The side effects of the pandemic on all-cause postoperative mortality in a COVID reference Hospital in Brazil: a before and after cohort study with 15156 patients
Os efeitos colaterais da pandemia na mortalidade pós-operatória por todas as causas em um hospital de referência para COVID no Brasil: um estudo de coorte antes e depois com 15.156 pacientes
Luciana C. Stefani, Brasil Silva Neto, Débora Roberta de Avila Dornelles, Mariana Brandão, Marcio Rahel Guimarães, Pedro Knijnik, Jeruza N. Neyeloff, Stela M.J. Castro f, Paulo Corrêa da Silva Neto, Gilberto Braulio
Abstract
Background
Before the pandemic, healthcare systems in Low-Middle Income Countries (LMIC) experienced a limited capacity to treat postoperative complications. It is uncertain whether the interference of the Coronavirus (COVID-19) pandemic on surgical systems has increased postoperative mortality.
Methods
This before and after cohort study aimed to assess the pandemic’s impact on in-hospital postoperative mortality in a university COVID-19 reference hospital in southern Brazil. Data from patients who underwent surgery before (January 2018 to December 2019) the pandemic were compared to data from patients who underwent surgery during the pandemic (February to December 2020). The primary outcome was in-hospital mortality. We developed Poisson regression models to examine the mortality risk of being operated on during the COVID-19 pandemic.
Results
We assessed 15156 surgical patients, 12207 of whom underwent surgery before the pandemic and 2949 during the first year of the pandemic. Mortality rates were 2.5% (309/12207) in the pre-pandemic versus 7.2% (212/2949) in the pandemic. Of these, 25.8% (32/124) of patients with COVID-19 and 6.4% (80/2816) of patients without COVID-19 died. The proportion of urgent surgeries and ASA-PS III was higher in the pandemic group. After adjusting for mortality-related variables, the Relative Risk (RR) associated with undergoing surgery during the pandemic was 1.51 (95% CI 1.27 to 1.79). We excluded COVID-19-positive to perform a sensitivity analysis that confirmed the increased risk of undergoing surgery during the pandemic RR = 1.50 (95% CI 1.27 to 1.78).
Conclusion
The substantial number of additional deaths, even amongst those without COVID-19 infection, suggests the pandemic disrupted the surgical service in an LMIC context. Fragile surgical systems may suffer more significant adverse impacts from external stressors such as a pandemic, and urging measures are needed to increase their performance and resilience.
Keywords
Resumo
Introdução
Antes da pandemia, os sistemas de saúde em países de renda média e baixa (LMIC) tinham capacidade limitada para tratar complicações pós-operatórias. Não se sabe se a interferência da pandemia do Coronavírus (COVID-19) nos sistemas cirúrgicos aumentou a mortalidade pós-operatória.
Métodos
Este estudo de coorte antes e depois teve como objetivo avaliar o impacto da pandemia na mortalidade pós-operatória hospitalar em um hospital universitário de referência para COVID-19 no sul do Brasil. Dados de pacientes submetidos à cirurgia antes (janeiro de 2018 a dezembro de 2019) da pandemia foram comparados com dados de pacientes submetidos à cirurgia durante a pandemia (fevereiro a dezembro de 2020). O desfecho primário foi a mortalidade hospitalar. Desenvolvemos modelos de regressão de Poisson para examinar o risco de mortalidade de ser operado durante a pandemia de COVID-19.
Resultados
Avaliamos 15.156 pacientes cirúrgicos, 12.207 dos quais foram submetidos à cirurgia antes da pandemia e 2.949 durante o primeiro ano da pandemia. As taxas de mortalidade foram de 2,5% (309/12207) na pré-pandemia versus 7,2% (212/2949) na pandemia. Destes, 25,8% (32/124) dos pacientes com COVID- 19 e 6,4% (80/2816) dos pacientes sem COVID-19 morreram. A proporção de cirurgias urgentes e ASA-PS III foi maior no grupo pandêmico. Após o ajuste para variáveis relacionadas à mortalidade, o Risco Relativo (RR) associado à realização de cirurgia durante a pandemia foi de 1,51 (IC 95% 1,27 a 1,79). Excluímos os positivos para COVID-19 para realizar uma análise de sensibilidade que confirmou o risco aumentado de realização de cirurgia durante a pandemia RR = 1,50 (IC 95% 1,27 a 1,78).
Conclusão
O número substancial de mortes adicionais, mesmo entre aqueles sem infecção por COVID-19, sugere que a pandemia interrompeu o serviço cirúrgico em um contexto de LMIC. Sistemas cirúrgicos frágeis podem sofrer impactos adversos mais significativos de estressores externos, como uma pandemia, e medidas urgentes são necessárias para aumentar seu desempenho e resiliência.
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References
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Submitted date:
12/30/2024
Accepted date:
02/04/2025
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