key: cord-0951452-cz5czxdn
authors: Prajapati, Ashwin; Gupta, Srinath; Nayak, Prakash; Gulia, Ashish; Puri, Ajay
title: The effect of COVID-19: Adopted changes and their impact on management of musculoskeletal oncology care at a tertiary referral centre
date: 2021-10-22
journal: J Clin Orthop Trauma
DOI: 10.1016/j.jcot.2021.101651
sha: d317ad94b26ec89cc0efb71123fef918fabe8a41
doc_id: 951452
cord_uid: cz5czxdn

BACKGROUND: COVID-19 pandemic has disrupted access to healthcare. Delay in diagnosis and onset of care increases cancer related mortality. We aim to analyse its impact on patient profile, hospital visits, morbidity in surgically treated patients, and process outcomes. METHODS: We analysed an ambi-directional cohort from 16th March to June 30, 2020 (Pandemic cohort, PC) as compared to 2019 (Pre-pandemic cohort, PPC). We measured, new patient registrations, proportion of ‘within state’ patients vs ‘rest of India’, median time to treatment decision, proportion of patients seeking ‘second opinions’, modality of initial treatment (surgery/radiotherapy/chemotherapy), 30-day post-operative morbidity/mortality, conversion of inpatient-to ‘teleconsult’ in the PC. RESULTS: Between the 2 cohorts, new registrations declined from 235 to 69 (70% reduction). The percentage of ‘within state’ patients increased from 41.7% to 53.6% (11.9% increase). There was a decline in second opinion consults from 25% to 16%. The median time to decision-making decreased to 16 days in PC vs 20 days in PPC (20% reduction). Surgery was the first line of treatment in 40% as compared to 34% in the PPC with a mean time to surgery of 24 days in PC compared to 36 days in PPC (33% reduction). 66 surgeries were performed in the PC compared to 132 in the PPC. Thirty day post operative morbidity needing readmission remained similar (18% PC, vs 17% PPC). Perioperative intensive care remained similar in both cohorts. Teleconsultation was deemed medically safe in 92.8% (439/473 patients). CONCLUSIONS: The COVID 19 pandemic has substantially reduced access and onset to cancer care. Post operative morbidity and mortality did not seem to worsen with triage. Teleconsultation is an effective tool in optimizing follow up strategy.

Email -aashishgulia@gmail.com  List of Tables - Table 1 : Geographical distribution of new patient registration Background: COVID-19 pandemic has disrupted access to healthcare. Delay in diagnosis and onset of care increases cancer related mortality. We aim to analyse its impact on patient profile, hospital visits, morbidity in surgically treated patients, and process outcomes.

We analysed an ambi-directional cohort from 16 th March to 30 th June 2020 (Pandemic cohort, PC) as compared to 2019 (Pre-pandemic cohort, PPC). We measured, new patient registrations, proportion of 'within state' patients vs 'rest of India', median time to treatment decision, proportion of patients seeking 'second opinions', modality of initial treatment (surgery/radiotherapy/chemotherapy), 30-day post-operative morbidity/mortality, conversion of inpatient-to 'teleconsult' in the PC.

Results: Between the 2 cohorts, new registrations declined from 235 to 69 (70% reduction).

The percentage of 'within state' patients increased from 41.7% to 53.6% (11.9% increase).

There was a decline in second opinion consults from 25% to 16%. Based on the changing dynamics of disease spread and workload, policies will vary depending on diverse geographical locations and individual institutions. As these changing policies may often be guided by instinct and experience rather than evidence, continuously auditing the processes and outcomes allow for real-time feedback and improvement and help make them evidence-based.

At our institute, we adopted a series of policy changes to continue offering in-person consults for all new patients with untreated or cancers on active treatment while offering remote tele-consults primarily targeting long-term follow-up patients who missed appointments due to nationwide travel restrictions.

In this article, we measure variables for provision of continued access to cancer case across 2 cohorts (pre pandemic and pandemic). We also analysed demographics of the patients and 30 day outcomes in patients who underwent surgical management during the pandemic. We also describe a triage system that other institutes/units may adapt to suit their needs. The triage system outlined here provides context to the outcome measures. 

We 

We utilized existing online electronic medical records (EMR) and outpatient appointment schedules to call all eligible patients. We offered to defer an avoidable visit in patients with stable disease and functional status. These patient contacts were documented in the EMR.

Any interaction that prompted concern was encouraged to seek an in person consult at TMC. All active treatment schedules for post-operative patients were continued.

All patients underwent a preoperative real-time reverse transcription-polymerase chain reaction (RT-PCR) test from nasopharyngeal and oropharyngeal swabs at least 48 hours before the scheduled surgery. They were isolated at triage areas in the hospital until the results. The tests were interpreted as negative, inconclusive, and positive as per standard criteria. Two inconclusive tests were treated as positive and re swabbed on day 14.

Patients who tested positive were admitted to a dedicated COVID-19 ward and monitored for symptoms and disease severity, asymptomatic patients were offered home isolation. We triaged our elective OR lists to defer patients requiring complex surgeries likely to require multiple blood transfusions and prolonged ICU stay(non COVID related) over 1 day(>1 day).

Morbidity was defined as any post or intra operative complication which required readmission, prolonged intensive care due or not due to perioperative COVID positivity, and delay (over 4 weeks from surgery for chemotherapy and over 8 weeks for adjuvant radiation) in adjuvant therapy. We measured the number of in-person long term follow up outpatient visits in PPC and compared it to in-person + tele consult follow up patients PC.

We defined long term-follow up patients as those beyond 6 months of surgery with no active adjuvant therapy.

We outline the changes implanted in patient flow and triage process to put our measurements in perspective table 1.

Sixty-nine new BST DMG cases were registered from 16 th March to 30 th June 2020.

This was a drastic 70% drop compared with 235 pre-COVID 2019 (including second opinion consultation) ( Table 2 ).

The ratio of patients coming from Maharashtra (home state) and those from the rest of India increased to 1.2 in the PC (37:30) compared to 0.7 (98:135) in the PPC cohort again a drop reflecting impact of travel restrictions (Table 2) . Notably, no new international patients were registered during this period. We treated 36 [one third compared to pre-COVID cohort (108)] patients with primaries of musculoskeletal system (including squamous cell cancers) in PC.

Primaries of the musculoskeletal system treated with palliative intent in both cohorts were similar; 6/36 (17%) in the PC compared to 15/108 (14%) in the PPC. The remaining analyses is restricted to 30 from the PC and 93 from the PCC which were treated with curative intent (Figure 1 and Figure 2 ).

J o u r n a l P r e -p r o o f in the PPC (Figure 3 ). Meantime to surgery was 24 days in the PC (1 LTFU excluded and 1 turned COVID positive pre-surgery) compared to 36 days (5 LTFU excluded) in the PPC (Table 3) .

We performed 66 surgeries in PC, compared to 132 in the PPC (50% reduction). In Major resources were diverted to bridge this gap therefore care of patients suffering from non-COVID illness especially cancer was compromised (3). Non-standardization of oncology care in the COVID era due to the unforeseen nature of pandemic crisis also contributed to compromised in cancer care (6) . predicted cancer-related mortality due to delayed or denied care, prompted various oncology institutes to continue cancer care even in peak pandemic (4).

Our Institute continued routine, emergency oncologic care and COVID care under one roof, with no breaks throughout the pandemic, with safe and sustainable outcomes.

The administrative measures taken to enable this have been published elsewhere (4). We reported early outcomes of the major cancer surgery performed through the pandemic (7).

The demography of patients treated in the pandemic year was different than the control group of 2019. We had less than one-third of new case registrations, 69 cases from 16 th March 2020 to 30 th June 2020 compared to 235 new case registrations during the same period in 2019, reflecting our patient pool that has a significant nationwide footprint and an inevitable pool of patients that were denied care. We are likely to see its impact on mortality and stage migration in the coming times.

We had younger patients, lower ASA grades, lesser predicted blood loss and lower hospital stay. This was aligned with the diversion of resources to pandemic care and shortage of blood products across the city ( pandemic (6) . This article provides structured recommendations for Health care personals to adapt to the situation, optimize treatment protocols with judicious use of all resources while providing evidence-based treatment for sarcoma patients.

Being retrospective in nature, over a relatively short time period, this ambidirectional observational cohort study may underestimate the denial or deferral of care as we were unable to document lack of care, stage migration, denied care in the population who were unable to reach us. However, this data does point toward the care gap that had widened through the pandemic despite our best efforts to ameliorate it. This was demonstrated in the first National Cancer Grid study conducted in India, across over 40 institutes (11) .

Pandemic preparedness has led to an acute overhaul and optimization of many legacy inefficiencies within hospital systems. Despite the best efforts of institutes to ensure continued care, the widening gap of availability of care and worsened access to care is likely to worsen cancer outcomes in the coming years. These best practices could also be used in pandemic free times to maximize efficiency, cost-effectiveness without compromising patient safety or care.

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