Abstract
Introduction and hypothesis
The objective was to characterize the impact of the COVID-19 pandemic on the surgical treatment of female stress urinary incontinence (FSUI) in Brazil.
Methods
This study was conducted with population-based data from the Brazilian public health system database. We obtained data on the number of surgical procedures for FSUI in 2019 (before the coronavirus disease [COVID-19] pandemic), 2020, and 2021 (during the pandemic) in each of the 27 Brazilian states. We included official Brazilian Institute of Geography and Statistics (IBGE) data on the population, Human Development Index (HDI), and annual per capita income of each state.
Results
A total of 6,718 surgical procedures for FSUI were performed in the Brazilian public health system in 2019. The number of procedures was reduced by 56.2% in 2020, and an additional reduction of 7.2% was seen in 2021. The distribution of procedures by state showed important differences, ranging from 4.4 procedures/1,000,000 inhabitants in Paraíba and Sergipe to 67.6 procedures/1,000,000 inhabitants in Paraná (p<0.01) in 2019. The number of surgical procedures was higher in states with a higher HDI (p=0.0001) and per capita income (p=0.042). The decrease in the number of surgical procedures affected the whole country and its rate did not correlate with HDI (p=0.289) or per capita income (p=0.598).
Conclusion
The impact of the COVID-19 pandemic on the surgical treatment of FSUI in Brazil was significant in 2020 and persisted in 2021. Access to surgical treatment of FSUI varied according to geographic region, HDI, and per capita income, even before COVID-19.
Keywords: COVID-19, Suburethral sling, Urinary incontinence, Stress, Surgery, Urinary incontinence, Female
Introduction
The coronavirus disease (COVID-19) pandemic has caused profound changes in medical practice worldwide. Regular patient care has been dramatically affected since the focus of health systems shifted toward the management of patients with COVID-19 [1]. The avoidance of non-emergency treatments and medical procedures was recommended worldwide and varied according to the rate of new cases, deaths, and the availability of hospital beds [2].
Urinary incontinence (UI) is a major health problem as it is a highly prevalent condition that affects 18.7% to 35% of women, has a tremendous negative impact on patients’ quality of life [3], and is associated with an increased mental health burden [4]. The care of women with UI and other conditions such as pelvic organ prolapse has suffered a major cutback in many countries since the beginning of the pandemic [5, 6]. Specialists are becoming increasingly worried about the potential harm and impact on the quality of life of the long-term deferral of medical assessment and treatment of conditions such as female stress urinary incontinence (FSUI), pelvic organ prolapse, and overactive bladder [7–9].
Brazil has been one of the countries most affected by the COVID-19 pandemic. Studies performed a few months after the onset of the pandemic have shown a dramatic reduction in elective patient visits and surgical procedures in the whole country [10], most of them between March and August 2020. Also, at the end of 2020 and at the beginning of 2021, there were further cancellations. Given its continental dimensions and significant geographical and socioeconomic heterogeneity, the impact of the COVID-19 pandemic may differ across different regions of Brazil [11]. With 27 states grouped into five regions, Brazil has significant differences in the Human Development Index (HDI), income, and health care access [12, 13]. Complex and high-cost treatments are concentrated in the southeastern and southern regions. A national survey showed that people living in the southern and southeastern regions had greater access to health care services [14]. Seventy-seven percent of myocardial revascularization procedures in the country were performed in these regions, even though they are home to only 56.3% of the population [15]. To our knowledge, the distribution of surgical procedures for female UI has never been assessed.
We are not aware of any studies reporting official numbers of surgical treatments for female UI in any nationwide health system during the pandemic. In order to fill this gap, the Brazilian Society of Urology conducted this study to characterize the impact of 2 years of COVID-19 on the number of surgical procedures for FSUI from the perspective of the Brazilian public health system.
Materials and methods
Study design and population
We performed a retrospective analysis focused on individuals whose access to health care through the Brazilian public health system (Sistema Único de Saúde [SUS]) of the Ministry of Health, which provides health care to approximately 73% of the country’s population [16].
This study was conducted with population-based data from the SUS database (DATASUS), which includes hospital data collected by the SUS Hospital Information System (Sistema de Informações Hospitalares [SIH]). These official data are available online (http://tabnet.datasus.gov.br/cgi/tabcgi.exe?sih/cnv/qiuf.def). Data from surgical procedures performed for FSUI in the SUS from 1 January 2019 to 31 December 2021 in each of the 27 Brazilian states were included. The procedure codes for surgical procedures for FSUI and the International Classification of Diseases 10th revision codes for UI were used to identify all procedures performed in the study period. The surgeries that are performed in the public health system in Brazil for FSUI are synthetic midurethral slings, autologous fascia pubovaginal sling, and Burch colposuspension. Bulking agents are not covered. Additionally, we included official data from the Brazilian Institute of Geography and Statistics (IBGE) on the population, HDI, and annual per capita income in each of the 27 states.
Outcomes
Outcomes included the change in total number of surgical procedures for FSUI, number per region, and per federal district. We also analyzed variations in the number of surgical procedures in the 27 Brazilian federal districts (26 states and the capital city of Brasilia), considering the HDI and annual per capita income in each state. We compared the results from 2019 with those from 2020 and 2021 to evaluate the impact of COVID-19. DATASUS and IBGE data are in the public domain; as such, approval from an ethics committee was not required. The study was conducted in accordance with Strengthening the Reporting of Observational Studies in Epidemiology guidelines for cohort studies.
Data collection and statistical analyses
Data were collected electronically in March 2022 through the aforementioned websites and were tabulated for statistical analysis. Numerical variables were expressed as medians and interquartile ranges, whereas categorical variables were expressed as absolute values, percentages, or proportions. Student’s t or analysis of variance tests were used to compare continuous variables. Categorical variables were compared using the Chi-squared or Fisher’s exact tests. Associations were described as odds ratios, with the respective confidence intervals. All tests were two-tailed and a p value <0.05 was considered statistically significant. GraphPad Prism version 8.0.4 (San Diego, CA, USA) was used for data analysis.
Results
Surgical procedures for FSUI before and after COVID-19
A total of 6,718 surgical procedures for FSUI were performed in the SUS in 2019, the year before the COVID-19 pandemic. With a population of 211.7 million inhabitants, the rate of surgical procedures for FSUI in the whole country was 31.7/1,000,000 in 2019.
Throughout 2020, a total of 2,944 surgical procedures for FSUI were performed in the country within the SUS. This represented a reduction of 56.2% compared with 2019. In 2021, a total of 2,733 surgical procedures for FSUI were performed, representing an additional 7.2% decrease in comparison with 2020. Figure 1 shows the comparison of the total number of surgical procedures for FSUI in 2019, 2020, and 2021 per state.
Fig. 1.
Number of surgical procedures adjusted to population per state in 2019, 2020, and 2021. Each dot represents the number of surgical procedures adjusted by the population of each Brazilian state in each year
Distribution of surgical procedures according to region and state before and after COVID-19
In 2019, the southeastern region had the most surgical procedures (47.4%) whereas the northern region had 4.3%. The distribution of surgical procedures by state varied significantly, ranging from 4.4 surgical procedures/1,000,000 inhabitants in Paraíba and Sergipe (northeastern region) to 67.6 surgical procedures/1,000,000 inhabitants in Paraná (southern region; p<0.01). The number of surgical procedures was higher in states with a higher HDI (p=0.0001) and per capita income (p=0.042).
During the 2 years of the COVID-19 pandemic, all states were similarly affected in terms of a decrease in FSUI procedures. The socioeconomic differences also remained in 2020 and 2021. The rate of reduction did not correlate with HDI (p=0.289) or per capita income (p=0.598) (Fig. 2). The number of surgical procedures in 2020 ranged from 3.3/1,000,000 inhabitants in Amazonas to 33.2/1,000,000 inhabitants in Santa Catarina. The national rate of surgical procedures for FSUI was 13.9/1,000,000 inhabitants in 2020 and 12.9/1,000,000 inhabitants in 2021.
Fig. 2.
Correlation between the number of surgical procedures per state and the Human Development Index in 2019, 2020, and 2021. Each dot represents the number of surgical procedures adjusted by the population of each Brazilian state according to the year of assessment and Human Development Index (HDI)
The distribution of surgical procedures by state and geographic region, with adjustments by population, HDI, and annual income in 2019, 2020, and 2021, is described in Table 1.
Table 1.
Number of surgeries for FSUI in 2019, 2020 and 2021 according regions, Federative Units and demographic data
* In comparison with 2019
** Federation Units with less than 40 surgical procedures in 2019 were grouped
Blue – North region; Yelloy – North East region; Pink – Southeast region; Green – South region; Brown – Midwest region.
Discussion
This study showed a major influence of the COVID-19 pandemic on the number of FSUI performed in Brazil. A reduction of 56.2% in FSUI surgical procedures performed within the public health system (SUS) in Brazil was observed in the year 2020 compared with the previous year. An additional 7.2% reduction occurred in 2021. All states were similarly affected. We have also shown a major disparity in surgical procedures for FSUI across states and geographical regions in Brazil, with the richest and most developed federal units concentrating higher numbers before and after the COVID-19 pandemic.
A significant reduction in surgical hospital admissions in Brazil occurred in 2020, in both the public and private health systems. Considering all surgical admissions for any type of surgery, reductions of 19% and 21.5% were seen in the public and private systems respectively (https://www.gov.br/ans/pt-br/assuntos/noticias/numeros-do-setor/planos-de-saude-realizaram-1-3-bilhao-de-procedimentos-em-2020; https://portal.cfm.org.br/noticias/pandemia-derruba-quase-30-milhoes-de-procedimentos-medicos-em-ambulatorios-do-sus/). An Italian survey estimated that from March to June 2020, 82.7% of functional urology surgical procedures were postponed or cancelled [17]. Globally, the rate of postponement and cancellation of operations for benign conditions was about 80% at the beginning of the pandemic [2]. From March to December 2020, a reduction of 2.8 million elective surgical procedures (-38%) in comparison with the same period of the previous year was reported by the Federal Medical Council in Brazil (https://portal.cfm.org.br/noticias/sus-tem-quase-3-milhoes-de-cirurgias-eletivas-suspensas/). The 56.2% decrease in surgical procedures for the treatment of FSUI verified in our study is higher than these figures. This is probably because higher priority surgical procedures, such as oncological procedures, were less affected by the pandemic. Brazil has been one of the countries with the highest rates of infection and deaths due to COVID-19 and a major reduction in medical visits and surgical procedures was seen in the whole country [18]. It is thus not surprising that surgical procedures for FSUI were significantly decreased during these years.
A systemic cutback of surgical procedures on this scale has never happened in the past 50 years and has certainly not happened since the advent of the SUS. It is expected to have an significant impact on the quality of life of patients and may have severe consequences for the health system. As a stronger COVID-19 wave struck Brazil in late 2020 and remained in 2021 [19], with new restrictions and more postponed procedures, the consequences were even worse, with an additional reduction of 7.2% in the number of surgical procedures in 2021. Once hospitals resumed elective procedures, oncological procedures, transplantations, and other time-sensitive surgical procedures were prioritized and elective surgical procedures for benign diseases have remained more strongly affected [2]. This situation may lead to a deterioration of the population’s health and produce important economic and social costs, opening up a debate about ethics and patient safety issues [20].
Some studies highlighted the time to clear the backlog resulting from COVID-19 disruption. The COVIDSurg Collaborative [2] estimated that 12 weeks of around 89% of cancellations or postponing of surgical procedures should require 45 weeks to clear the backlog if the number of surgical procedures increases in 20% of the normal threshold. If the increase in the number of surgical procedures is 10%, the estimated time to clear the backlog is around 90 weeks. An Italian survey [19] estimated that the time to clear this backlog would be 90 months, considering an increase of 20% from the pre-COVID-19 number of pelvic floor dysfunction procedures. In Brazil, a 20% increase in comparison with the pre-COVID-19 number of surgical procedures is nearly impossible to reach, because the SUS was working at its maximum capacity before COVID-19 [13, 16, 19]. Therefore, we expect an even bigger undertreatment of our patients with FSUI.
The SUS is a free-of-charge, universal health system that represents the only option of health assistance for 73% of the population. The remaining 27% also have access to the private health system [14]. FSUI is the most prevalent type of UI among women and it affects 20.4% of Brazilian women aged 40 and older [21]. This corresponds to 7.7 million women based on population data reported by the IBGE in January 2021. Almost 6 million women rely solely on the SUS to treat FSUI. The 6,718 surgical procedures for FSUI performed within the SUS in 2019 represent a very low and concerning number. Assuming that half of the Brazilian women with FSUI need surgical treatment and maintaining this annual rate of surgical procedures, it would take 446 years to treat them all. In the USA, the total number of surgical procedures for FSUI performed in 2003 was 165,776, yielding a rate of 571/1,000,000 inhabitants [22]. In a UK study, around 400 FSUI procedures/1,000,000 inhabitants/year were performed between April 2013 and March 2016 [23]. Our mean number of 31.7 FSUI surgical procedures/1,000,000 inhabitants per year before the COVID-19 pandemic is 10 to 15 times lower than the numbers of developed countries, representing a major unmet health care need.
Some characteristics of the Brazilian health system can help to explain these results. The concentration of health services and professionals in more developed regions, chronic underfunding, and the need to cover all preventive and curative care to the whole population are the main problems. A 2017 survey showed that Brazil spent US$ 389.00 per capita/year on health care, whereas other countries with public health systems had per capita investments that were almost 10 times higher: US$ 3,376.00 in France, US$ 3,505.00 in Canada, and US$ 1,770.00 in Spain (https://portal.cfm.org.br/noticias/paises-ricos-gastam-quase-dez-vezes-mais-que-o-brasil-2/).
Our data showed that the states with highest HDI and per capita income were those with the most surgical procedures for FSUI, before and during the pandemic. Other health indicators also show this discrepancy in health care between different Brazilian regions. The southeastern and southern regions, for example, where the HDI and per capita income indices are higher, have a greater number of cardiovascular surgical procedures than the northern, northeastern, and central-western regions [15]. The lowest infant mortality rates are also found in the southeastern and southern regions [24]. Covre et al. [25] showed an important regional difference in the number of surgical procedures performed by the SUS between 2008 and 2016, with the southern region showing the best rate (2.56 surgical procedures per 100 inhabitants/year); the northeastern and northern regions, where the HDI and per capita income indices are the lowest, showed the worst rates (2.04 and 1.92 surgical procedures per 100 inhabitants/year respectively). An analysis of 2002 [26] showed that around 80% of all urologists are located in the southeastern (61.6%) and southern (17.8%) regions and that the density of this specialty (urologist/inhabitants) can reach up to 5 times that of other regions (1:33,943 and 1:161,037 respectively).
Despite these limitations, the SUS has managed to vastly improve access to primary and emergency care, reach universal coverage of vaccination and prenatal care, and invest heavily in the expansion of human resources and technology. As an underfunded system with universal access, the focus on life-threatening conditions and little effort made to treat quality-of-life conditions such as FSUI is expected. The lack of access to an overloaded health system and restricted resources can thus be considered the main causes of the low number of FSUI surgical procedures [16].
A key strength of this study was its population-based approach over 3 years. Our results provide insight into the current surgical management of FSUI in Brazil, providing estimates of the major impact that COVID-19 had on this important health parameter. To the best of the authors’ knowledge, such data are presently lacking in the literature. This study has limitations inherent to its retrospective nature and the use of aggregate data. The units of analysis were each of the Brazilian states. The quality of data was also limited by the efficiency of government agencies in collecting and providing precise and comprehensive information. However, the large number of procedures evaluated (6,718) in a country with continental dimensions and 211 million inhabitants seem to make the findings robust and reliable. Another limitation is the absence of data from the private health system, which is responsible for the health of 27% of our population.
This study provides new evidence on the surgical management of FSUI within the SUS. Our results showed that the surgical treatment of FSUI in those covered by the SUS was severely impacted by the COVID-19 pandemic in the whole country. Additionally, we identified that number of FSUI surgeries in Brazil has been decreased since COVID-19, and more severely in the poorer states. Future research including the public and private health systems is needed to better understand the current overall scenario of the treatment of FSUI in Brazil and to propose changes for improving the care of these women.
Acknowledgements
The authors would like to thank the Brazilian Society of Urology for administrative support for this study.
Funding
The authors declare that there are no conflicts of interest or financial disclosures regarding this study.
Declarations
Conflicts of interest
None.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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