Healthcare systems around the world have been facing further challenges determined by an increasing demand for patient care (not necessarily those with/after COVID19). Combined with subjective factors (fear, disinformation, telemedicine and mobility limitations), channels of healthcare delivery for all beneficiaries are being disrupted12,13,14,15,16,17. When healthcare systems are overwhelmed, as was the case with pandemic, and the society does not have an access to the care they need, the direct costs of care as well as the unquantifiable results such as observed mortality would increase. The analysis of the number of hospitalised patients and the value of delivered hospital health services in the years 2020 and 2021 compared to the pre-covid period 2015–2019 in Poland showed a significant impact of the COVID-19 pandemic on the indices of care of non-covid patients.
The largest decrease in the number of hospitalised patients was observed in 2020, during the first wave of the pandemic, when strict epidemiologic restrictions have been introduced. This decline was not consistent in all medical fields and may have been caused by a variety of reasons. A striking reduction in hospitalisations due to infectious diseases other than COVID-19 may be partly explained by a reduction in demand and the disruption of transmission channels for all infectious diseases. The disruption in specialised care was rather due to the fact that many hospitals were converted into COVID-19 treatment centres18. Therefore, the prioritisation of COVID-19 care reduced the availability of hospital beds, medical resources and technology for non-COVID-19 services18. For other fields, in which the largest decline in numbers was observed (e.g. otolaryngology, dermatology, paediatrics, allergology, geriatrics, internal medicine, diabetology), fear of contagion (diabetes, cardiovascular disease are risk factors for severe COVID-19), increased hospitalisation thresholds, the transfer of healthcare or hospital professionals to COVID-19 care and prevention, and barriers imposed by COVID-19-related epidemiological strictures may have contributed to the reduction in healthcare. It is noteworthy, that the decrease in the value of services in these fields was less significant than the decline in the number of patients, which may indicate that more severe cases were admitted18. More than 20% drop in the number of patients in fields of transplantology, cardiac surgery, cardiology, paediatric surgery, general surgery, maxillofacial surgery, was probably due to the cancellation of elective procedures during each wave of COVID-19 and patients avoiding or delaying seeking care due to the restrictions of being forced to stay at home19.
The impact of COVID-19 on oncology care varied: the largest reductions were seen in oncology surgery, gynaecological oncology, paediatric oncology and haematology; a relatively small decrease was seen in radiotherapy and brachytherapy, but there was an increase in chemotherapy. Thus, it can be assumed that chemotherapy treatment was provided without delay for patients diagnosed before and during the pandemic, while surgical treatment was postponed and, since in these cases the decrease in the number of patients was accompanied by an increase in the value of services, it is likely that hospital treatment was provided to patients with a more severe course or more advanced condition20. A significant increase in the number of patients and an growth in the value of services during the pandemic period is characterised by treatment programmes, con-firming that well-organised care, well-defined indications and patient motivation are crucial to ensure access to services under all conditions.
Although the subsequent waves of COVID-19 were more extensive than the initial, their impact on healthcare use in the second year of the pandemic was less significant. This may have been a result partly due to the fact that healthcare workers had already learnt how to cope with the pandemic situation, and even the patients themselves were more able to access medical care after the introduction of vaccination and the reduction of pandemic restrictions. Nevertheless, our forecast for the period following the pandemic indicates that a return of the health care system to its status in 2015–2019 will most likely only be possible in the next 5 years. Our study also confirmed that the organisational, labour resources and financial determinants of the healthcare system were related to the number of patients in the system in the years 2020–2021. This demonstrates the importance of preparing the healthcare system for the future in such a way that the redistribution of resources in a crisis situation does not impair access to healthcare for remaining beneficiaries.
The impact of COVID-19 on the use of healthcare resources has been evaluated in numerous countries, in various phases of the pandemic and by considering different components of the healthcare system12,13,14,15,16,17,21,22,23,24,25,26,27,28,29,30,31.
A systematic review of the literature, which included 81 studies from 20 countries indicated that compared to the pre-pandemic period, the median reduction in health care consumption by May 2020 was in total of 37% and was highest in terms of outpatient visits (42%), while it was 28% for hospital admissions, 31% for diagnostics and 30% for therapeutic and preventive interventions32. Nearly half of the 30 studies also reported on the severity of disease symptoms of healthcare users showed greater reductions in the utilisation among populations with milder or less severe disease32. According to the literature review on orthopaedic services alone in the first phase of the pandemic, the number of elective operations, trauma procedures and outpatient visits decreased by 80%, 47% and 63%, respectively33. US study showed that COVID-19 decreased access to hip and knee arthroplasties and also worsened pre-existing disparities: most affected were non-English speakers and people without a private insurance were most affected22. Similar findings are presented in a study on the use of oncology and cardiology services in Italy in March 202034. For oncology, the number of planned procedures decreased from 3.8 to 2.6 per week, there was a 48.4% reduction in admissions for myocardial infarction, a 32% reduction in PCI procedures and a 39.2% extension of the time from occurrence of symptoms to coronary angiography34. According to a 2020 US study, outpatient visits dropped dramatically (by 80% in the first days of the pandemic) and hospitalisations and emergency care visits decreased by 30.2% and 37% respectively, with a fourfold increase in the number of tele-visits. By the end of June 2020, the total number of outpatient visits and tele-visits had returned to pre-pandemic levels35. Similar results are reported by another US study, which found that the number of outpatient visits in all selected disease areas showed a rapid decline in the early period of the pandemic compared to the pre-pandemic period36. An increase in per capita prescription expenditures was observed in all disease domains during the pandemic compared with the pre-pandemic period, while expenditures on home care and outpatient care decreased36. The observed popularisation of telemedicine during the pandemic was supported by regulatory changes that led to an expansion of public funding for such services37,38. In Poland, there has been a significant increase in the provision of remote services and medical advice (especially in primary care)39. The development of this form of medical service provision has appeared to be very much needed, indicating a potential in re-duction of existing resource shortages (especially human resources). The Japanese study, which covers the period to November 202021 indicate that overall hospitalisations and outpatient visits number decreased by 27% and 22% in May 2020, most notably in paediatrics (60% and 51% respectively). Hospitalisations due to respiratory, cardiovascular and malignant neoplasms decreased by 55%, 32% and 10% respectively, while endoscopic procedures and rehabilitation incidences decreased by more than 30%, whereas for outpatient chemotherapy and chronic dialysis this drop was no higher than 10% or none21. Reduction in surgeries, longer waiting time between the onset of symptoms and arrival at the emergency room and increase in in number of complications in elective procedures were reported also in Spain24,25, Argentina26, United Kingdom27 and India28.
Individual components of cancer care delivery have been studied in many countries. In the US, the proportion of patients receiving at least 1 of common cancer screening examinations during the first 3Â months of the pandemic amounted to only 24.0% of the total receiving at least 1 examination in the 3Â months prior to the pandemic29. In Scotland, the receipt of scheduled anticancer systemic therapy delivery deceased 28.7% in the first 2Â months after the outbreak of the pandemic compared with the 2Â months prior to the pandemic, with particularly large reductions for some cancers, including colorectal cancer (43.4%)30. Canadian study examined the changes in cancer care during the COVID-19 pandemic across the continuum of care, including screening, imaging, surgical treatment, pathological reporting, systemic treatment, radiation treatment, and psychosocial oncological care31. This study demonstrated an overall deficit in the first year of the pandemic, particularly pronounced for cancer screening tests, followed by rebounding trends later in the year.
The COVID-19 pandemic has caused severe but heterogeneous disruptions in the availability of healthcare services worldwide with yet unknown remote health consequences. The differences observed between countries may be caused by the different response of governments to the pandemic, the intensity of restrictive measures for Sars Cov-2 containment in the first months of the pandemic and also the resilience of national healthcare systems to emergencies. This resilience largely depends on the organisation of the healthcare system prior to the pandemic. The strength of our study is a focus on the Polish health care system. Because this system relies on universal, publicly funded health care coverage that provides free medically necessary services for all citizens and permanent residents, there was much less likelihood that the study findings were biased owing to differential access to care between the pre-pandemic and pandemic periods. In addition the estimates of in-patient health care services reductions rely on the experience of utilisation in the 5-year period prior to the pandemic. This long baseline period allowed to establish whether service volumes were trending higher over time. Our results, in general terms, reflect the same trend seen worldwide, reflecting a general reduction in the use of health services, but the impact of COVID-19 varies according to the context analysed. The increase in utilization of chemotherapy services observed during COVID-19 outbreak period in Poland confirms that well-organised care continued to provide timely cancer treatment despite significant pandemic-driven disruption. In addition our study explain the gap in knowledge on whether the services have recovered to pre-pandemic levels of care use and, if yes, in what time.
The results of our study can be used for the ongoing planning and reorganisation of the healthcare system and for the management in emergency situations arising from mass events and future pandemics. The pandemic induced natural experiment of reduced healthcare utilisation is an unprecedented opportunity to learn more about which services represent a lower priority for the population and the healthcare system when rapid redistribution of resources is needed to minimise the mortality rate. Indeed, some of the undelivered health services may represent services that are not necessary. According to some studies, a significant reduction in emergency department visits for non-emergent indications may reflect the possibility of implementing a new care strategy that maximises the popularity of such visits in the future40,41. The results of our study are a first step towards a better understanding of this crucial issue. There is an urgent need for the health system to plan and implement compensation measures for missed services, which include amongst other things identifying and addressing any adverse health consequences resulting from reduced availability of healthcare. In order to fully understand the indirect health effects of the pandemic and the factors responsible for the disruption of medical services, further research is needed to monitor non-COVID-19 mortality trends. The extent and impact of the wider use of substitution methods, such as tele-medicine, also requires further research with a long-term time horizon.
To conclude, the impact of the COVID-19 pandemic on the delivery of hospital services in Poland varied depending on the specialty. The reduction in services was not greater than in other European countries, and even no disruption was observed in the delivery of services such as chemotherapy and drug/therapy programmes. The aspect of examining the direct impact of COVID-19 restrictions on the number of health ser-vices provided will only be possible once the reported data has stabilised at the end of 2023. The long-term consequences of the disruption of service delivery on the health of the population are so far unknown, but an accurate assessment of these outcomes in the future and the identification of health policy instruments to mitigate this negative impact is key to preparing a health system.
