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. 2021 May 22;5(3):zrab039. doi: 10.1093/bjsopen/zrab039

Impact of COVID-19 on surgical emergencies: nationwide analysis

A Lazzati 1,2,✉, M Raphael Rousseau 3, S Bartier 2,4,5,6,7, Y Dabi 4,8, A Challine 9, B Haddad 4,8, N Herta 4,10, E Souied 4,10, M Ortala 11, S Epaud 11, M Masson 11, N Salaün-Penquer 11, A Coste 2,4,5,6,7, C Jung 12
PMCID: PMC8140197  PMID: 34021327

Abstract

Background

The COVID-19 pandemic has had a major impact on healthcare in many countries. This study assessed the effect of a nationwide lockdown in France on admissions for acute surgical conditions and the subsequent impact on postoperative mortality.

Methods

This was an observational analytical study, evaluating data from a national discharge database that collected all discharge reports from any hospital in France. All adult patients admitted through the emergency department and requiring a surgical treatment between 17 March and 11 May 2020, and the equivalent period in 2019 were included. The primary outcome was the change in number of hospital admissions for acute surgical conditions. Mortality was assessed in the matched population, and stratified by region.

Results

During the lockdown period, 57 589 consecutive patients were admitted for acute surgical conditions, representing a decrease of 20.9 per cent compared with the 2019 cohort. Significant differences between regions were observed: the decrease was 15.6, 17.2, and 26.8 per cent for low-, intermediate- and high-prevalence regions respectively. The mortality rate was 1.92 per cent during the lockdown period and 1.81 per cent in 2019. In high-prevalence zones, mortality was significantly increased (odds ratio 1.22, 95 per cent c.i. 1.06 to 1.40).

Conclusion

A marked decrease in hospital admissions for surgical emergencies was observed during the lockdown period, with increased mortality in regions with a higher prevalence of COVID-19 infection. Health authorities should use these findings to preserve quality of care and deliver appropriate messages to the population.

This study assessed the change in acute surgical conditions during the lockdown period on a nationwide scale. There was an overall reduction in emergency operations of 20.9 per cent, with great variability according to prevalence of COVID-19 admissions. Mortality increased in regions with a high prevalence of COVID-19 infection.

Introduction

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2; COVID-19) pandemic has had profound effects on healthcare systems globally. Hospitals, in particular, have been overwhelmed by the massive influx of infected patients. To cope with the burden of disease, hospital workforce was reallocated and elective surgery significantly delayed. Various countries implemented a national lockdown, with major restrictions on all non-essential travel outside the home. In France, an initial lockdown was declared from 17 March to 11 May 20201.

Few studies have reported on the impact on emergency department visits for acute illnesses not related to COVID-19 during the lockdown period, although decreased attendances have been described for myocardial infarction, trauma, and acute gastrointestinal conditions including appendicitis and acute cholecystitis1–4.

Although individual centres and specialties rapidly identified the impact of COVID-19 on surgical services, there remains a lack of information on its effect on emergency surgery at a nationwide level during lockdown.

This study investigated how the sudden disruption of usual healthcare during the lockdown period affected acute surgery. The aim was to quantify changes in hospital admissions for emergency surgical conditions according to the regional prevalence of COVID-19, comparing the lockdown period with the same time interval in 2019. Potential changes in mortality were investigated.

Methods

 

This was an observational, analytical study of the impact of a national lockdown during the SARS-CoV-2 pandemic on the rate of surgical emergencies. Data were extracted from a national discharge database, the Programme De Médicalisation des Systèmes d’Information (PMSI), which collects all discharge reports from all hospitals in France, irrespective of facility ownership or academic affiliation. Discharge reports are mandatory and represent the basis for hospital funding. The database is comprehensive for all reimbursed surgical interventions in the country.

Data collected included patient demographics (age, sex, postal code, admission and discharge dates) along with primary and associated diagnoses based on ICD-10.

Participants

All adult patients aged at least 18  years admitted during the period of lockdown between 17 March and 11 May 2020 and the equivalent period in 2019 (19 March and 13 May) were considered. Patients were identified in the database through the diagnosis-related group classification, used to identify any hospital stay in which a surgical event occurred. Only emergency admissions were considered, defined as any admission passing through the emergency department. In the case of multiple admissions for the same patient, all hospital stays were included.

Exposures and confounders

The exposure variable was the year of admission, 2019 versus 2020, the year 2019 being the reference group. Potential confounders in readmission destination were assessed at several levels. Baseline patient characteristics included age, sex, BMI, and co-morbidities, according to the Charlson Co-morbidity Index (using Bannay weighting)5.

Regional differences were based on the reported ratios of hospital admissions for COVID-19 infection per 100 000 inhabitants. Three regional groups were established based on the numbers of admissions: 30 or more per 100 000 in high-prevalence regions, 15–29 per 100 000 in intermediate-prevalence regions, and fewer than 15 per 100 000 in low-prevalence regions2.

In the ICD-10 catalogue, diagnosis codes have a hierarchical classification in four levels6 based on 22 chapters, each using a letter code. Each chapter is divided into blocks of homogenous three-character categories (for instance, codes K35–K38 represent diseases of appendix). In this study, these two first levels of classification are referred to as chapters and blocks. Within each block, ICD-10 codes are classified into three-character categories (K35 represents acute appendicitis) and four-character subcategories (K35.2 represents acute appendicitis with generalized peritonitis), defining disease characteristics in increased detail. In this study, the last four-character level is referred to as a subcategory.

In the present study, 90 per cent of the most frequent diagnoses using the four-character subcategories of ICD-10 codes were selected, reducing the number of diagnoses from over 10 000 to approximately 500. Complete attrition is reported in Fig.S1.

Outcomes

The main outcome of this study was the rate of admission for adult surgical emergencies during the lockdown period in France compared with the same interval in 2019. A secondary outcome was in-hospital mortality after admission. Mortality was assessed irrespective of the time between the day of admission and death. The impact of active SARS-CoV-2 infection on mortality was assessed in a subgroup analysis.

Data access and linkage

In the PMSI database, each patient is assigned a unique identifier, which remains unchanged over time, making linkage between hospital stays in different hospitals possible. Because the identifier is anonymous, patient consent was not required. Access to the database was submitted for authorization by the National Commission on Informatics and Liberty (authorization number 01947391).

Statistical analysis

The balance among patient co-variables was assessed using standardized mean differences (SMDs); a difference of 10 per cent or less was considered a well balanced result7. The paired-samples Wilcoxon signed-rank test was used to examine the difference in median number of emergencies between lockdown and control periods.

Potential confounders among measured co-variables were assessed by propensity score analysis. The probability of each patient being admitted during the lockdown was calculated by logistic regression incorporating all patient variables. Matching between the lockdown and control groups was performed using the nearest neighbour for propensity score and the exact method for the diagnosis code (using the 3-character category), sex, and age group. In the matched cohort, the balance between co-variables was also assessed using the SMD. Mortality odds ratios (ORs) for each surgical disease were estimated by means of a logistic univariable regression model.

A similar method was used to calculate the OR for mortality associated with COVID-19. Patients with COVID-19 from the lockdown period were matched with those admitted during the same interval using the propensity score, as described above. An adjusted OR for mortality with confidence interval was calculated using the logistic regression model. All statistical analyses were done with R software (R Foundation for Statistical Computing, Vienna, Austria).

Results

 

During the lockdown, 57 589 emergency surgical admissions occurred in France, representing a decrease of 20.9 per cent compared with the same period in 2019 (72 819 admission). The nadir of admissions was observed during week 12 (–36.1 per cent), followed by gradual increases, until the first week after the end of lockdown (week 20), when the difference between 2019 and 2020 was negligible (Fig. 1a).

Fig. 1.

Fig. 1

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Acute surgical admissions

a Overall and b according to regional prevalence of COVID-19 admission. The shaded area represents the period of lockdown in 2020.

The decrease in emergency surgical admissions differed between regions, reflecting the overall prevalence of admissions for COVID-19 infection. This amounted to 15.6 and 17.2 per cent decreases for low- and intermediate-prevalence regions respectively, with a 26.8 per cent decrease for high-prevalence regions where the nadir in week 13 was 42.3 per cent (Fig. 1b).

The characteristics of patients admitted during the lockdown were similar to those of patients admitted during the same interval in 2019, with a mean(?) SMD of 0.015(0.013); no co-variable had a SMD larger than 0.100 (Table 1).

Table 1.

Baseline characteristics

Control group (2019)
(n = 72 819) 		Lockdown group (2020)
(n = 57 589) 		SMD
Age (years)* 56.49(23.08) 57.34(23.01) 0.037
 < 30 13 104 (18.0) 9461 (16.4)
 30–39 10 611 (14.6) 8744 (15.2)
 40–49 7203 (9.9) 5658 (9.8)
 50–59 8127 (11.2) 6318 (11.0)
 60–75 14 294 (19.6) 11 178 (19.4)
 > 75 19 501 (26.8) 16 230 (28.2)
Women 40 452 (55.5) 32 466 (56.4) 0.017
Charlson Co-morbidity Index score* 0.42 (0.87) 0.44 (0.89) 0.026
 0 54 382 (74.7) 42 275 (73.4)
 1–2 15 578 (21.4) 12 856 (22.3)
 >3 2880 (4.0) 2458 (4.3)
Myocardial infarction 875 (1.2) 676 (1.2) 0.003
Congestive heart failure 3698 (5.1) 3140 (5.5) 0.017
Peripheral vascular disease 2046 (2.8) 1738 (3.0) 0.012
Cerebrovascular disease 1700 (2.3) 1352 (2.3) 0.001
Dementia 3027 (4.2) 2393 (4.2) <0.001
Chronic pulmonary disease 2413 (3.3) 2228 (3.9) 0.030
Rheumatic disease 350 (0.5) 300 (0.5) 0.006
Peptic ulcer disease 427 (0.6) 317 (0.6) 0.005
Mild liver disease 684 (0.9) 608 (1.1) 0.012
Diabetes without chronic complication 5172 (7.1) 4276 (7.4) 0.013
Diabetes with chronic complication 1399 (1.9) 1009 (1.8) 0.013
Hemiplegia or paraplegia 1281 (1.8) 1014 (1.8) <0.001
Renal disease 2518 (3.5) 2119 (3.7) 0.012
Any malignancy, including lymphoma and leukaemia, except malignant neoplasm of skin 3330 (4.6) 2933 (5.1) 0.024
Moderate or severe liver disease 156 (0.2) 154 (0.3) 0.011
Metastatic solid tumour 1321 (1.8) 1119 (1.9) 0.01
AIDS/HIV 81 (0.1) 54 (0.1) 0.005
Obesity 3588 (4.9) 3026 (5.3) 0.015
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Values in parentheses are percentages unless indicated otherwise; *values are mean(s.d.). SMD, standardized mean difference; AIDS/HIV, acquired immune deficiency syndrome/human imuunodeficiency virus.

Trends in admission by chapter and category are reported in Table 2. The decrease in number of emergency admissions affected all chapters, except other reasons for admission, where numbers were relatively small. Admissions related to the injury and digestive system chapters were the most prevalent, and decreases of 27 and 19 per cent respectively were noted (P < 0.001). Chapters that had the greatest decrease were eye and adnexa (–40.5 per cent; P = 0.002) and respiratory system (–40.7 per cent; P < 0.001), whereas the least affected were neoplasms and pregnancy (8.5 and 7.5 per cent decrease respectively; P = 0.032 and 0.014).

Table 2.

Surgical emergencies classified by chapter and category

Chapter Block code Block label Control group (2019) Lockdown group (2020) Difference
(%) 		P
Infectious diseases A30–A49 Other bacterial diseases 111 (0.15) 72 (0.13) –35.14 0.014
Total 111 (0.15) 72 (0.13) –35.14 0.016
Neoplasms C15–C26 Malignant neoplasms, digestive organs 671 (0.92) 641 (1.11) –4.47 0.433
C50–C58 Malignant neoplasms, breast and female genital organs 65 (0.09) 42 (0.07) –35.38 0.040
C60–C63 Malignant neoplasms of male genital organs 38 (0.05) 42 (0.07) 10.53 0.687
C64–C68 Malignant neoplasms, urinary organs 276 (0.38) 263 (0.46) –4.71 0.581
C69–C72 Malignant neoplasms, eye, brain, and central nervous system 47 (0.06) 34 (0.06) –27.66 0.206
C76–C80 Malignant neoplasms, secondary and ill defined 217 (0.3) 186 (0.32) –14.29 0.087
C81–C96 Malignant neoplasms, stated or presumed to be primary, of lymphoid, haematopoietic, and related tissue 47 (0.06) 42 (0.07) –10.64 0.521
D10–D36 Benign neoplasms 99 (0.14) 85 (0.15) –14.14 0.395
Total 1460 (2) 1335 (2.32) –8.56 0.032
Nervous system G00–G09 Inflammatory diseases of the central nervous system 25 (0.03) 18 (0.03) –28 0.404
G50–G59 Nerve, nerve root, and plexus disorders 76 (0.1) 49 (0.09) –35.53 0.011
G90–G99 Other disorders of the nervous system 25 (0.03) 9 (0.02) –64 0.017
Total 126 (0.17) 76 (0.13) –39.68 0.003
Eye and adnexa H15–H19 Disorders of sclera and cornea 134 (0.18) 57 (0.1) –57.46 0.083
H25–H28 Disorders of lens 26 (0.04) 0 (0) –100 <0.001
H30–H36 Disorders of choroid and retina 165 (0.23) 147 (0.26) –10.91 0.536
H43–H45 Disorders of vitreous body and globe 70 (0.1) 31 (0.05) –55.71 0.031
Total 395 (0.54) 235 (0.41) –40.51 0.002
Circulatory system I20–I25 Ischaemic heart diseases 285 (0.39) 187 (0.32) –34.39 <0.001
I30–I52 Other forms of heart disease 1841 (2.53) 1480 (2.57) –19.61 <0.001
I60–I69 Cerebrovascular diseases 322 (0.44) 264 (0.46) –18.01 0.031
I70–I79 Diseases of arteries, arterioles, and capillaries 1011 (1.39) 897 (1.56) –11.28 0.051
Total 3459 (4.75) 2828 (4.91) –18.24 <0.001
Respiratory system J30–J39 Other diseases of upper respiratory tract 304 (0.42) 151 (0.26) –50.33 <0.001
J85–J86 Suppurative and necrotic conditions of lower respiratory tract 24 (0.03) 17 (0.03) –29.17 0.26
J90–J94 Other diseases of pleura 185 (0.25) 136 (0.24) –26.49 0.005
Total 513 (0.7) 304 (0.53) –40.74 <0.001
Digestive system K00–K14 Diseases of oral cavity, salivary glands, and jaws 278 (0.38) 165 (0.29) –40.65 0.004
K20–K31 Diseases of oesophagus, stomach, and duodenum 179 (0.25) 157 (0.27) –12.29 0.204
K35–K38 Diseases of appendix 5520 (7.58) 4357 (7.57) –21.07 <0.001
K40–K46 Hernia 1614 (2.22) 1209 (2.1) –25.09 <0.001
K55–K63 Other diseases of intestines 3528 (4.84) 2789 (4.84) –20.95 <0.001
K65–K67 Diseases of peritoneum 494 (0.68) 343 (0.6) –30.57 <0.001
K80–K87 Disorders of gallbladder, biliary tract, and pancreas 3292 (4.52) 3107 (5.4) –5.62 0.089
K90–K93 Other diseases of the digestive system 75 (0.1) 46 (0.08) –38.67 0.016
Total 14 980 (20.57) 12 173 (21.14) –18.74 <0.001
Skin and subcutaneous tissue L00–L08 Infections of the skin and subcutaneous tissue 2557 (3.51) 1773 (3.08) –30.66 <0.001
L60–L75 Disorders of skin appendages 137 (0.19) 104 (0.18) –24.09 0.04
L80–L99 Other disorders of the skin and subcutaneous tissue 123 (0.17) 96 (0.17) –21.95 0.13
Total 2817 (3.87) 1973 (3.43) –29.96 <0.001
Musculoskeletal system and connective tissue M00–M03 Infectious arthropathies 638 (0.88) 483 (0.84) –24.29 <0.001
M15–M19 Arthrosis 37 (0.05) 12 (0.02) –67.57 0.004
M20–M25 Other joint disorders 29 (0.04) 6 (0.01) –79.31 <0.001
M45–M49 Spondylopathies 46 (0.06) 47 (0.08) 2.17 0.942
M50–M54 Other dorsopathies 224 (0.31) 226 (0.39) 0.89 0.941
M65–M68 Disorders of synovium and tendon 600 (0.82) 475 (0.82) –20.83 0.007
M70–M79 Other soft tissue disorders 371 (0.51) 348 (0.6) –6.2 0.469
M80–M85 Disorders of bone density and structure 126 (0.17) 82 (0.14) –34.92 <0.001
M86–M90 Other osteopathies 437 (0.6) 282 (0.49) –35.47 <0.001
M95–M99 Other disorders of the musculoskeletal system and connective tissue 558 (0.77) 454 (0.79) –18.64 0.012
Total 3066 (4.21) 2415 (4.19) –21.23 <0.001
Genitourinary system N00–N08 Glomerular diseases 24 (0.03) 14 (0.02) –41.67 0.096
N10–N16 Renal tubulointerstitial diseases 1801 (2.47) 1714 (2.98) –4.83 0.284
N17–N19 Renal failure 159 (0.22) 139 (0.24) –12.58 0.265
N20–N23 Urolithiasis 2572 (3.53) 2590 (4.5) 0.7 0.860
N25–N29 Other disorders of kidney and ureter 27 (0.04) 32 (0.06) 18.52 0.442
N30–N39 Other diseases of urinary system 90 (0.12) 56 (0.1) –37.78 0.012
N40–N51 Diseases of male genital organs 642 (0.88) 446 (0.77) –30.53 <0.001
N60–N64 Disorders of breast 24 (0.03) 21 (0.04) –12.5 0.655
N70–N77 Inflammatory diseases of female pelvic organs 720 (0.99) 539 (0.94) –25.14 <0.001
N80–N98 Non-inflammatory disorders of female genital tract 408 (0.56) 293 (0.51) –28.19 <0.001
Total 6467 (8.88) 5844 (10.15) –9.63 <0.001
Pregnancy, childbirth, and the puerperium O00–O08 Pregnancy with abortive outcome 2161 (2.97) 1925 (3.34) –10.92 0.026
O10–O16 Oedema, proteinuria and hypertensive disorders in pregnancy, childbirth, and the puerperium 238 (0.33) 247 (0.43) 3.78 0.748
O20–O29 Other maternal disorders predominantly related to pregnancy 51 (0.07) 45 (0.08) –11.76 0.565
O30–O48 Maternal care related to the fetus and amniotic cavity, and possible delivery problems 1841 (2.53) 1701 (2.95) –7.6 0.123
O60–O75 Complications of labour and delivery 3118 (4.28) 2987 (5.19) –4.2 0.331
O80–O84 Delivery 71 (0.1) 15 (0.03) –78.87 0.3
O95–O99 Other obstetric conditions, not elsewhere classified 31 (0.04) 27 (0.05) –12.9 0.684
Total 7511 (10.31) 6947 (12.06) –7.51 0.014
Others symptoms and diseases R00–R09 Circulatory and respiratory systems 98 (0.13) 77 (0.13) –21.43 0.253
R10–R19 Digestive system and abdomen 35 (0.05) 18 (0.03) –48.57 0.024
R30–R39 Urinary system 202 (0.28) 162 (0.28) –19.8 0.025
R50–R69 General symptoms and signs 144 (0.2) 112 (0.19) –22.22 0.049
Total 479 (0.66) 369 (0.64) –22.96 0.001
Injuries S00–S09 Injuries to the head 794 (1.09) 493 (0.86) –37.91 <0.001
S10–S19 Injuries to the neck 46 (0.06) 22 (0.04) –52.17 0.005
S20–S29 Injuries to the thorax 185 (0.25) 111 (0.19) –40 0.019
S30–S39 Injuries to the abdomen, lower back, lumbar spine, and pelvis 684 (0.94) 366 (0.64) –46.49 <0.001
S40–S49 Injuries to the shoulder and upper arm 2080 (2.86) 1411 (2.45) –32.16 <0.001
S50–S59 Injuries to the elbow and forearm 4264 (5.85) 3016 (5.24) –29.27 <0.001
S60–S69 Injuries to the wrist and hand 5049 (6.93) 4329 (7.52) –14.26 0.002
S70–S79 Injuries to the hip and thigh 11695 (16.06) 9269 (16.1) –20.74 <0.001
S80–S89 Injuries to the knee and lower leg 5506 (7.56) 3096 (5.38) –43.77 <0.001
S90–S99 Injuries to the ankle and foot 353 (0.48) 277 (0.48) –21.53 0.005
T79 Certain early complications of trauma 27 (0.04) 19 (0.03) –29.63 0.133
T80–T88 Complications of surgical and medical care, not elsewhere classified 551 (0.76) 368 (0.64) –33.21 <0.001
Total 31 234 (42.88) 22777 (39.55) –27.08 <0.001
Other reasons for admission Z80–Z99 Persons with potential health hazards related to family and personal history, and certain conditions influencing health status 222 (0.3) 241 (0.42) 8.56 0.592
Total 222 (0.3) 241 (0.42) 8.56 0.762
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Values in parentheses are percentages.

Diseases were classified in 78 blocks of categories. Among these, admissions decreased in 71 categories (91 per cent) and increased in seven (9.0 per cent), although these increases were not significant compared with 2019. Among the most common categories requiring emergency surgery, the greatest reduction was observed for injuries to the knee and lower leg (–43.8 per cent; P < 0.001) and injuries to the shoulder and upper arm (–32.2 per cent; P < 0.001). An important reduction for diseases of appendix was also observed (–21.0 per cent; P < 0.001), and admissions related to disorders of gallbladder, biliary tract, and pancreas decreased by 5.6 per cent, although this was not significantly different from 2019 (P = 0.089). Urolithiasis had a moderate increase (0.7 per cent), but the rate was not significantly different from that in 2019 (P = 0.860).

Subcategories occurring in at least 400 admissions are reported in Table 3, and the complete list is available in Table S1. The number of operations for fractures, notably fracture of head and neck of femur (–20.5 per cent), pertrochanteric fracture (–16.8 per cent), fracture of lower leg, including ankle (irrespective of location: –56.0 per cent for upper end of tibia, –53.0 per cent for shaft of tibia, –41.4 per cent for lateral malleolus, –38.5 per cent for other fractures of lower leg) as well as fracture of shoulder and upper arm (upper end of humerus –28.7 per cent, shaft of humerus–36.5 per cent) all decreased significantly compared with 2019.

Table 3.

Surgical emergencies classified by subcategory (selection of most common)

Chapter Subcategory code Subcategory label Control group (2019) Lockdown group (2020) Difference
(%)		 P*
Circulatory system I442 Atrioventricular block, complete 750 (1.03) 589 (1.02) –21.47 0.002
I743 Embolism and thrombosis of arteries of the lower extremities 450 (0.62) 459 (0.8) 2 0.826
Digestive system K352 Acute appendicitis with generalized peritonitis 607 (0.83) 531 (0.92) –12.52 0.184
K353 Acute appendicitis with localized peritonitis 1945 (2.67) 1588 (2.76) –18.35 0.002
K358 Other and unspecified acute appendicitis 2843 (3.9) 2160 (3.75) –24.02 0.003
K565 Intestinal adhesions (bands) with obstruction (after infection) 884 (1.21) 721 (1.25) –18.44 0.008
K566 Other and unspecified intestinal obstruction 460 (0.63) 394 (0.68) –14.35 0.152
K610 Anal abscess 905 (1.24) 679 (1.18) –24.97 0.004
K800 Calculus of gallbladder with acute cholecystitis 1507 (2.07) 1411 (2.45) –6.37 0.67
K801 Calculus of gallbladder with other cholecystitis 497 (0.68) 433 (0.75) –12.88 0.159
K810 Acute cholecystitis 557 (0.76) 526 (0.91) –5.57 0.231
Skin and subcutaneous tissue L022 Cutaneous abscess, furuncle, and carbuncle of trunk 456 (0.63) 317 (0.55) –30.48 0.013
L024 Cutaneous abscess, furuncle, and carbuncle of limb 589 (0.81) 381 (0.66) –35.31 <0.001
L050 Pilonidal cyst and sinus with abscess 744 (1.02) 583 (1.01) –21.64 0.003
Musculoskeletal system and connective tissue M650 Abscess of tendon sheath 434 (0.6) 319 (0.55) –26.5 0.008
M966 Fracture of bone following insertion of orthopaedic implant, joint prosthesis, or bone plate 558 (0.77) 454 (0.79) –18.64 0.078
Genitourinary system N132 Hydronephrosis with renal and ureteral calculous obstruction 584 (0.8) 589 (1.02) 0.86 0.9
N136 Pyonephrosis 442 (0.61) 414 (0.72) –6.33 0.326
N201 Calculus of ureter 1698 (2.33) 1806 (3.14) 6.36 0.393
Pregnancy, childbirth, and the puerperium O001 Tubal pregnancy 602 (0.83) 516 (0.9) –14.29 0.09
O342 Maternal care owing to uterine scar from previous surgery 765 (1.05) 764 (1.33) –0.13 0.887
O630 Prolonged first stage (of labour) 410 (0.56) 378 (0.66) –7.8 0.716
O680 Labour and delivery complicated by fetal heart rate anomaly 1179 (1.62) 1173 (2.04) –0.51 0.879
Injuries S422 Fracture of upper end of humerus 1095 (1.5) 781 (1.36) –28.68 <0.001
S423 Fracture of shaft of humerus 551 (0.76) 350 (0.61) –36.48 0.009
S520 Fracture of upper end of ulna 431 (0.59) 275 (0.48) –36.19 <0.001
S525 Fracture of lower end of radius 2720 (3.73) 2061 (3.58) –24.23 <0.001
S526 Fracture of lower end of ulna 496 (0.68) 335 (0.58) –32.46 0.002
S626 Fracture of other and unspecified finger(s) 506 (0.69) 331 (0.57) –34.58 0.002
S644 Injury of digital nerve of other and unspecified finger 484 (0.66) 472 (0.82) –2.48 0.64
S663 Injury of extensor muscle, fascia, and tendon of other and unspecified finger at wrist and hand level 980 (1.35) 917 (1.59) –6.43 0.096
S720 Fracture of head and neck of femur 6020 (8.26) 4785 (8.31) –20.51 <0.001
S721 Pertrochanteric fracture 3685 (5.06) 3066 (5.32) –16.8 0.029
S722 Subtrochanteric fracture of femur 527 (0.72) 403 (0.7) –23.53 0.118
S723 Fracture of shaft of femur 681 (0.93) 454 (0.79) –33.33 <0.001
S821 Fracture of upper end of tibia 704 (0.97) 310 (0.54) –55.97 0.001
S822 Fracture of shaft of tibia 745 (1.02) 350 (0.61) –53.02 <0.001
S823 Fracture of lower end of tibia 450 (0.62) 286 (0.5) –36.44 <0.001
S826 Fracture of lateral malleolus 541 (0.74) 319 (0.55) –41.04 <0.001
S828 Other fractures of lower leg 1750 (2.4) 1084 (1.88) –38.06 0.001
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Values in parentheses are percentages.

Mortality

Some 2433 deaths (1.87 per cent) were identified in the original population and 2129 (1.87 per cent) in the matched population (Table S2). After matching, the overall mortality rate was 1.92 per cent (1096 of 56 982) during the lockdown period and 1.81 per cent (1033 of 56 982) in 2019. The adjusted OR for death in the matched population was 1.06 (95 per cent c.i. 0.97 to 1.15). A significant increase in mortality rate was seen in high-prevalence zones (OR 1.22, 1.06 to 1.40); there were no changes in the low- and intermediate-prevalence zones (Table 4).

Table 4.

Mortality by zone of prevalence of COVID-19 infection

Prevalence zone Deaths*
 Odds ratio†
Control period Lockdown period
High 374 (1.66) 417 (2.02) 1.22 (1.06, 1.40)
Intermediate 283 (2.01) 303 (2.05) 1.02 (0.87, 1.20)
Low 376 (1.85) 376 (1.75) 0.94 (0.81, 1.09)
Total 1033 (1.81) 1096 (1.92) 1.06 (0.97, 1.15)
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Values in parentheses are

*percentages and

†95 per cent confidence intervals.

Patients with COVID-19

In the subgroup of 863 patients with a diagnosis of COVID-19 infection, the overall mortality rate was 4.0 per cent among those with asymptomatic infection (OR 1.21, 95 per cent c.i. 0.44 to 2.80) and 12.3 per cent for those with symptomatic infection (OR 4.00, 2.60 to 6.32).

Discussion

This study reports a major decrease in emergency procedures during the COVID-19 pandemic lockdown period in France. The comprehensive data have permitted an in-depth analysis at a national level. There was a 20.9 per cent reduction in emergency surgical admissions to hospital between the 2020 lockdown and the corresponding interval in 2019. Over the weeks after the end of lockdown, no significant difference was observed between the two periods, suggesting a progressive return to usual surgical practices. The decrease in hospital admissions was associated with the regional prevalence of COVID-19, with the greatest reduction seen in the zones of highest prevalence. As no difference was observed between low- and intermediate-COVID-19 prevalence regions, two levels of impact on emergency surgeries were evident: a major impact in high-prevalence regions and a significantly lower level for all other regions. After matching on all available data, in-hospital mortality was slightly and significantly greater in the lockdown group than in the control group in high-prevalence zones. Additionally, the curve for the number of urgent operations week by week during the lockdown was a mirror image of the curve for number of hospital admissions for COVID-198, suggesting that the availability of hospital beds and operating rooms, requisitioned at the peak of the epidemic, had an impact on the operating capacities of the hospitals.

These findings seem to confirm other experiences reported in the media in the early lockdown periods regarding the dramatic and unexpected reduction in non-COVID emergencies9,10.

The present data are consistent with preliminary reports on acute-care surgery in other countries. In Spain, a 60 per cent decrease in acute surgery activity during the acute phase of the pandemic was reported by three tertiary hospitals in Madrid and Barcelona11. Similarly, an important reduction in traumatic injuries (almost 38 per cent compared with 2019) was observed in a major trauma centre in the UK2. A multicentre study12 from 18 general surgery units in a red zone of COVID-19 contagion reported a 45 per cent decrease in admissions for emergency surgical disease and a 41 per cent decrease in operations, despite no discernible differences in overall management approaches to patients who were admitted during the lockdown.

Several factors have been put forward to explain the reduction in emergency surgery. The most common is the patients’ fear of being taken to hospitals receiving people with COVID-19 and the risk of contracting the virus in that environment. This fear has probably been nourished by worrying information transmitted by the media about the situation in hospitals, such as being overwhelmed by patients with COVID and facing equipment shortages including personal protection, and the lack of reassuring messages from hospitals on the management of patients without COVID. Precise reasons for hospital avoidance remain unclear; only indirect evidence is available. A study13 from the UK reported that people with low-risk conditions were less likely to present to an emergency department whereas the numbers of non-deferrable emergencies remained constant.

There is already some evidence that avoidance of hospital attendance has led to delayed visits to an emergency department, resulting in more advanced disease. The study11 from Spain reported an increased delay of almost 24 h from the onset of symptoms to arrival at a hospital compared with that of a historical control group. A report3 from three medical centres in the state of New York found an increase in paediatric perforated appendicitis compared with uncomplicated appendicitis during the surge of COVID-19 outbreak. Similarly, a number of reports have documented decreases in emergency visits for kidney stone disease, with an increase in severe presentations necessitating admission14,15. These data are consistent with the findings of the present study, where there was a moderate increase (0.7 per cent) in the category urolithiasis (N20–N23).

Lockdown restrictions led to unprecedented modifications in lifestyle, resulting in a reduction in road traffic collisions and consequent trauma. In the UK, road casulaties dicreased of 67 per cent compared with 201916. Associations between acute diseases and other lifestyle changes such as food and alcohol consumption, or physical activity, is less straightforward. During the 8-week lockdown in France, a survey of 3000 adults found that men gained an average of 2.7 kg and women 2.3 kg17. If short-term weight gain influences the risk of cholecystitis, this might provide partly explain why the reduction in acute cholecystitis (K810, decrease of 5.6 per cent) was relatively modest.

Another issue may have been a shift, when possible, from surgical to medical treatment. This has been suggested for uncomplicated appendicitis or cholecystitis18,19. This might also explain why some disorders for which there is no non-surgical alternative, such as incarcerated hernia or bowel perforation, showed a more moderate reduction13. In the absence of evidence of catching up at the end of the lockdown period in the present study, it can be argued that conservative treatment represented a feasible solution for some patients. This warrants further study in relevant conditions.

In many healthcare settings, elective surgery has been severely curtailed. Although this inevitably resulted in fewer complications requiring urgent surgical revision11,20, this must be set against patients listed for elective surgery whose problems deteriorated, leading to an urgent surgical admission. Despite this, the reduction for some conditions remains difficult to explain, in particular for life-threatening diseases such as bowel perforation or incarcerated hernia.

The decrease in admissions for emergencies requiring surgical treatment in the present study was also related to the local prevalence of COVID-19. The analysis highlighted that the decrease in surgical emergencies was identical in zones with a low and intermediate prevalence of COVID-19 infection, and different from that in high-prevalence zones. The mortality rate was also associated with the regional prevalence of hospital admission for COVID-19, with an increased odds of a fatal event. This might suggest that, when a threshold is exceeded in emergency departments, the quality of care may be affected and the mortality rate increases. Previous studies2,11,12 with contradictory findings may have suffered from having relatively small sample sizes.

The present study has limitations. It was based on an administrative database using classification of disease (ICD-10) codes, rather than on clinical data. Although ICD codes can be extremely accurate, they are not always consistent with clinical classification; for instance, there is no correlation between the Hinchey classification for perforated diverticulitis and ICD codes21. The use of a standardized classification does, however, facilitate reproducibility and comparison. Furthermore, admissions were classified only with respect to the main diagnosis, which seemed appropriate for most patients, but could be a simplification for complex emergencies, such as patients with multiple traumatic injuries. No information on conservative treatment in primary or secondary care or medical treatment for surgical emergencies is available. As a result, the decrease in surgical admissions might have overestimated the real incidence of acute surgical conditions. These limitations, however, must be seen in the context of a comprehensive data set at national level which, as a result of using ICD-10 codes, permits comparison with other countries.

The pandemic coupled with a national lockdown had a massive impact on emergency operations, especially in zones with a higher prevalence of COVID-19 infection, where in-hospital mortality increased significantly. Although the surgical community has the ability to adapt and cope with emerging viral infections, such as the human immunodeficiency virus and severe acute respiratory syndrome21, it is essential that health authorities act to preserve an adequate workforce, prevent scarcity of resources, and continue to deliver appropriate messages to the public in order to maintain adequate surgical services.

Disclosure. All authors delcare no conflict of interest concerning the present study.

Supplementary material

Supplementary material is available at BJS Open online.

Supplementary Material

zrab039_Supplementary_Data
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Presented to the Congress of the French Society of Digestive Surgery webinar, November 2020

References

Associated Data

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Supplementary Materials

zrab039_Supplementary_Data
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