Letter to the Editor: Impact of COVID‐19 Pandemic on Readmission Rates Following Colorectal Surgery—A Retrospective Cohort Study

We write with regards the recent paper by Lemke et al. [1] providing a retrospective analysis of colorectal surgery readmission rates from the American College of Surgeons’ National Surgical Quality Improvement Program (ASC-NSQIP). They reported no significant difference between the readmission rates in 2019 (9.6%) and 2020 (9.4%), the latter being the first year of the pandemic. Although readmission rates may be potentially influenced by length of hospital admission, their results suggest that surgical teams maintained a consistent approach both before and during the first year of the pandemic. That fewer patients were discharged to another facility in 2020 may also indicate clinician and patient preference to avoid the cross-infection risks of residential facilities during the COVID-19 pandemic. Lemke et al.’ results indicate that, for those major planned colorectal procedures which were undertaken in 2020, safety and quality were not compromised during the first year of the pandemic despite the challenges posed to the healthcare system as a whole. For example, their matched cohort mortality of 0.8% was consistent in both 2019 and 2020 whilst there was also no significant difference in the anastomotic leak rates (2.7% and 2.8% respectively). Their findings are consistent with an Australian publication that also reported no difference for mortality, return to theatre or post-operative surgical complications for Colorectal Cancer patients treated during the COVID-19 pandemic [2]. However, their results do contrast with COVIDSurg's global prospective study that examined the outcomes of elective Colorectal Cancer Surgery on over 2000 patients [3]. COVIDSurg demonstrated fewer anastomotic leaks but an increase in peri-operative mortality during the COVID-19 pandemic [3]. Lemke et al.'s paper also provides an important insight into the impact of COVID-19 on Colorectal Surgery activity in those institutions providing data to NSQIP. These are largely hospitals from high income countries, such as the USA, Canada and Australia. The 17.7% decrease in Colorectal Surgery activity represents a significant reduction, consistent with other published series of planned surgery during the early years of the pandemic. The reasons are likely to be multi-factorial in nature including less screening, less access to referral for symptoms, less willingness to see a doctor, and less health system capacity to perform colonoscopies. During 2020, there was certainly a decrease in colonoscopy activity, deliberate deferral of perceived non-urgent elective surgery, and a need to re-deploy healthcare workers to meet the demands of the pandemic. The full effect of this reduced activity on Colorectal Surgical outcomes, particularly as a result of untreated comorbidities, and/or more advanced disease at presentation is yet to be reported. Another recent publication also compared 2019 and 2020 ASC-NSQIP data to investigate colorectal surgical outcomes and readmission rates [4]. Despite slightly different time periods of inclusion, they also reported reduced colorectal surgical activity (20.8%), but again no difference in readmission rates or length of stay. There was a higher ASA grading of patients undergoing surgery in 2020, suggestive of greater comorbidity. There was more emergent and less laparoscopic surgery performed. In contrast to Lemke et al., Chen et al. demonstrated an overall increase in morbidity and mortality in the latter half of 2020. Whilst supportive of Lemke's et al.'s main results, consideration should be given to the potential of COVID-19 workforce issues leading to less data being captured and entered, which may bias COVID-19 related data. ASC-NSQIP represents a multi-centred registry of largely, but not exclusively, North American Hospitals. The impact of COVID-19 varied significantly between geographical areas largely due to both a variation of incidence of COVID-19 as well as the availability of healthcare resources. Lemke et al.'s data must be viewed in the North American context and may not be applicable outside of North America. Nevertheless, their findings are consistent with a recently published Swedish paper reporting no significant difference in surgical complications, reoperation or death within 30 days as a result of the COVID-19 pandemic [5]. Further research from other countries is indicated. Lemke et al.'s decision to compare 2019 and 2020 data provided a good comparator to examine the impact of COVID-19 on the provision of surgical services. Many other research groups have used the same or similar timeframes. It certainly represents a period witnessing the most significant change in surgical service during the COVID-19 pandemic. However, COVID-19 is a rapidly evolving, dynamic disease with new variants emerging such as Delta (2021) and Omicron (2022). Therefore, extending the data set to include the impact of vaccination and emerging variants through 2021 and 2022 represents a further area of future research that will help understand the impact of COVID-19 on the health system and how we should respond. Neither corresponding authors are recipients of a research scholarship nor surgeons in training. Both authors are in agreement with the contents of this editorial. There are no conflicts of interest to declare. The manuscript has not been previously published and is not under consideration elsewhere.

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