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The Impact of the SARS-Cov-2 Pandemic on Healthcare Provision

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The Impact of the SARS-Cov-2 Pandemic on Healthcare Provision medRxiv preprint doi: https://doi.org/10.1101/2020.09.17.20192088; this version posted September 18, 2020. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY-NC-ND 4.0 International license . 1 The impact of the SARS-CoV-2 pandemic on 2 healthcare provision in Italy to non-COVID patients: 3 a systematic review 4 5 Lugli Gianmarco, MD1,10,* · Ottaviani Matteo Maria, MD2,10,* · Botta Annarita,MD1,10 · 6 Ascione Guido, MD3,10 · Bruschi Alessandro, MD4,10 · Cagnazzo Federico, MD5 · 7 Zammarchi Lorenzo, MD1,6, Romagnani Paola, MD,PhD7,8 · Portaluri Tommaso, 8 MSc9,10 9 10 1 Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy. 11 2 Sant'Anna School of Avdanced Studies, Pisa, Italy 12 3 Department of Cardiac Surgery, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, 13 Milan, Italy 14 4 Rizzoli Orthopaedic Insititute, University of Bologna, Bologna, Italy 15 5 Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier 16 University Medical Center, 80, Avenue Augustin Fliche, Montpellier, France. 17 6 Unit of Infectious and Tropical Disease, University Hospital Careggi, Florence, Italy 18 7 Nephrology and Dialysis Unit, Department of Pediatrics, Meyer Children's University Hospital, 19 Florence, Italy 20 8 Department of Biomedical Experimental and Clinical Sciences "Mario Serio", University of Florence, 21 Florence, Italy 22 9 IN Srl, Udine, Italy 23 10 CEST Centre for Excellence and Transdisciplinary Studies, Turin, Italy 24 25 (*equal contribution) 26 27 Corresponding Author: Lugli Gianmarco, MD 28 E-Mail: [email protected] 29 30 31 32 33 34 35 36 37 38 39 40 NOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice.1 medRxiv preprint doi: https://doi.org/10.1101/2020.09.17.20192088; this version posted September 18, 2020. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY-NC-ND 4.0 International license . 41 Abstract 42 Background Italy has been one of the countries most affected by the SARS-CoV-2 43 pandemic and the regional healthcare system has had to quickly adapt its 44 organization to meet the needs of infected patients. This has led to a drastic change 45 in the routine management of non-communicable diseases with a potential long-term 46 impact on patient health care. We investigated the management of non-COVID-19 47 patients across all medical specialties during the pandemic in Italy. 48 Methods A PRISMA guideline-based systematic review of the available literature 49 was performed using PubMed, Embase, and Scopus, restricting the search to the 50 main outbreak period in Italy (from 20 February to 25 June, 2020). We selected 51 articles in English or Italian that detailed changes in the Italian hospital care for non- 52 COVID-19 patients due to the pandemic. Our keywords included all medical 53 specialties in combination with our geographical focus (Italy) and COVID-19. 54 Findings Of the 4643 potentially eligible studies identified by the search, 247 studies 55 were included in the systematic review. A decrease in the management of 56 emergencies in non-COVID patients was found together with an increase in 57 mortality. Similarly, non-deferrable conditions met a tendency toward decreased 58 diagnosis. All specialties have been affected by the reorganization of healthcare 59 provision in the hub-and-spoke system and have benefited from telemedicine during 60 the pandemic. 61 62 Interpretation Our work highlights the changes taking place in the Italian public 63 healthcare system in order to tackle the developing health crisis due to the COVID- 64 19 pandemic. The findings of our review may be useful to analyze future directions 65 for the healthcare system in the case of new pandemic scenarios. 66 67 Keywords: COVID-19; non-COVID patients; Italy; National Health System; 68 69 70 71 2 medRxiv preprint doi: https://doi.org/10.1101/2020.09.17.20192088; this version posted September 18, 2020. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY-NC-ND 4.0 International license . 72 Introduction 73 74 Since the first case of the novel coronavirus (COVID-19) was reported in Wuhan, 75 China in December 2019, viral infection spread at an alarming rate worldwide. On 76 January 30, 2020, the World Health Organization (WHO) described COVID-19 as a 77 Public Health Emergency of International Concern, and by March 11, 2020, it was 78 officially declared a pandemic.1 Italy was the first European country to be affected by 79 COVID-19 with the first case being diagnosed on 20 February in a man living in the 80 province of Lodi (NorthWest Italy).2 The epidemic went on to affect all regions in 81 Italy, with higher incidence rates in the north. The peak of the COVID-19 epidemic in 82 Italy was reached in the last week of March with over 5500 new cases per day. 83 There has been a gradual decline since then as a result of strict containment 84 measures that shaped the Italian lockdown phase. However, especially during the 85 first phase of the epidemic, the outbreak put the Italian National Health System 86 (Servizio Sanitario Nazionale, SSN) under unprecedented pressure. 87 In an attempt to direct the available resources at counteracting and limiting the 88 effects of the pandemic, deferrable and non-urgent medical activities were 89 suspended. On the other hand, patients with life-threatening conditions, such as 90 myocardial infarction and stroke, or chronic conditions, such as diabetes, retained 91 the right to their medical needs being met. 92 In these circumstances, several medical domains have been constrained by different 93 resource allocations with unpredictable long-term consequences on patient health 94 care.3,4,5 95 Here, we present a systematic review of the literature which illustrates the direct and 96 indirect effects of the COVID-19 pandemic on the management of non-COVID 97 patients across all medical specialties. 98 99 Methods 100 101 This systematic review was performed in accordance with PRISMA guidelines.6 The 102 search was conducted on 25 June 2020 on three different databases: PubMed, 103 Embase, and Scopus without any date restriction. All the keywords were investigated 104 within the title and abstract in both “AND” and “OR” combinations. Our keywords 3 medRxiv preprint doi: https://doi.org/10.1101/2020.09.17.20192088; this version posted September 18, 2020. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY-NC-ND 4.0 International license . 105 included all medical specialties (and potential synonyms) in combination with our 106 geographical focus (Italy or Italian) and COVID-19. The full search strategy is 107 reported in Table 1, Supplementary Material. 108 109 Selection of the studies 110 The literature search returned original papers published between 1979 and 2020 – 111 especially for the keyword “coronavirus”. Since our focus was the novel severe acute 112 respiratory syndrome coronavirus 2 (SARS-CoV-2) and the first positive case in Italy 113 was detected on 20 February, the literature search was restricted to the period from 114 20 February to 25 June 2020. The databases were queried via an R script on their 115 respective APIs, checked and cleaned for duplicates (via title, DOI and/or database 116 id), and exported into Excel. 117 In the second stage, studies were selected based on their titles and abstracts: each 118 study was independently evaluated by three different raters (AnB, GA, GL). When 119 there was a lack of agreement among the screeners, ensemble majority voting was 120 used for the final decision. The full texts of the selected papers were thus analyzed 121 by two reviewers in terms of relevance and inclusion/exclusion criteria (MMO and 122 GA). When these reviewers disagreed over the inclusion or exclusion of a paper, a 123 third reviewer was responsible for the final decision (GL). In addition, the reference 124 lists of selected papers were reviewed in order to find pertinent studies not identified 125 during the initial search. 126 127 Inclusion and exclusion criteria 128 The simultaneous co-occurrence of the following characteristics was considered for 129 the inclusion of articles: (i) articles focusing on the SARS-CoV-2 infection/COVID-19 130 disease; (ii) articles focusing on the impact on patients based in Italy or on the Italian 131 hospital organization; (iii) articles detailing COVID-19-associated changes in the 132 Italian hospital care for non-COVID-19 patients. All the investigated articles were 133 published in English or Italian. 134 135 Type of studies 136 Original papers, editorials, comments, research letters, case series and studies 137 focusing on non-COVID patients in Italy were included. 138 4 medRxiv preprint doi: https://doi.org/10.1101/2020.09.17.20192088; this version posted September 18, 2020. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
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