In this observational study, we assessed the impact of the first wave of the COVID-19 pandemic on non-COVID-19 patients with HF. Specifically, we investigated whether the health crisis affected the quality of care provided to elderly patients by analyzing delays in surgical interventions, LOS and timely rehabilitation as process indicators, and 30-day mortality as the main health outcome.
Our study shows that the pandemic negatively affected non-COVID-19 patients with HF. The quality of care has been undermined by the unavoidable services’ reorganization needed to address the emergency. The proportion of patients undergoing surgery and receiving timely treatment decreased, as well as the mean LOS and the timely use of rehabilitation services. Health outcomes suffered as well: patients with HF experienced an increased mortality rate, particularly in March 2020. In the following months, HF mortality returned to approach pre-crisis levels, demonstrating the adaptation and resilience of the healthcare system.
Interpretation within the context of the wider literature
Our analysis shows that the first wave of the COVID-19 pandemic determined a significant reduction in HF hospitalizations in Emilia-Romagna, one of the most severely hit areas of Italy and Europe, although the patient characteristics did not differ between 2020 and 2019. This finding is consistent with other studies [21–23] and can be explained by the enforcement of a strict national lockdown from March 9 to May 4, 2020. By confining people at home, interrupting mobility and work activities, and reducing road traffic, the frequency of travel- and work-related injuries dropped; this led to an overall reduction in the number of patients accessing emergency departments and hospitals. Fear of hospitalization could also have been responsible for this reduction [24, 25]. Moreover, COVID-19 infections, hospitalizations and fatalities might have averted the overall number of HFs in the elderly population.
The disruption of the healthcare services determined an increase in the percentage of patients with HF that did not undergo surgery and a decline in the proportion of patients undergoing timely surgery within 48 hours of hospital admission, together with a reduction in mean LOS. These changes could be ascribed to the sudden hospital overload experienced during the first months of 2020, which coerced healthcare institutions to enforce prioritization of their services. Many professionals’ skills, such as surgeons’ and anesthesiologists’, were repurposed to attend to COVID-19 patients in dedicated wards. This created service gaps, reducing both the number of physicians and the time dedicated to non-COVID-19 patients [21]. Diminished healthcare capacity was the reason behind the curb of peri- and post-operative care in HF patients, which is shown by the significantly reduced mean LOS. Following health policy-maker’s suggestions, early discharge was recommended to decrease the risk of hospital-acquired infections and to convert non-COVID-19 hospital beds to COVID-19 beds. Other studies described similar gaps in the healthcare services’ capacities and capabilities during the pandemic and reported similar results [22, 25].
Further considering health services’ performance, we found that the number of patients receiving bed-based rehabilitation within 30 days of hospital admission from February to May 2020 was lower compared with the same period of the previous year. The performance of rehabilitative care could have been undermined by the difficulty to reorganize treatment pathways for non-COVID-19 patients. In Emilia-Romagna, many rehabilitation centers experienced COVID-19 outbreaks, preventing them from providing adequate standards of care and safety [21]. As shown in several studies, the inability of outpatient rehabilitation facilities (i.e., community hospitals and nursing homes) to accept and treat patients coming from acute care hospitals could be responsible for the reduction and delay of timely rehabilitation treatment [26, 27].
Since the initial outbreak of the pandemic, several authors reported an excess of mortality for patients with COVID-19 affected by HF [28–30]. Our study shows that in 2020 the 30-day mortality rate of non-COVID-19 elderly patients with HF was higher compared with the previous year. This increase was significant in March 2020, which was the month with the highest incidence of COVID-19 cases in Emilia-Romagna during our study period (see S1 Fig). The risk of dying (adjusted by age, sex, and comorbidities) was twice as high as the one observed in March 2019. This could be related to the extreme pressure that healthcare structures had to withstand [9, 16], to the abrupt changes in healthcare organization and management, and to the possible lack of attention to the treatment pathways [22, 23, 30].
In keeping with existing literature [28], our analysis confirms that timely surgery after HF was associated with reduced mortality within 30 days of hospital admission. Considering this, it may seem surprising that March 2020 did not exhibit a significant reduction in the proportion of patients undergoing timely surgery, but rather a slight non-significant increase when compared with March 2019. On the one hand, it is possible that in March 2020 there was greater availability of operating rooms and resources to treat HFs due to a reduction in elective surgical procedures for other conditions. One the other hand, the worsening of 30-day mortality in those weeks of 2020 may be marginally explained by a significant reduction in LOS. However, the significant gap in mortality resulting from our multivariable model suggests that other variables should be seen as determinants of patient health after HF, such as misreporting, or misclassification of actual COVID-19 cases and additional factors related to patient clinical management not evaluated in this study.
In the following two months of 2020, 30-day mortality was higher than in April and May 2019, but the gap was not significant and narrower when compared to that observed between March 2019 and March 2020. However, during these months the process indicators remained significantly worse than in 2019. These findings underline the Emilia-Romagna healthcare system’s capacity to respond to the initial health crisis and to take effective actions to mitigate the impact of the pandemic.