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James C, Denholm R, Wood R. The cost of keeping patients waiting: retrospective treatment-control study of additional healthcare utilisation for UK patients awaiting elective treatment. BMC Health Serv Res 2024; 24:556. [PMID: 38693557 PMCID: PMC11061904 DOI: 10.1186/s12913-024-10931-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 03/29/2024] [Indexed: 05/03/2024] Open
Abstract
OBJECTIVE Long waiting times for elective hospital treatments are common in many countries. This study seeks to address a deficit in the literature concerning the effect of long waits on the wider consumption of healthcare resources. METHODS We carried out a retrospective treatment-control study in a healthcare system in South West England from 15 June 2021 to 15 December 2021. We compared weekly contacts with health services of patients waiting over 18 weeks for treatment ('Treatments') and people not on a waiting list ('Controls'). Controls were matched to Treatments based on age, sex, deprivation and multimorbidity. Treatments were stratified by the clinical specialty of the awaited hospital treatment, with healthcare usage assessed over various healthcare settings. Wilcoxon signed-rank tests assessed whether there was an increase in healthcare utilisation and bootstrap resampling was used to estimate the magnitude of any differences. RESULTS A total of 44,616 patients were waiting over 18 weeks (the constitutional target in England) for treatment during the study period. There was an increase (p < 0.0004) in healthcare utilisation for all specialties. Patients in the Cardiothoracic Surgery specialty had the largest increase, with 17.9 [interquartile-range: 4.3, 33.8] additional contacts with secondary care and 17.3 [-1.1, 34.1] additional prescriptions per year. CONCLUSION People waiting for treatment consume higher levels of healthcare than comparable individuals not on a waiting list. These findings are relevant for clinicians and managers in better understanding patient need and reducing harm. Results also highlight the possible 'false economy' in failing to promptly resolve long elective waits.
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Affiliation(s)
- Charlotte James
- The National Institute for Health and Care Research Bristol Biomedical Research Centre (NIHR Bristol BRC), University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK.
- The National Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West) at University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK.
- Population Health Sciences, Bristol Medical School, Bristol, UK.
- Modelling and Analytics, UK National Health Service (BNSSG ICB), Bristol, UK.
| | - Rachel Denholm
- The National Institute for Health and Care Research Bristol Biomedical Research Centre (NIHR Bristol BRC), University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
- Population Health Sciences, Bristol Medical School, Bristol, UK
- Health Data Research UK South West, Bristol, UK
| | - Richard Wood
- Modelling and Analytics, UK National Health Service (BNSSG ICB), Bristol, UK
- Centre for Healthcare Innovation and Improvement (CHI2), School of Management, University of Bath, Bath, UK
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Ferrara L, Otto M, Aapro M, Albreht T, Jonsson B, Oberst S, Oliver K, Pisani E, Presti P, Rubio IT, Terkola R, Tarricone R. How to improve efficiency in cancer care: dimensions, methods, and areas of evaluation. J Cancer Policy 2022; 34:100355. [PMID: 36007873 DOI: 10.1016/j.jcpo.2022.100355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 08/03/2022] [Accepted: 08/17/2022] [Indexed: 12/01/2022]
Abstract
Efficiency in healthcare is crucial since available resources are scarce, and the opportunity cost of an inefficient allocation is measured in health outcomes foregone. This is particularly relevant for cancer. The aim of this paper was to gain a comprehensive overview of how efficiency in cancer care is defined, and what the indicators, different methods, perspectives, and areas of evaluation are, to provide recommendations on the areas and dimensions where efficiency can be improved. METHODS: A comprehensive scoping literature review was performed searching four databases. Studies published between 2000-2021 were included if they described experiences and cases of efficiency in cancer care or methods to evaluate efficiency. The results of the literature review were then discussed during two rounds of online consultation with a panel of 15 external experts invited to provide their insights and comments to deliberate policy recommendations. RESULTS: 46 papers met the inclusion criteria. Based on the papers retrieved we have identified six areas for achieving efficiency gains throughout the entire care pathway and, for each area of efficiency, we have categorized the methods and outcome used to measure efficiency gain CONCLUSION: This is the first attempt to systematize a scattered body of literature on how to improve efficiency in cancer care and identify key areas to improve it. Based on the findings of the literature review and on the opinion of the experts involved in the consultation, we propose seven recommendations that are intended to improve efficiency in cancer care throughout the care pathway.
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Affiliation(s)
- Lucia Ferrara
- Cergas SDA Bocconi School of management, via Sarfatti, 11 - 20136 Milano (Italy).
| | - Monica Otto
- Cergas SDA Bocconi School of management, via Sarfatti, 11 - 20136 Milano (Italy).
| | - Matti Aapro
- Genolier Hospital Genolier Cancer Center, SPCC - Sharing Progress in Cancer Care, Route du Muids 3, 1272 Genolier (Switzerland).
| | - Tit Albreht
- Centre for Health Care, National Institute of Public Health, Ljubljana, (Slovenia) iPAAC - Innovative Partnership for Action against Cancer.
| | - Bengt Jonsson
- Department of Economics, Stockholm School of Economics, Stockholm, Sweden.
| | - Simon Oberst
- OECI - Organisation of European Cancer Institutes, rue d'Egmont 11, B-1000 Brussels (Belgium).
| | - Kathy Oliver
- IBTA - International Brain Tumor Alliance, Tadworth, Surrey (United Kingdom).
| | - Eduardo Pisani
- All.Can - All.Can International asbl, Brussels, rue du Luxemburg 22-24, BE-1000 Brussels (Belgium).
| | - Pietro Presti
- SPCC - Sharing Progress in Cancer Care, Piazza Indipendenza 2, 6500 Bellinzona (Switzerland).
| | - Isabel T Rubio
- Clinica Universidad de Navarra, Madrid, ESSO - European Society of Surgical Oncology, Av. de Pío XII, 36, 31008 Pamplona, Navarra (Spain).
| | - Robert Terkola
- University Medical Center Groningen; University of Florida -College of Pharmacy; ESOP - European Society of oncology pharmacy.
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Hansen CP, Storkholm JH, Sillesen MH, Krohn PS, Burgdorf SK, Hillingsø JG. Pancreatic surgery during the COVID-19 pandemic 2020-2021: an observational cohort study from a third level referral center. BMC Surg 2022; 22:200. [PMID: 35597984 PMCID: PMC9124050 DOI: 10.1186/s12893-022-01651-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 05/06/2022] [Indexed: 11/18/2022] Open
Abstract
Background During the COVID pandemic there has been limited access to elective surgery including oncologic surgery in several countries world-wide. The aim of this study was to investigate if there was any lockdown effect on pancreatic surgery with special focus on malignant pancreatic and periampullary tumours. Methods Patients who underwent pancreatic surgery during the two Danish lockdown periods from 11. March 2020 and the following 12 months were compared with patients who were operated the preceding 3 years. Data on patients’ characteristics, waiting time, operations, and clinical outcomes were evaluated. Results During lockdown and the previous three years the annual number of resections were 242, 232, 253, and 254, respectively (p = 0.851). Although the numbers were not significantly different, there were fluctuations in operations and waiting time during the lockdown. During the second outbreak of COVID October 2020 to March 2021 the overall median waiting time increased to 33 days (quartiles 26;39) compared to 23 (17;33) days during the first outbreak from March to May 2020 (p = 0.019). The same difference was seen for patients with malignant tumours, 30 (23;36) vs. 22 (18;30) months (p = 0.001). However, the fluctuations and waiting time during lockdown was like the preceding three years. Neither 30- nor 90-days mortality, length of stay, number of extended operations, and complications and tumour stage were significantly different from previous years. Conclusions There were significant fluctuations in waiting time for operations during the lockdown, but these variations were not different from the preceding three years, wherefore other explanations than an impact from COVID are conceivable.
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Affiliation(s)
- Carsten Palnæs Hansen
- Department of Surgery and Transplantation, Rigshospitalet Copenhagen University Hospital, 2100, Copenhagen, Denmark.
| | - Jan Henrik Storkholm
- Department of Surgery and Transplantation, Rigshospitalet Copenhagen University Hospital, 2100, Copenhagen, Denmark
| | - Martin Hylleholt Sillesen
- Department of Surgery and Transplantation, Rigshospitalet Copenhagen University Hospital, 2100, Copenhagen, Denmark
| | - Paul Suno Krohn
- Department of Surgery and Transplantation, Rigshospitalet Copenhagen University Hospital, 2100, Copenhagen, Denmark
| | - Stefan Kobbelgaard Burgdorf
- Department of Surgery and Transplantation, Rigshospitalet Copenhagen University Hospital, 2100, Copenhagen, Denmark
| | - Jens Georg Hillingsø
- Department of Surgery and Transplantation, Rigshospitalet Copenhagen University Hospital, 2100, Copenhagen, Denmark
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Bjurling-Sjöberg P, Göras C, Lohela-Karlsson M, Nordgren L, Källberg AS, Castegren M, Condén Mellgren E, Holmberg M, Ekstedt M. Resilient performance in healthcare during the COVID-19 pandemic (ResCOV): study protocol for a multilevel grounded theory study on adaptations, working conditions, ethics and patient safety. BMJ Open 2021; 11:e051928. [PMID: 34880017 PMCID: PMC8655346 DOI: 10.1136/bmjopen-2021-051928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 11/19/2021] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Since early 2020, the COVID-19 pandemic has challenged societies and revealed the built-in fragility and dependencies in complex adaptive systems, such as healthcare. The pandemic has placed healthcare providers and systems under unprecedented amounts of strain with potential consequences that have not yet been fully elucidated. This multilevel project aims to explore resilient performance with the purpose of improving the understanding of how healthcare has adapted during the pandemic's rampage, the processes involved and the consequences on working conditions, ethics and patient safety. METHODS An emerging explorative multilevel design based on grounded theory methodology is applied. Open and theoretical sampling is performed. Empirical data are gathered over time from written narratives and qualitative interviews with staff with different positions in healthcare organisations in two Swedish regions. The participants' first-person stories are complemented with data from the healthcare organisations' internal documents and national and international official documents. ANALYSIS Experiences and expressions of resilient performance at different system levels and times, existing influencing risk and success factors at the microlevels, mesolevels and macrolevels and inter-relationships and consequences in different healthcare contexts, are explored using constant comparative analysis. Finally, the data are complemented with the current literature to develop a substantive theory of resilient performance during the pandemic. ETHICS AND DISSEMINATION This project is ethically approved and recognises the ongoing strain on the healthcare system when gathering data. The ongoing pandemic provides unique possibilities to study system-wide adaptive capacity across different system levels and times, which can create an important basis for designing interventions focusing on preparedness to manage current and future challenges in healthcare. Feedback is provided to the settings to enable pressing improvements. The findings will also be disseminated through scientific journals and conferences.
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Affiliation(s)
- Petronella Bjurling-Sjöberg
- Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
- Centre for Clinical Research, Uppsala University, Region Sörmland, Eskilstuna, Sweden
| | - Camilla Göras
- Department of Anesthesia and Intensive Care Unit, Falun Hospital, Region Dalarna, Falun, Sweden
- School of Health and Welfare, Dalarna University, Falun, Sweden
| | - Malin Lohela-Karlsson
- Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
- Centre for Clinical Research, Uppsala University, Region Västmanland, Västerås, Sweden
| | - Lena Nordgren
- Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
- Centre for Clinical Research, Uppsala University, Region Sörmland, Eskilstuna, Sweden
| | - Ann-Sofie Källberg
- School of Health and Welfare, Dalarna University, Falun, Sweden
- Department of Emergency Medicine, Falun Hospital, Region Dalarna, Falun, Sweden
| | - Markus Castegren
- Centre for Clinical Research, Uppsala University, Region Sörmland, Eskilstuna, Sweden
- CLINTEC, Karolinska Institute, Stockholm, Sweden
| | | | - Mats Holmberg
- Centre for Clinical Research, Uppsala University, Region Sörmland, Eskilstuna, Sweden
- Department of Health and Caring Sciences, Linneuniversitet, Kalmar/Växjö, Sweden
| | - Mirjam Ekstedt
- Department of Health and Caring Sciences, Linneuniversitet, Kalmar/Växjö, Sweden
- LIME, Karolinska Institutet, Stockholm, Sweden
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Truche P, Campos LN, Marrazzo EB, Rangel AG, Bernardino R, Bowder AN, Buda AM, Faria I, Pompermaier L, Rice HE, Watters D, Dantas FLL, Mooney DP, Botelho F, Ferreira RV, Alonso N. Association between government policy and delays in emergent and elective surgical care during the COVID-19 pandemic in Brazil: a modeling study. ACTA ACUST UNITED AC 2021; 3:100056. [PMID: 34725652 PMCID: PMC8552244 DOI: 10.1016/j.lana.2021.100056] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 08/09/2021] [Accepted: 08/12/2021] [Indexed: 12/01/2022]
Abstract
Background The impact of public health policy to reduce the spread of COVID-19 on access to surgical care is poorly defined. We aim to quantify the surgical backlog during the COVID-19 pandemic in the Brazilian public health system and determine the relationship between state-level policy response and the degree of state-level delays in public surgical care. Methods Monthly estimates of surgical procedures performed per state from January 2016 to December 2020 were obtained from Brazil's Unified Health System Informatics Department. Forecasting models using historical surgical volume data before March 2020 (first reported COVID-19 case) were constructed to predict expected monthly operations from March through December 2020. Total, emergency, and elective surgical monthly backlogs were calculated by comparing reported volume to forecasted volume. Linear mixed effects models were used to model the relationship between public surgical delivery and two measures of health policy response: the COVID-19 Stringency Index (SI) and the Containment & Health Index (CHI) by state. Findings Between March and December 2020, the total surgical backlog included 1,119,433 (95% Confidence Interval 762,663–1,523,995) total operations, 161,321 (95%CI 37,468–395,478) emergent operations, and 928,758 (95%CI 675,202–1,208,769) elective operations. Increased SI and CHI scores were associated with reductions in emergent surgical delays but increases in elective surgical backlogs. The maximum government stringency (score = 100) reduced emergency delays to nearly zero but tripled the elective surgical backlog. Interpretation Strong health policy efforts to contain COVID-19 ensure minimal reductions in delivery of emergent surgery, but dramatically increase elective backlogs. Additional coordinated government efforts will be necessary to specifically address the increased elective backlogs that accompany stringent responses.
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Affiliation(s)
- Paul Truche
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, United States
| | | | - Enzzo Barrozo Marrazzo
- Institute of Biological Sciences, Faculty of Medicine Pontifícia Universidade Católica de Minas Gerais Poços de Caldas, MG, Brazil
| | - Ayla Gerk Rangel
- Faculty of Medical Sciences, Universidad Católica Argentina, Buenos Aires, Argentina
| | - Ramon Bernardino
- School of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | - Alexis N Bowder
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, United States
| | - Alexandra M Buda
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, United States
| | - Isabella Faria
- School of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | - Laura Pompermaier
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, United States
| | - Henry E Rice
- Duke University Medical Center and Duke Global Health Institute, Durham, NC, United States
| | - David Watters
- Deakin University and Barwon Health, Melbourne, Australia
| | | | | | | | | | - Nivaldo Alonso
- Department of Plastic Surgery, University of São Paulo, São Paulo, Brazil
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6
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BJS commission on surgery and perioperative care post-COVID-19. Br J Surg 2021; 108:1162-1180. [PMID: 34624081 DOI: 10.1093/bjs/znab307] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 07/26/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) was declared a pandemic by the WHO on 11 March 2020 and global surgical practice was compromised. This Commission aimed to document and reflect on the changes seen in the surgical environment during the pandemic, by reviewing colleagues' experiences and published evidence. METHODS In late 2020, BJS contacted colleagues across the global surgical community and asked them to describe how severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) had affected their practice. In addition to this, the Commission undertook a literature review on the impact of COVID-19 on surgery and perioperative care. A thematic analysis was performed to identify the issues most frequently encountered by the correspondents, as well as the solutions and ideas suggested to address them. RESULTS BJS received communications for this Commission from leading clinicians and academics across a variety of surgical specialties in every inhabited continent. The responses from all over the world provided insights into multiple facets of surgical practice from a governmental level to individual clinical practice and training. CONCLUSION The COVID-19 pandemic has uncovered a variety of problems in healthcare systems, including negative impacts on surgical practice. Global surgical multidisciplinary teams are working collaboratively to address research questions about the future of surgery in the post-COVID-19 era. The COVID-19 pandemic is severely damaging surgical training. The establishment of a multidisciplinary ethics committee should be encouraged at all surgical oncology centres. Innovative leadership and collaboration is vital in the post-COVID-19 era.
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MESH Headings
- Adult
- Biomedical Research/organization & administration
- COVID-19/diagnosis
- COVID-19/economics
- COVID-19/epidemiology
- COVID-19/prevention & control
- Education, Medical, Graduate/methods
- Education, Medical, Graduate/trends
- Female
- Global Health
- Health Resources/supply & distribution
- Health Services Accessibility/trends
- Humans
- Infection Control/economics
- Infection Control/methods
- Infection Control/standards
- International Cooperation
- Male
- Middle Aged
- Pandemics
- Perioperative Care/education
- Perioperative Care/methods
- Perioperative Care/standards
- Perioperative Care/trends
- Practice Patterns, Physicians'/standards
- Practice Patterns, Physicians'/trends
- Surgeons/education
- Surgeons/psychology
- Surgeons/trends
- Surgical Procedures, Operative/education
- Surgical Procedures, Operative/methods
- Surgical Procedures, Operative/standards
- Surgical Procedures, Operative/trends
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7
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Abbott TEF, Fowler AJ, Dobbs TD, Gibson J, Shahid T, Dias P, Akbari A, Whitaker IS, Pearse RM. Mortality after surgery with SARS-CoV-2 infection in England: a population-wide epidemiological study. Br J Anaesth 2021; 127:205-214. [PMID: 34148733 PMCID: PMC8192173 DOI: 10.1016/j.bja.2021.05.018] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 05/14/2021] [Accepted: 05/20/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The COVID-19 pandemic has heavily impacted elective and emergency surgery around the world. We aimed to confirm the incidence of perioperative severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and associated mortality after surgery. METHODS Analysis of routine electronic health record data from NHS hospitals in England. We extracted data from Hospital Episode Statistics in England describing adult patients undergoing surgery between January 1, 2020 and February 28, 2021. The exposure was SARS-CoV-2 infection defined by International Classification of Diseases (ICD)-10 codes. The primary outcome measure was 90 day in-hospital mortality. Data were analysed using multivariable logistic regression adjusted for age, sex, Charlson Comorbidity Index, Index of Multiple Deprivation, presence of cancer, surgical procedure type and admission acuity. Results are presented as n (%) and odds ratios (OR) with 95% confidence intervals (CI). RESULTS We identified 2 666 978 patients undergoing surgery of whom 28 777 (1.1%) had SARS-CoV-2 infection. In total, 26 364 (1.0%) patients died in hospital. SARS-CoV-2 infection was associated with a much greater risk of death (SARS-CoV-2: 6153/28 777 [21.4%] vs no SARS-CoV-2: 20 211/2 638 201 [0.8%]; OR=5.7 [95% CI, 5.5-5.9]; P<0.001). Amongst patients undergoing elective surgery, 2412/1 857 586 (0.1%) had SARS-CoV-2, of whom 172/2412 (7.1%) died, compared with 1414/1 857 586 (0.1%) patients without SARS-CoV-2 (OR=25.8 [95% CI, 21.7-30.9]; P<0.001). Amongst patients undergoing emergency surgery, 22 918/582 292 (3.9%) patients had SARS-CoV-2, of whom 5752/22 918 (25.1%) died, compared with 18 060/559 374 (3.4%) patients without SARS-CoV-2 (OR=5.5 [95% CI, 5.3-5.7]; P<0.001). CONCLUSIONS The low incidence of SARS-CoV-2 infection in NHS surgical pathways suggests current infection prevention and control policies are highly effective. However, the high mortality amongst patients with SARS-CoV-2 suggests these precautions cannot be safely relaxed.
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Affiliation(s)
- T E F Abbott
- William Harvey Research Institute, Queen Mary University of London, London, UK.
| | - A J Fowler
- William Harvey Research Institute, Queen Mary University of London, London, UK
| | - T D Dobbs
- Reconstructive and Regenerative Medicine Group (ReconRegen), Institute of Life Sciences, Swansea University Medical School, Swansea, UK; Welsh Centre for Burns and Plastics, Morriston Hospital, Swansea, UK
| | - J Gibson
- Reconstructive and Regenerative Medicine Group (ReconRegen), Institute of Life Sciences, Swansea University Medical School, Swansea, UK; Welsh Centre for Burns and Plastics, Morriston Hospital, Swansea, UK
| | - T Shahid
- William Harvey Research Institute, Queen Mary University of London, London, UK
| | - P Dias
- William Harvey Research Institute, Queen Mary University of London, London, UK
| | - A Akbari
- Health Data Research UK, Swansea University Medical School, Swansea, UK
| | - I S Whitaker
- Reconstructive and Regenerative Medicine Group (ReconRegen), Institute of Life Sciences, Swansea University Medical School, Swansea, UK; Welsh Centre for Burns and Plastics, Morriston Hospital, Swansea, UK
| | - R M Pearse
- William Harvey Research Institute, Queen Mary University of London, London, UK
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Okuno T, Takada D, Shin JH, Morishita T, Itoshima H, Kunisawa S, Imanaka Y. Impact of the early stage of the coronavirus disease 2019 pandemic on surgical volume in Japan. Br J Surg 2021; 108:e173-e174. [PMID: 33793774 PMCID: PMC7929118 DOI: 10.1093/bjs/znab028] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 12/08/2020] [Accepted: 01/11/2021] [Indexed: 11/14/2022]
Affiliation(s)
- T Okuno
- Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, Kyoto City, Kyoto, Japan
| | - D Takada
- Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, Kyoto City, Kyoto, Japan
| | - J-H Shin
- Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, Kyoto City, Kyoto, Japan
| | - T Morishita
- Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, Kyoto City, Kyoto, Japan
| | - H Itoshima
- Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, Kyoto City, Kyoto, Japan
| | - S Kunisawa
- Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, Kyoto City, Kyoto, Japan
| | - Y Imanaka
- Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, Kyoto City, Kyoto, Japan
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