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https://orcid.org/0000-0002-5985-9595
Abstract
Abstract
Background
The adoption of health care restrictions due to the COVID-19 pandemic led to the cancellation of elective surgical care. However, the impact on patients is unknown.
Objective
To evaluate the psychological and economic impact of the cancellation of scheduled spinal operations.
Methods
We identified 50 patients with cancelled surgeries between 16 March 2020 and 24 April 2020. Forty-nine (98%) participants were contacted, with whom the modified WES-Pi questionnaire was filled in during a telephone interview.
Results
Of the 49 respondents, 28 (57.2%) were aged <65 years. The most often reported problem (85.7%) was an ongoing limitation in basic daily activities. At least moderate sadness was experienced by 65.3% and disappointment by 73.5% of the patients. More than 80% reported concerns about the continuation and 73.5% about the progression of their symptoms. Out of 27 employees (55.1%), 63% could not work due to severe pain or movement limitation (p < .001). The inability to work was associated with anger (p = .037). The work-related impact of the cancellation was associated with stress (p < .0001) and concerns about continuing the symptoms (p = .004). Two-third of patients would undergo immediate surgery despite the current epidemic situation.
Conclusions
The cancellations of elective spinal surgeries have a serious psychological impact on patients. This together with potential economic consequences is especially evident in employees unable to work due to pain or movement disability. The information is beneficial for health management. Every effort should be made to resume planned surgical treatment if the epidemiological situation allows it.
Introduction
On 12 March 2020, a state of emergency was declared in the Czech Republic in connection with the SARS CoV-2 (severe acute respiratory syndrome coronavirus-2, COVID-19) pandemic. In addition to the restriction of social contacting and free movement, it also included complete suspension of all non-acute outpatient activities and elective procedures.1,2
From the following week, we started to triage the patients in accordance with the recommendations published by spinal surgeons3,4 or NHS UK5 advocating acute spinal surgery in cases which are at risk of permanent and/or potentially reversible serious neurological dysfunction. All other spinal cases have been cancelled indefinitely.
World neurosurgical literature have responded to the current situation mainly in the form of editorials and short reports written by leading figures in the field,3,4,6–8 describing the current strategy to continue providing urgent and acute procedures and halting all elective surgeries. Patients with chronic spinal conditions suffering from pain are affected not only by cancellation of their surgeries but also by the suspension of pain clinics9 or rehabilitation units.10 However, our review of literature failed to find any article describing the influence of the COVID-19 restrictions on chronic patients requiring elective procedures. This is particularly important due to the fact that it is not yet possible to estimate how long the pandemic and the resulting health care restrictions will last.
The aim of the present study was to quantify the psychological and economic impact on patients following the cancellation of their elective spinal surgery due to governmental health care restrictions in response to the COVID-19 pandemic.
Materials and methods
The records of a prospective database of patients cancelled due to a governmental decree were reviewed. The study was approved by the local institutional review board. A total of 50 patients with chronic spinal conditions were identified during a 6-weeks period between 16 March 2020 (the beginning of the restrictions) and 24 April 2020. The study was conducted in compliance with STROBE statement.11
The following data were extracted from the database:
Patient demographics including gender, and age.
Date of an out-patient examination and the assigned date of the operation.
Spinal pathology and type of surgery.
Date of the cancellation.
The Winter Elective Surgery Cancellation and Psychological impact (WES-Pi) survey12 was used as a basis to quantify the financial and psychological impact on patients following the cancellation of elective surgery. The questionnaires were filled in by a junior physician during phone interviews with the patients (from 29 April 2020 to 5 May 2020). The patients were asked about their work status (employed, self-employed, in education, unemployed, retired), ability to work (able to work, not able due to pain or disability/pandemic restrictions), possible work-related consequences (extra days off, fear of dismissal, other) or extra costs caused by the cancellations. They were also asked about social activities and hobbies missed due to the postponement of the surgery (such as family days out, attendance at weddings, visiting friends, or ability to physically participate in hobbies or interests outside of work), feelings (sadness, disappointment, anger and stress) and future concerns at the time the operation was cancelled (fear of continuing of the symptoms for an unpredictable period of time; fear of worsening of the symptoms). Feelings and future concerns were rated as 1 – not at all, 2 – slightly, 3 – moderately, 4 – very and 5 – extremely. The patients were specifically asked about the new feelings they had experienced when they had received a call from the hospital about the cancellation of their surgeries. One additional question was asked: if elective surgeries were performed again, would the patient undergo the procedure (1) immediately, (2) would wait (understands the difficult situation, the order of the others, etc.), or (3) would not undergo it for fear of COVID-19 infection.
Statistical analysis
The statistical analysis was performed using R version 4.0.0 (Vienna, Austria). Descriptive statistics were used to summarize characteristics of study participants. Categorical parameters are expressed as counts and frequencies and continuous parameters as mean ± standard deviation. If the variables were continuous, t-test was used; if they were binary, then Fisher’s exact test was used for comparing the groups. Significance was assumed at p < .05.
Results
We were able to contact 49 of 50 patients whose surgeries were cancelled (98%). Data on participant characteristics and types of surgeries are displayed in Table 1.
Table 1. Patient characteristics.
There were 22 women (44.9%) and 27 men (55.1%) ranging in age from 35 to 75 years (mean 59 ± 12 years). The mean period from the first assessment in the spinal out-patient clinic to the proposed date of surgery (waiting time for surgery) was 51 ± 21 days and the mean period between cancellation and scheduled operation (cancellation period) was 7.2 ± 4.7 days. Six patients (12.2%) had their operations cancelled within 24 hours, 30 surgeries (61.2%) were cancelled between 24 hours and seven days, and 13 cases (26.6%) more than one week prior to the proposed operation.
Only six patients (12%) reported direct economic impact meaning extra payment for medication, child care or extra carer support, etc. The most often reported problem (85.7%) was an ongoing limitation in basic daily activities like cooking or cleaning.
Twenty-seven patients (55.1%) were employed at the time of cancellation. Only nine (33.3%) of the working adults were able to return to work during the time they had originally scheduled off for their operation. One patient could not work due to work-related governmental restrictions, while the majority of employees could not work due to severe pain or movement limitation (17 cases, 63%, p < .001). In this last group, the mean period from the scheduled date of surgery to interview was 33.5 ± 8.7 days. In 12 cases (44.4%), the employed patients reported serious work-related issues. Three patients (6.1%) reported that they would not have to miss any key social activity or hobby due to the cancellation. Forty-six patients (93.9%) answered this question as ‘Not applicable’ due to all social activities being restricted by government.
Table 2 shows the reported emotions felt by the patients at the time of cancellation. Extreme sadness and disappointment were felt by 24.5% and 28.6% of patients, respectively. At least moderate sadness was experienced by 32 patients (65.3%) and disappointment by 36 patients (73.5%). On the contrary, at least moderate anger and stress were felt by only eight (16.2%) and 13 (26.4%) patients, respectively. However, 44.9% of the patients felt extreme and 81.7% at least moderate concerns about the continuation of their symptoms. Extreme fear of the worsening of the symptoms was experienced by 36.8% and at least moderate by 73.5% of the patients. The feeling of emotions was not influenced by sex, age, or waiting time for surgery (p>.05). However, at least moderate feeling of sadness (p = .01) or disappointment (p = .03) was significantly associated with the shorter cancellation period. The concern of worsening of the symptoms was significantly more often experienced by patients with limitation of basic daily activities (p = .01). Employed patients unable to work due to severe pain or movement limitation were more commonly angry (p = .037). Although they felt more often also stress and concern about the worsening of the symptoms, these associations were not statistically significant (p = .05 and p = .08, respectively). Patients with the work-related impact caused by the postponement of their surgeries were more commonly in stress (p < .001) and had concerns about continuing symptoms (p = .004).
Table 2. Responses to questions on psychological impact.
Thirty-two patients (65.3%) would accept immediate surgery at the time of the phone interview. Sixteen patients (32.7%) understand the current situation and will wait for a scheduled operation in the future, while only one patient (2%) would refuse surgery in the following weeks due to the fear of catching COVID-19 infection.
The analysis of representative feelings and impacts is presented in the thematic analysis as a radar diagram (Figure 1).
Published online:
18 January 2021Figure 1. Radar diagram of thematic analysis (figures represent percentage of responders).
![]({"type":"image","src":"/na101/home/literatum/publisher/tandf/journals/content/ibjn20/0/ibjn20.ahead-of-print/02688697.2020.1868404/20210506/images/medium/ibjn_a_1868404_f0001_c.jpg"})
Figure 1. Radar diagram of thematic analysis (figures represent percentage of responders).
Discussion
To the best of our knowledge, this is the first study to report the impact of cancellation of elective surgeries in chronic condition patients during the COVID-19 pandemic circumstances. Tait et al. demonstrated that cancellation of planned paediatric outpatient surgeries has a considerable impact on patients and their families both emotionally and economically.13 Herrod et al. performed a study to quantify the economic and psychological impact of the cancellation of operations during the so-called ‘Winter National Health Service (NHS) Crisis’ due both to an anticipated seasonal rise in admissions and an unexpectedly severe epidemic of winter influenza. Their WES-Pi survey was developed jointly with patient groups to establish usability, acceptability and internal validity. Over 30% of their participants reported extreme levels of sadness, disappointment, anger, frustration and stress. Seventy percent of participants reported at least moderate concern about continued symptoms and 59% about their deteriorating condition.12 With a similar survey used in our study, we have demonstrated that around 70% of our patients felt at least moderate level of sadness and disappointment at the time their surgery was cancelled. The higher intensity of these emotions was associated with the shorter length of the cancellation period. This seems understandable because cancellation of the surgery one or few days before the proposed date has to be very emotionally demanding. Only 16% of them reported anger and 26% stress probably due to the fact they understand the current difficult situation and the need for the restrictions. Fear of continued symptoms for an indefinite time period was felt by vast majority of our patients (80%). More than 70% of them mentioned also concerns regarding deterioration of the symptoms. This was especially reported by those who were limited in their basic daily activities. This is obvious because this most affected group of patients fears of an even worse condition.
Two-third of our employed patients were unable to work at the time of the interview due to their ongoing pain or movement disability. Aware of the fact that about 90% of patients generally return to work after spinal surgery,14 we can say that the majority of these 17 cases have already potentially lost an average of one working month. Almost half of the employees reported work-related impact of the cancellation like the need of extra days off or fear of dismissal. Understandably, these patients experienced a higher level of anger and stress or concerns about the symptoms continuing because cancellation can have significant economic consequences for them. Also Herrod et al. demonstrated that a large proportion of patients suffered a negative economic impact from both the additional work days lost and the additional non-refundable travel and childcare costs.12 However, only 12% of our patients reported a direct economic burden by extra payment for additional therapy, child care or extra carer support. This low number was predictable for the fact that almost all non-basic services have been shut down due to pandemic restrictions. Almost all of our patients (93.9%) marked the question about missing social activities as a consequence of cancelled surgery as irrelevant (not applicable) due to the suspension of all social activities and free movement at the time of the interview. Therefore, we were unable to analyse possible connection between the postponement of operations and restriction in social gathering or going out. Herrod et al.12 do not specify the results regarding this question in their article. To our knowledge, a study using WES-Pi survey has not been performed since the publication of this paper in 2019. For this reason, we cannot compare our results with other studies.
One of the main issues associated with COVID-19 pandemic is a general fear in population. Patients may be concerned about catching the COVID-19 infection while seeking care in COVID-19-designated receiving hospitals and so, understandably, avoid or delay seeking care.15 Chang et al. performed a prospective study on 102 patients who were on the waiting list for an elective hip or knee procedures during the COVID-19 pandemic. They found that only 56.8% of patients wanted to continue with planned surgical care at the earliest possibility.16 Clement et al. found that the rate of patients wanting to proceed with their planned elective orthopaedic surgery increased during the COVID-19 pandemic. This was probably due to a lower perceived risk of contracting COVID-19 perioperatively or worsening of symptoms while waiting.17 Nevertheless, two-third of our patients would accept immediate operation regardless of the current pandemic situation. Almost one-third understands the adopted restrictions and agrees to wait for the elective surgeries to be performed again. Only one patient (2%) would not undergo surgery in the near future due to the fear of catching the infection. These results show that the majority of our spinal patients waiting for their cancelled elective procedures were probably so severely suffering that they would rather undergo surgery immediately than wait at home isolation for an unpredictable time period for an elective procedure performed after the improvement of the local epidemic situation.
Limitations
This is a preliminary study with a limited number of patients. Although we have specifically asked about the new feelings experienced at the time when their surgery was cancelled, we cannot exclude the influence of the psychological reaction to a pandemic. Despite the fact that the measurements were made under the pandemic circumstances, the economic impact of the cancellations identified in this study cannot be directly related to the COVID-19 restrictions due to the lack of a comparative group. Our aim, however, is to provide information about patients’ perception of the health care restrictions for all those who have to deal with cancelling of the elective procedures. Moreover, it is the authors’ opinion that all the data gathered during this emergency will provide the scientific foundation for healthcare organizations in future circumstances similar to the current one.
Conclusions
In conclusion, our findings suggest that the cancellation of elective spinal surgeries have a serious psychological impact on patients. Due to the persistence of severe symptoms, two-third of patients would undergo immediate surgery despite the current epidemic situation. The information is beneficial for health management. Every effort should be made to resume planned surgical treatment if the epidemiological situation allows it.
| Age | <65 years | 28 (57.2%) |
| ≥65 years | 21 (42.8%) | |
| Sex | Males | 27 (55.1%) |
| Females | 22 (44.9%) | |
| Type of surgery | ACDF | 3 (6.1%) |
| Lumbar microdiscectomy | 12 (24.5%) | |
| (Thoraco)-lumbar fusion | 19 (38.8%) | |
| Resection of benign spinal tumour | 1 (2%) | |
| Decompression for lumbar stenosis | 14 (28.6%) | |
| Economic impact (additional costs) | 6 (12%) | |
| Impact on daily activities | 42 (85.7%) | |
| Missing social activities/hobbies | Yes | 0 (0%) |
| No | 3 (6.1%) | |
| Not applicable | 46 (93.9%) | |
| Employment status | Employed | 22 (44.9%) |
| Self-employed | 5 (10.2%) | |
| Unemployed | 2 (4%) | |
| Retired | 20 (40.9%) | |
| Ability to work | Yes | 9 (33.3%)a |
| No – COVID-19 restrictions | 1 (3.7%)a | |
| No – pain/movement limitation | 17 (63%)a | |
| Impact on work | 12 (44.4%)a | |
| Interest for surgery during COVID-19 | Immediately | 32 (65.3%) |
| Electively (would wait) | 16 (32.7%) | |
| No – fear of COVID-19 infection | 1 (2%) | |
ACDF: anterior cervical discectomy and fusion.
a Percentage of 27 employees (employed and self-employed).
| Sadness | Disappointment | Anger | Stress | Concerns about continuing symptoms | Concerns about worsening of symptoms | |
|---|---|---|---|---|---|---|
| Not at all | 9 (18.4%) | 8 (16.3%) | 37 (75.7%) | 32 (65.5%) | 4 (8.1%) | 9 (18.4%) |
| Slightly | 8 (16.3%) | 5 (10.2%) | 4 (8.1%) | 4 (8.1%) | 5 (10.2%) | 4 (8.1%) |
| Moderately | 13 (26.5%) | 14 (28.6%) | 4 (8.1%) | 6 (12.2%) | 9 (18.4%) | 12 (24.5%) |
| Very | 7 (14.3%) | 8 (16.3%) | 0 (0%) | 3 (6.1%) | 9 (18.4%) | 6 (12.2%) |
| Extremely | 12 (24.5%) | 14 (28.6%) | 4 (8.1%) | 4 (8.1%) | 22 (44.9%) | 18 (36.8%) |
Acknowledgements
The authors thank Nisaharan Srikandarajah, MRCS, MBBS, PhD and Gautham Ullas, BMBS, BmedSci for their help in the formal arrangement of the text.
Disclosure statement
No potential conflict of interest was reported by the author(s).