Effect of the COVID-19 pandemic on procedure volumes in gastroenterology in the Netherlands

Abstract

The COVID-19 pandemic has challenged health-care systems across the globe. Reallocation of resources and personnel to COVID-19 wards severely affected all aspects of care, including closure of outpatient clinics and cancellation or postponement of procedures.1Sonneveld MJ Veldhuijzen IK van de Laar TJW Op de Coul ELM van der Meer AJ Decrease in viral hepatitis diagnoses during the COVID-19 pandemic in the Netherlands.J Hepatol. 2021; (published online April 21.)https://doi.org/10.1016/j.jhep.2021.04.015Summary Full Text Full Text PDF Scopus (3) Google Scholar, 2Lantinga MA Theunissen F Ter Borg PCJ Bruno MJ Ouwendijk RJT Siersema PD Impact of the COVID-19 pandemic on gastrointestinal endoscopy in the Netherlands: analysis of a prospective endoscopy database.Endoscopy. 2021; 53: 166-170Crossref PubMed Scopus (32) Google Scholar We aimed to quantify the effect of the COVID-19 pandemic on nationwide procedure volumes in gastroenterology in the Netherlands during the early and later stages of the pandemic. We used claims data extracted from the Dutch national health insurers information system (Vektis) to identify all gastroenterological health-care activities performed from Jan 1, 2019, to March 28, 2021, as part of a diagnosis treatment combination plan with a hepatogastroenterologist as the treating physician. The activities were analysed overall and across procedure types and diagnosis groups of interest (appendix pp 2–5). We compared absolute and relative changes for the index week during the COVID-19 pandemic with the reference week in 2019. We defined three timeframes on the basis of the number of weekly COVID-19 admissions:3National Institute for Public Health and the EnvironmentDevelopment of SARS-CoV-2 in graphs.https://www.rivm.nl/coronavirus-covid-19/grafiekenDate: 2022Date accessed: January 20, 2022Google Scholar the first wave from week 9 through week 22 of 2020; a subsequent recovery phase with relatively few admissions from week 23 through week 35; and a second wave with high ongoing admission rates from week 36 through to the end of the study period (figure). We analysed 980 075 procedures. During the peak of the first COVID-19 wave, the number of procedures decreased by 64·1% (figure). There was a deficit of 43 052 procedures at the end of the first wave, corresponding to a 34·5% decrease versus the reference period in 2019 (p=0·004; appendix p 6). During the recovery phase, the total procedure volume returned to reference levels (–1·2% vs 2019; p=0·590; appendix p 6) and remained stable during the second wave (0·5%; p=0·975; appendix p 6). At the end of the study period, a total deficit of 42 882 procedures remained. Change in procedure volumes varied across procedure types (p<0·001) and diagnosis groups (p=0·018; figure; appendix p 6). In terms of procedure type, the largest absolute decrease was observed for lower endoscopy (–28 628 procedures, –9·8%), whereas the most pronounced relative decrease was observed for non-endoscopic diagnostic procedures (–30·4%). The smallest difference was observed for urgent interventions (–2·5%). In terms of diagnosis groups, the most pronounced decrease was observed for procedures performed for colorectal cancer screening (–18·6%), motility disorders (–13·4%), or chronic abdominal pain and irritable bowel syndrome (–10·3%). Conversely, a smaller decrease was observed in the number of procedures performed for diagnosis or treatment of pancreatic or biliary neoplasia (–0·9%). During the recovery phase, procedure volumes returned to near or more than reference levels in most diagnosis groups, except for colorectal cancer screening (–49·3%). During the second wave, only small decreases in procedure volumes were observed for most diagnosis groups; the major exception was the colorectal cancer screening programme (2342, 7·3%). This study illustrates the enormous effect of the COVID-19 pandemic on gastroenterology departments in the Netherlands. This effect was mainly accounted for by a large decrease in procedure volumes during the first COVID-19 wave. Although overall procedure volume levels returned to reference levels during subsequent phases of the pandemic, major deficits remained at the end of the study period. The decrease in the number of procedures performed for colorectal cancer screening and surveillance could have important long-term sequelae. Based on the advanced neoplasia detection rate of 35·9% reported in the Dutch colorectal cancer screening programme,4Kortlever TL de Jonge L Wisse PHA et al.The national FIT-based colorectal cancer screening program in the Netherlands during the COVID-19 pandemic.Prev Med. 2021; 151106643Crossref PubMed Scopus (11) Google Scholar a large number of patients with advanced neoplasia potentially remain undiagnosed and untreated. Furthermore, postponement or cancellation of procedures for surveillance of people at risk for colorectal cancer might increase their risk of advanced stage colorectal cancer.5van Leerdam ME Roos VH van Hooft JE et al.Endoscopic management of Lynch syndrome and of familial risk of colorectal cancer: European Society of Gastrointestinal Endoscopy (ESGE) guideline.Endoscopy. 2019; 51: 1082-1093Crossref PubMed Scopus (47) Google Scholar Concerns about missed diagnoses are furthered by a 42% decline in the number of colorectal cancer diagnoses during the first months of the pandemic.6Toes-Zoutendijk E Vink G Nagtegaal ID et al.Impact of COVID-19 and suspension of colorectal cancer screening on incidence and stage distribution of colorectal cancers in the Netherlands.Eur J Cancer. 2022; 161: 38-43Summary Full Text Full Text PDF PubMed Scopus (7) Google Scholar Attention should be given to the unfavourable long-term effects on colorectal cancer-related morbidity and mortality because of the temporary suspension of colorectal cancer screening and surveillance programmes. Procedure volumes linked to malignancies more likely to present with urgent symptoms such as pancreatic cancer or cholangiocarcinoma were relatively preserved, which has translated to a smaller decline in the number of biliary and pancreatic cancer diagnoses in 2020.7Dutch Cancer RegistrationCancers.https://iknl.nl/kankersoortenDate accessed: February 22, 2022Google Scholar We observed major reductions in the number of procedures performed for diagnosis or treatment of chronic abdominal pain, inflammatory bowel disease, and other non-malignant disorders. The effect of this decrease on morbidity and quality of life of affected patients could also be significant as a result of delayed diagnosis and treatment.8Basnayake C Kamm MA Stanley A et al.Standard gastroenterologist versus multidisciplinary treatment for functional gastrointestinal disorders (MANTRA): an open-label, single-centre, randomised controlled trial.Lancet Gastroenterol Hepatol. 2020; 5: 890-899Summary Full Text Full Text PDF PubMed Scopus (37) Google Scholar, 9Mönnikes H Quality of life in patients with irritable bowel syndrome.J Clin Gastroenterol. 2011; 45: S98-101Crossref PubMed Scopus (102) Google Scholar Nevertheless, some of these procedures could also have been superfluous and might not have needed to be performed.10de Jong JJ Lantinga MA Tan ACITL et al.Web-based educational intervention for patients with uninvestigated dyspepsia referred for upper gastrointestinal tract endoscopy: a randomized clinical trial.JAMA Intern Med. 2021; 181: 825-833Crossref PubMed Scopus (3) Google Scholar In conclusion, we observed profound reductions in gastroenterological procedure volumes during the first wave of the COVID-19 pandemic. Procedure volumes returned to or increased above reference levels during subsequent phases of the pandemic, which is a testament to the resilience and creativity of gastroenterology departments across the nation. Nevertheless, a significant backlog of postponed or cancelled procedures remained at the end of the study period; the long-term effects on quality of life, morbidity, and mortality requires careful further evaluation. We declare no competing interests. The study was sponsored by the Foundation for Liver and Gastrointestinal Research (SLO) in Rotterdam, the Netherlands. The SLO had no influence on study design, writing of the manuscript, or the decision to submit for publication. Download .pdf (.2 MB) Help with pdf files Supplementary appendix