Trends of surgical-care delivery during the COVID-19 pandemic: A multi-centre study in India (IndSurg Collaboration)S Jain1, A Mahajan2, PM Patil3, P Bhandarkar3, M Khajanchi4, IndSurg Collaboration5
1 Dayanand Medical College and Hospital, Ludhiana, Punjab, India
2 Government Medical College, Amritsar, Punjab, India
3 Department of Biostatistics, BARC Hospital, Mumbai, Maharashtra, India
4 Department of Surgery, Seth G.S. Medical College and K.E.M Hospital, Mumbai, Maharashtra, India
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/jpgm.jpgm_485_22
Source of Support: None, Conflict of Interest: None
Keywords: Cancellation of surgeries, emergency surgeries, essential surgeries, India, global lockdown, low- and middle-income country
The COVID-19 pandemic and the resultant worldwide lockdown led to a drop in surgical volumes globally. With successive waves of the surge in COVID-19 cases, hospitals and healthcare found themselves overburdened with patient care, tackling the severe shortage of resources (manpower/essential supplies/equipment). There was a global call for the deferment of all elective surgeries to reorganize the healthcare facilities, infrastructure, and workforce for providing care to COVID-19-affected patients. However, with this shift of human and material resources, despite all previous priority settings and protocols, a natural selection of surgeries was observed. Alongside cancellation and postponements of non-essential or elective surgical services, it was seen that rates of emergency and essential surgical care delivery also took a major hit.,,,
Studies from Italy and Spain reported an 85% and 65.5% decrease in emergency surgical activity during lockdowns following the first major wave of COVID-19 cases in March 2020., Many of these surgeries are categorized as 'essential surgeries' by the World Bank in 'Disease Control Priorities-3' (DCP-3) and are needed to be performed to avert l. 5 million preventable deaths, globally per year. Among these essential surgeries, cesarean births, exploratory laparotomy, and fracture fixation surgeries are considered 'bellwether procedures' which indicate the capacity of the healthcare system to perform essential and emergency surgeries. Failure and delay to meet these surgical demands come at a huge societal cost and contribute significantly to the burden of avoidable mortality and morbidity.
Low- and middle-income countries (LMICs) harbor the poorest 1/3rd of the total population, but receive only 6% of global surgical volume, despite contributing towards a considerable burden of surgical diseases., Thus, the consequences of COVID-19 on emergency and essential surgeries in LMICs will inevitably be much worse. While an extensive body of literature has dealt with practice guidelines, prioritization, and resource management in a pandemic in subspecialties like surgical oncology, urology, minimal access surgery, otolaryngology, and neurosurgery amongst others,,,,, very few studies have quantified and analyzed the effect and trends during the COVID-19 pandemic with its successive waves of rise and fall of cases on the essential surgical load. Adequate quantification of the essential surgical-care delivery and disruption may help highlight the gaps/deficiencies in the healthcare systems. At the same time, it may serve to inform measures for improvement during this pandemic and beyond. Hence, we aimed to reflect, quantify and analyze the trends of essential surgeries and bellwether procedures during the waxing and waning of the COVID-19 pandemic, across various hospitals in India.
A research consortium 'IndSurg', led by World Health Organization Collaboration Center (WHOCC) for Research in Surgical Care Delivery in LMICs, India, conducted this retrospective study. The healthcare centers with the capacity to provide all the 'essential surgeries', including the bellwether procedures of cesarean sections, surgery for fractures, and exploratory laparotomies, were included. We recruited public and private hospitals which provided emergency and planned/elective surgical services in the departments of General Surgery, Orthopedics, and Obstetrics-Gynecology. The total and emergency surgical volumes in April 2020, November 2020 and April 2021 were collated and analyzed. Data from April 2019 was also analyzed as a pre-pandemic comparator. The month of April 2020 (Wave I) was selected to capture the initial impact of the pandemic and lockdown on surgical services, as the nationwide lockdown in India started on March 24th, 2020. The essential surgical services in India after the first lockdown started to escalate from October 2020 onwards. Therefore, November 2020 (Recovery I) was selected to analyze the rising trend of surgeries in the recovery period. April 2021 (Wave II) was the time when the second wave of COVID-19 hit India, which again affected essential surgical services and hence, this was the third point in our dataset. During this period between April 2020 to May 2021, many healthcare facilities were converted to dedicated COVID-19 facilities. Wave I is defined as the period when Wave I of the COVID-19 pandemic started and Wave II is defined as the period when Wave II COVID-19 pandemic started. Recovery I is defined as the period between Wave I and Wave II. This nomenclature was added for ease of understanding for this particular study.
We invited several hospitals across the country, based on convenience. Initially, 12 hospitals agreed to participate, but only 7 shared data for April 2019 and April 2020. Of these 7, only 5 hospitals could manage to collate data for all the data points in this study, which were then included in the study [Figure 1]. There were three government teaching hospitals namely Maulana Azad Medical College (MAMC) and Lok Nayak Hospital, New Delhi; Seth G.S. Medical College & King Edward Memorial Hospital Mumbai (SGSMC & KEMH), Mumbai; and Bhabha Atomic Research Center Hospital (BARC), Mumbai; one private teaching hospital namely Terna Medical College and Hospital (TMC), one private hospital namely Manipal Hospital, Delhi. The centers shared data of all the selected departments performing essential as well as non-essential surgeries.
The investigator team at each institute collected the data either from the electronic medical records of the hospitals or captured the snapshots of the operation theater registers where details of the surgeries were entered manually. Data variables collected from the centers were department names, patient unique identification number, age, sex, name, and date of the surgery, type of anesthesia administered, and whether surgery was elective or emergency.
The patient identification was masked and the hospital names were coded. The data analysis team collated and standardized the names of the surgeries. The names of the surgeries were finalized by discussion between the members of the team for uniformity. Any differences or discrepancies were resolved with a mutual discussion between the team members over periodic telephonic meetings. The standardized names were then grouped as an emergency and elective surgeries and essential and non-essential ones as per DCP-3. Ambiguous/illegible surgery names were excluded from the analysis [Figure 1]. The surgeries were further classified retrospectively by the authors as per the 'National Health Service (NHS) list for prioritization of surgeries in COVID-19 pandemic document'. For this categorization, we used two separate lists, one published for Obstetrics-Gynecology and another one for subspecialties of surgery., NHS surgery prioritization lists describe various surgical procedures as per the urgency of carrying them out without risk to life. Category 1a includes high-priority surgeries that cannot be postponed beyond 24 hours, like laparotomy for perforated hollow viscus or cesarean sections. Category 1b includes procedures that cannot be postponed beyond 72 hours. Similarly, categories 2, 3, and 4 include procedures that cannot be postponed beyond one month, can be postponed only up to three months, and beyond three months, respectively. We combined categories 1a and 1b for ease of analysis.
We used Microsoft Excel 2019 and SPSS Version 20 (SPSS Inc., IBM Corporation, Chicago) for the analysis. The frequency of surgeries performed during the following months (pre-pandemic period April 2019, Wave I April 2020, Recovery I November 2020, Wave II April 2021) was estimated, number of surgeries was calculated across age groups, sex, specialty, and participation centers. We calculated the difference in emergency and elective surgeries and differences across NHS categories one to four. For ethical reasons, we did not compare the surgeries and reductions in numbers between various hospitals. Our primary outcome measure was to calculate the change and trend in the total number of essential surgeries performed in April 2020, November 2020, and April 2021 as compared to April 2019. This change and trends in surgery numbers were plotted against the case-positivity rate of COVID-19 during the middle of each month. The secondary outcomes were to document the change in essential surgeries and bellwether procedures of cesarean section, fracture fixation, and exploratory laparotomies.
Ethics was obtained from the IRB of all the recruited hospitals.
Fifteen surgical departments from five hospitals across Indian cities participated in the study. We analyzed the records of 5063 surgeries from these centers. The recruitment algorithm for the surgeries is shown in [Figure 1].
Compared to the pre-pandemic period, during Wave I, the total number of surgeries was reduced by 77%, which then improved to a 52% reduction during Recovery I. However, during Wave II the surgical volumes again reduced to around 68% with a reduction less compared to Wave I. Surgeries categorized as essential (as per DCP-3 Categorization) were affected along with the non-essential ones [Figure 2].
The demographic characteristics of the patients and the reduction in surgical volumes across various parameters during the evolution of the pandemic are described in [Table 1]. Overall, a higher reduction in surgical volume was seen in surgeries being performed on males, patients requiring general surgery procedures, surgeries requiring general anesthesia (GA), and surgical procedures categorized as Non-Essential (DCP-3 Category), Category 4 (NHS Prioritization list) and Elective surgeries.
Specialty-wise changes in the essential and non-essential surgical volumes during the pandemic period are described in [Table 2]. Among the essential surgeries, the trends of the 'Bellwether procedures' during the various periods of the pandemic showed a maximum reduction in the management of fractures and a minimum in cesarean sections during both Waves I and II [Figure 3].
Our study documented a 77% reduction in the overall surgical volumes across various levels of healthcare facilities due to the impact of the first lockdown in April 2020 (Wave I) and a 68% reduction due to the partial lockdown during the second wave of COVID-19 in April 2021 (Wave II). The COVID-19 pandemic affected the pre-existing frail surgical care delivery system in LMIC like India where the workforce, as well as infrastructure resources, are limited. The reduced access to hospitals due to the national lockdown and subsequently reduced admissions and footfalls further affected the number of surgeries being performed., The 'COVID Surg Collaborative' in its prediction of the effect of a pandemic on cancellations of surgeries had estimated that 72% of the total surgeries would be canceled due to the pandemic. A study from Italy documented a reduction in emergency surgery by 86% in the first month after the nationwide lockdown which was despite reserving a center, especially for emergency medical and surgical care in patients, other than COVID-19-infected patients. A similar 70% reduction in surgical admissions and 50% reduction in major surgeries were documented in the Ebola epidemic in Sierra Leone. However, only a handful of studies documented the trend in the surgical volumes during the various periods of waxing and waning of the pandemic. A noteworthy study from the United States documented an initial fall during the lockdown period of more than half the surgical capacity as compared to the pre-pandemic period. But, after reopening, the rate of surgical procedures rebounded to 2019 levels and this trend was maintained throughout the pandemic period despite multiple episodes of the resurgence of COVID-19-infected patients. Contrary to this, we found only a partial recovery in the surgical volumes with still a 52% reduction during November 2020 (Recovery I) when the surgical services had started escalating with the waning of the first wave. However, this partial improvement could not be sustained and the surgical volumes dropped again in April 2021 (Wave II) to 68% of the pre-pandemic period. On the positive side, the surgical volumes were relatively better than in Wave I. This relative improvement in surgical volumes during Wave II which was more devastating in India than the first wave may be attributed to relatively better preparedness (better availability of COVID-19 test kits, 3-ply masks, PPE kits, and better knowledge about virus spread) of the healthcare system to handle the surge and surgical services not being completely shut down. It may also reflect upon the ability of our healthcare infrastructure to readjust certain facilities to better cope with the surgical volumes. The other factors could be more accidents and emergencies (which were non-existent during Wave I due to the complete lockdown) and better access to care. But at the same time, certain factors like lack of availability of oxygen supplies throughout India could be incriminated as the reason for the inability to sustain the improvement in surgical volumes noted in the first recovery period. There was only a partial recovery for a long time after Wave I as, as per the experts, we could hit a second wave and so the operations and other services were given less priority, especially, in the government-run hospitals. Also, resource constraints including oxygen supply were hampered during Wave II.
With the reduction in the surgical volumes, we observed a 61% reduction even in emergency surgeries in the first wave, with a relatively improved picture in the first recovery period (43% reduction). However, this improvement could not be sustained for emergency surgeries too and a second drop (57% reduction) was observed in emergency surgical volumes in the second wave of the pandemic. This trend corroborates with the trends in the NHS I surgeries category. The reduction in emergency surgeries may be attributed to resource diversion to the care of COVID-19 patients, as well as lockdowns leading to poor access to healthcare. Omission of these emergency surgeries, which include essential surgeries, may have led to a huge disease burden and consequently a larger number of Disease Adjusted Life Years (DALYs) But at the same time, as the number of total surgeries reduced, the proportion of emergency surgeries in the three surgical departments considered, increased throughout the pandemic. The pandemic situation brought down the surgical systems all over the world to 'limited resource environments', where predominantly emergency surgeries were being performed and there were limited or no resources allotted for advanced and elective surgeries.
Cesarean sections were affected the least of all emergency surgeries with the least reduction during Wave I, documenting that redistribution of priorities happened even within the emergency surgery category And, surprisingly, the volumes of cesareans improved in the first recovery period and Wave II in comparison to the pre-pandemic period. A study from Italy showed a reduction in emergency obstetric admissions during the COVID-19 pandemic. However, there are no studies documenting the trends specific to cesarean sections during this pandemic. A study from Sierra Leone documented a 20-40% reduction in Cesarean surgeries during the initial period of the Ebola epidemic within the first 21 weeks from the onset of the pandemic. Another study documenting the narratives by healthcare workers during the Ebola epidemic demonstrated that the cesarean sections picked up and even increased within six months of the pandemic. This improved trend in cesarean sections in our study could be due to the effective sustainability of the healthcare facilities in India towards cesarean sections as also a better risk-taking ability of healthcare workers for cesarean sections. Also, as cesareans are done under spinal/epidural anesthesia, it wasn't a deterrent factor during the pandemic.
The higher number of reductions in surgeries for fractures and trauma during the first wave could be due to reduced numbers of vehicular accidents and road traffic restrictions enforced due to the lockdown. However, this reduction continued throughout the pandemic despite the curtailment of the lockdowns. A similar trend was also observed in abdominal laparotomies with just a minimal improvement noticed in the first recovery period. An orthopedic study considering femur fractures documented reduced femur fracture rates by 25%. A definite change of indications for operations was documented in the global neurosurgery survey and also in a study from Spain, where the threshold for surgery was higher than in the pre-pandemic period., A study from Spain documenting abdominal emergency surgeries, attributed the reduction partly to changed indications for surgeries. Appendicitis, cholecystitis, and some abdominal conditions may have been treated conservatively (as opposed to the pre-pandemic period) with a higher threshold for surgery. This may explain a similar decline in laparotomies and surgeries for fractures in our study. However, in our opinion, reduced access to hospitals and subsequent reduced footfalls and admissions due to fear of COVID-19 among the masses, remain the most likely reason for the reduction in all surgeries.
The strength of our study is that it is the first Indian study looking at the immediate impact and trends across various periods during the ongoing pandemic and lockdowns on the delivery of surgical services. Documenting trends across a timeline may help provide a snapshot in one single frame to evaluate the gaps in healthcare delivery. This may be used as a benchmark for identifying areas of potential strengthening of emergency surgical care delivery in India. Assessing workload and patient population has been recommended as a strategy while considering reopening and reorganization of services by the guidelines published by the Royal College of Surgeons. Reserving dedicated healthcare facilities or dedicated teams within the existing facilities for emergency surgical and medical care was also documented in various studies., In a limited resource country like India, healthcare facilities need to provide essential surgical care along with managing the COVID-19 patients which may be a sustainable solution over a prolonged duration. Strengthening government healthcare facilities to take the additional disease burden of COVID-19-affected patients, reserving different teams for continuing the emergency surgical services in patients affected with COVID-19 as well as those needing emergency care not affected by the virus, could be explored.
The limitations of our study are the relatively lesser number of representative healthcare institutions, compared to the size of our country. There is also a possibility of selection bias, due to the unequal distribution of public and private institutions in our study population. This study included hospitals from different cities, and may partly overcome the said limitations.
To conclude, our study quantified the effects of the COVID-19 pandemic on surgical care delivery across a timeline and documented that the overall surgical volumes reduced during the peaks of the pandemic with improvement as the surge of COVID-19 cases declined. The second wave of the pandemic showed improved surgical volumes as compared to the first one despite the effects of the COVID-19 mutation being more devastating. It may be attributable to the improved preparedness and the surgical services not being shut down. The proportion of reduction in emergency surgeries was less as compared to the elective ones, a picture simulating a 'limited resource' environment. Cesarean sections were affected the least with better delivery rates as the pandemic progressed in comparison to the pre-pandemic period.
We would like to acknowledge the contribution of Jyoti Kamble and Sakshi Shimpi who helped with data documentation and standardization
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]