key: cord-0810610-4himnrpc authors: Groen, Maarten te; Derks, Monica E.W.; Kuijpers, Chantal C.H.J.; Nagtegaal, Iris D.; Hoentjen, Frank title: Reduction of IBD healthcare during the COVID-19 pandemic: a nationwide retrospective cohort study date: 2020-10-22 journal: Gastroenterology DOI: 10.1053/j.gastro.2020.10.032 sha: 9a0e70557eb1f005d1cdfa7fc0f05de31ae77cc7 doc_id: 810610 cord_uid: 4himnrpc nan Coronavirus disease 19 (covid-19) caused a worldwide disruption of regular healthcare, with more than 37 million cases and over 1,000,000 deaths 1 The Netherlands -a country with 17.4 million inhabitants and universal healthcare -on February 27 th 2020, the pandemic rapidly spread across the country reaching its first peak in April 2020 2 . Regular healthcare, including inflammatory bowel disease (IBD) care was strongly reduced to establish sufficient capacity for covid-19 care and to prevent covid-19 spread by patients and healthcare workers. IBD healthcare includes scheduled out-patient monitoring and endoscopic or surgical procedures. Because of decreased hospital capacity for non-covid-19 care, many IBD-related appointments and procedures were cancelled or postponed. In addition, initial confinement measures to prevent spread of covid-19 had an emphasis on safeguarding vulnerable populations, including IBD patients 3 . Most of the consultations for general practitioners transitioned to tele-health or did not take place at all due to flooding of practices by covid-19 care. Lastly, fear of covid-19 increased the risk of delayed careseeking behavior by patients, leading to less hospital visits 4 . The exact consequences of these factors on regular IBD healthcare are unknown. This information may provide guidance for patients and healthcare workers to prevent mortality and morbidity in the IBD population, and could aid in improved healthcare management and prioritization during a new outbreak. Therefore, we aimed to determine the decrease in delivered IBD healthcare during the covid-19 pandemic of 2020 in comparison to national data of 2018-2019, utilizing a pathology database with full nationwide coverage. J o u r n a l P r e -p r o o f We conducted a search (date: 28 th of August 2020) in PALGA (the nationwide network and registry of histo-and cytopathology in the Netherlands) to identify IBD-related endoscopies or surgery, new diagnoses of IBD or IBD-related dysplasia and colorectal cancer (CRC) in a nationwide retrospective cohort study 5 . Incidences of these procedures and diagnoses were determined and displayed using graphs up to week 32, and compared to mean incidence data of 2018-2019. The covid-19 pandemic in the Netherlands was defined as the period from February 27 th 2020 up to the 9 th of August (week 32) 2 . Additional information is stated in supplementary file 1. The PALGA search resulted in 66,684 IBD-related procedures. A total of 61,097 procedures were eligible after exclusion of non-IBD diagnoses. A decline in total incidence of IBD-related procedures (endoscopy and surgery) was seen during the covid-19 pandemic. At the national peak of the pandemic in April 2020, a maximum decrease of 59.7% (310 procedures) was observed compared to the mean incidence of April 2018-2019. Although a relative increase of IBD procedures was seen in the subsequent weeks, an overall decrease of 14.2% New IBD diagnoses during the covid-19 pandemic decreased by 6.5% (125 diagnoses) compared to 2018-2019, with a maximum decrease of 46.3% (30 diagnoses). Indefinite (IND) and low-grade dysplasia (LGD) diagnoses decreased by 25.5% (214 diagnoses). No decrease was seen for high-grade dysplasia (HGD) or colorectal cancer (CRC) diagnoses. In this nationwide retrospective cohort study we found a large reduction in IBD healthcare during the covid-19 pandemic. At the height of the pandemic, almost 6 out of 10 IBD-related procedures were cancelled or postponed. Importantly, in the months of recovery after the peak of the pandemic this deficit was not fully compensated, leading to a net decrease in IBD-related procedures of approximately 14% compared to 2018 and 2019. The decrease in IBD-related procedures was smaller for surgical procedures compared to endoscopic procedures (5.5% vs 14.7%). In addition, no decrease in HGD and CRC diagnoses was seen. Both can be explained by higher prioritization, since the indication for surgery is often based on HGD, CRC or severe disease. Furthermore, these patients are more likely to present themselves with symptoms resulting from the underlying malignancy (anemia, rectal bleeding) than those with IND or LGD, leading to timely referral. Several clinical implications can be drawn from this study. Firstly, the incomplete recovery of missed procedures and diagnoses implicates there are still patients with undiagnosed dysplasia at risk of progression to CRC. A recent study estimated that a three-month delay in cancer surgery due to worldwide covid-19 care reduces the benefit in life-years gained (LYGs) of all covid-19 care by 19% 6 . This implies that optimization of healthcare management is needed to prevent negative outcomes for patients due to insufficient regular healthcare, including IBD healthcare. Secondly, the decrease in IBD-related procedures during the covid-19 pandemic will allow evaluation of the current CRC surveillance practice. Further research into mortality and morbidity after the covid-19 pandemic will open opportunities for appraisal and possible improvement of stratification and surveillance strategies. This study has multiple strengths, including the use of the nationwide PALGA database with excellent national coverage, with confirmed accuracy for IBD and IBD-related diagnoses 7, 8 . There are also limitations. Firstly, our results represent the procedures where histology was acquired, excluding endoscopic procedures without tissue sent for histologic evaluation. However, this might correlate with an absence of need to biopsy (no suspicion of dysplasia/CRC or inflammation), likely limiting the J o u r n a l P r e -p r o o f consequences of postponement for these patients. Secondly, due to the nature of PALGA, no data on type of endoscopy (surveillance or not), therapy or mortality were available. Nevertheless, the true consequences of the covid-19 pandemic on effective surveillance, therapy and mortality are likely not measurable yet, opening possibilities for future research the upcoming years. In conclusion, in this nationwide study we observed a decrease in IBD endoscopy and surgery during the covid-19 pandemic. Although the utilization of procedures has returned to comparable level with the preceding years, a deficit remains while the strong decrease in dysplasia diagnoses is concerning. These data may help healthcare providers and hospitals in planning healthcare during a second peak of covid-19 in the near future. J o u r n a l P r e -p r o o f The daily impact of COVID-19 in gastroenterology Government of The Netherlands. Corona virus graphs. 2020. Acces date: 2 Clinical outcomes of covid-19 in patients with inflammatory bowel disease: A nationwide cohort study Delayed access or provision of care in Italy resulting from fear of COVID-19 Pathology databanking and biobanking in The Netherlands, a central role for PALGA, the nationwide histopathology and cytopathology data network and archive Collateral damage: the impact on outcomes from cancer surgery of the COVID-19 pandemic Long-term Risk of Advanced Neoplasia After Colonic Low-grade Dysplasia in Patients With Inflammatory Bowel Disease: A Nationwide Cohort Study A 20-Year Temporal Change Analysis in Incidence, Presenting Phenotype and Mortality, in the Dutch IBDSL Cohort-Can Diagnostic Factors Explain the Increase in IBD Incidence