Non-COVID outcomes associated with the coronavirus disease-2019 (COVID-19) pandemic effects study (COPES): A systematic review and meta-analysis

Abstract

Background As the Coronavirus Disease-2019 (COVID-19) pandemic continues, healthcare providers struggle to manage both COVID-19 and non-COVID patients while still providing high-quality care. We conducted a systematic review/meta-analysis to describe the effects of the COVID-19 pandemic on patients with non-COVID illness and on healthcare systems compared to non-pandemic epochs. Methods We searched Ovid MEDLINE/EMBASE/Cochrane Database of Systematic Reviews/CENTRAL/CINAHL (inception to December 31, 2020). All study types with COVID-pandemic time period (after December 31, 2019) with comparative non-pandemic time periods (prior to December 31, 2019). Data regarding study characteristics/case-mix/interventions/comparators/ outcomes (primary: mortality; secondary: morbidity/hospitalizations/disruptions-to-care. Paired reviewers conducted screening and abstraction, with conflicts resolved by discussion. Effect sizes for specific therapies were pooled using random-effects models. Risk of bias was assessed by Newcastle-Ottawa Scale, with evidence rating using GRADE methodology. Results Of 11,581 citations, 167 studies met eligibility. Our meta-analysis showed an increased mortality of 16% during the COVID pandemic for non-COVID illness compared with 11% mortality during the pre-pandemic period (RR 1.38, 95% CI: 1.28–1.50; absolute risk difference: 5% [95% CI: 4–6%], p<0.00001, very low certainty evidence). Twenty-eight studies (17%) reported significant changes in morbidity (where 93% reported increases), while 30 studies (18%) reported no significant change (very low certainty). Thirty-nine studies (23%) reported significant changes in hospitalizations (97% reporting decreases), while 111 studies (66%) reported no significant change (very low certainty). Sixty-two studies (37%) reported significant disruptions in standards-to-care (73% reporting increases), while 62 studies (37%) reported no significant change (very low certainty). Conclusions There was a significant increase in mortality during the COVID pandemic compared to pre-pandemic times for non-COVID illnesses. When significant changes were reported, there was increased morbidity, decreased hospitalizations and increased disruptions in standards-of-care. Systematic review registration PROSPERO CRD42020201256 (Sept 2, 2020).

Coronavirus disease 2019 (COVID-19) excess mortality outcomes associated with pandemic effects study (COPES): A systematic review and meta-analysis

“…During the pandemic, differences in COVID-19 mortality rates were found depending on location, case mix, population structure, health system responses, and capacity, alongside individual jurisdictional healthcare policies (e.g., lockdowns, vaccine access, etc.) (7,(57)(58)(59)(60). Early during the pandemic, only hospitalized patients could have confirmatory testing for infection (61), which caused underreporting of COVID-19 cases by a factor of 2-3 times (62), with estimated COVID-19 deaths up 6-10 times higher than officially reported (63,64).…”

“…Certain countries (e.g., India, USA, Brazil) had the highest excess mortality, while others (e.g., Australia, New Zealand, Taiwan, Singapore) have reported negative excess mortalities (69), likely due to their COVID-19 containment strategies and differences in healthcare resource allocation with decreased non-COVID-19 mortality from their populations staying home. Each jurisdictional strategy (e.g., COVID-19 elimination vs. mitigation, access to vaccinations and medications, demographic and geographic factors) has likely led to discrepancies in the global impact of all-cause excess mortality alongside COVID-19 mortality (7), which has varied throughout different waves of the pandemic (28, 69). The continued pandemic has had profound effects on the health of non-COVID-19 patients (7, 71), as pandemic patients have utilized resources, caused invoking of pandemic control measures, and disrupted care throughout the entire healthcare system (7).…”

“…Our PRISMA checklist is included in Supplementary Table 1. This paper specifically focused on COVID-19 related excess mortality alongside all-cause excess mortality (with non-COVID-19 mortality) (7).…”

“…This can create uncertainty in producing accurate mortality data surrounding the pandemic. There is evidence to suggest non-COVID-19 mortality was excessive during the COVID-19 pandemic, due to disruptions in healthcare provisions and changes in acute care hospitalizations, leading to increased all-cause morbidity and mortality (7). Therefore, following COVID-19 mortality alone does not accurately estimate the full impact of the pandemic.…”

“…Multiple studies have demonstrated that COVID-19 deaths can be underestimated (10)(11)(12), where measuring total excess mortality can better capture the total impact of the pandemic, and total excess mortality may be a worthwhile measure to calculate attributable mortality from the pandemic (13). The ability to adapt and innovate during these periods of global disruption is key to mitigating the adverse effects of the pandemic on global health, both related to the immediate and prolonged complications of COVID-19, alongside any negative pandemic influences on non-COVID-19 mortality (7). To this end, we conducted a systematic review (SR) to describe the total burden of all-cause excess mortality during the pandemic (inclusive of both COVID-19 and non-COVID-19 mortality).…”