procedures globally 11. Real-world data showed that in many European countries elective planned surgery fell during 2020 12, with drops ranging from 88% during the first wave in Austria to 23% during the second wave in the Netherlands 13,14. Curtailments were reported for oncological procedures too, with reductions spanning from 8% during the whole 2020 in the Netherlands to 4% during the second wave in Austria 13,14. In Italy, both orthopaedic surgery and oncological procedures plunged during the first wave and throughout 2020 4,15,16 and surgery for fractures of the neck of the femur and hip replacement were still lower than expected at the end of 2021 17. The results of this study confirm what previous data have shown and, by extending the follow-up to 2021, provides an up-to-date picture of the mid-term effects of the COVID-19 pandemic on elective planned surgery. At the national level, the sustained contraction of oncological surgery, especially the breast cancer surgery, can be partially explained by the important delays in the organised screening activities caused by the lockdown first and the ongoing COVID-19 emergency later 18. Additionally, this decrease in the organised screening testing has been reported to be unequal, that is greater among the lower educated and the immigrants 19.
The good news is that volumes of most of the indicators of planned surgery considered in this study came back to pre-pandemic levels. Despite this achievement, the impending surgical backlog resulting from the activity contractions registered throughout 2020 and 2021 remains a critical concern for the National Health System. For example, it has been estimated that nationwide the number of hip replacement, laparoscopic cholecystectomy, and breast cancer surgical interventions dropped by 27,000, 42,000, and 7,800 procedures, respectively during the 2020-21 6. As it has been extensively argued 20,21, cancellations and delays of elective surgical procedures may result in a range of medical consequences affecting patients’ outcomes and wellbeing. Indeed, while the patient awaits surgery, the disease may progress and result in worse outcomes, more morbid operations, more intense and costly treatment, and higher mortality 20. Two recent meta-analyses quantified the consequences of surgery delays for breast, lung, and colon cancers. Hanna et al. reported a 6–8% increased chance of death for each 4-week delay in surgical treatment 22. Johnson et al. concluded that a 12-week delay in surgery was associated with decreased overall survival; estimates were larger for stage I and II breast cancer suggesting that survival in these patients may be especially sensitive to surgical delays 23. Treatment postponement
has also been associated with deterioration of mental wellbeing and quality of life in cancer patients 24 and in those awaiting orthopaedic surgery in the United States 25,26.
The bad news is that the recovery of surgical volumes has been socially unequal. Across all the indicators analysed, the most vulnerable strata of the population experienced the greatest contractions and the most modest resumption to pre-pandemic levels. In a previous paper, we reported that during the first seven months of the pandemic, the social gradient in hospital access and volumes, including the surgical ones, became steeper compared to the 2018-19 period 2. Adding to what was already a worrisome finding, the present study highlights not only that inequalities persist, but also that the pace of recovery has been slower throughout 2021 among the less educated. A slower recovery may be attributed to several reasons, including barriers of access in a still under-pressure health system, patient’s selection and prioritisation by surgical wards, or an actual shrinkage of the at-risk population due to the harvesting effect of COVID-19, which was likely stronger among the more deprived population groups. Social inequalities in the surgical backlog re-entry have been reported elsewhere. According to a study that looked at waiting lists in July 2021 for planned hospital treatment, including knee and hip replacements, people in England’s most deprived areas were 1.8 times more likely to experience a wait of over a year for hospital treatment than those in the most affluent areas 27. Results for the US return a mixed picture. On the one hand, a study based on the American Society for Clinical Oncology COVID-19 Registry, which followed about 5,000 patients with cancer from April 2020 to September 2022, found that both ethnicity and area-level social determinants of health were associated with cancer treatment delay or discontinuation 28. On the other hand, Glance et al. found that, among 3 470 905 adults with inpatient hospitalizations for major surgery, the reduction in operations was not differential between White and ethnic minority patients 29.
The important inequities heightened by COVID-19 worldwide represent a public health failure but also an opportunity to rethink and improve surgical care provision, as suggested by the World Health Organization 7. A multifaceted approach promoting the partnerships between surgeons, primary care professionals, public health experts, and social scientists has been proposed as an effective way forward to tackle inequalities in surgical practice 30. On a similar note, the Italian Association of Medical Oncology has called for patient-focused and decentralized care as a tool to improve outcomes and quality of life of patients and to reduce costs 31. Redesigning the organisational models and strengthening the networking between oncologists and other specialists, hospital services, general practitioners, and primary health facilities may optimise patient’s management and contribute to closing the equity gap in cancer care by retaining into the system hard-to-reach and vulnerable populations.
Strengths and limitations
To the best of our knowledge, this is the first study to assess educational inequalities in surgical volumes throughout the COVID-19 pandemic in Italy, and one of the few in Europe. Moreover, thanks to its extended follow-up, the study allowed us to track the recovery’s pace over time and to assess inequalities trends. The health information and administrative registries sources virtually cover the entire resident population, reducing the risk of selection bias, and allow to efficiently follow people over time and to explore multiple outcomes simultaneously. Moreover, its wide geographical coverage provides a fair approximation of the national situation during the first two years of the COVID-19 pandemic.
The main limitation of the study is that we assumed that 2018-19 was the best comparison time for both 2020 and 2021. This approach, which has been widely used in studies assessing the impact of the pandemic, does not account for the harvesting effect of COVID-19, which, as mentioned before, was likely stronger among the more deprived population groups. Moreover, we could include only those four Italian regions where integrated health and socioeconomic data for the resident population are available through the longitudinal studies. Although these regions are scattered throughout the country and therefore provide a fair approximation of the national picture, it is pivotal to work towards data integration in all the regions in order to have a common and consistent system for monitoring health inequalities on a national scale. Finally, data for Piedmont were not available for the last observation period resulting in a reduction of the statistical power of the study.