Is this the tip of the iceberg six month outcomes for patients declining endoscopic investigation

ABSTRACT

Introduction: The COVID 19 pandemic has had a profound effect on our lives and the way that medical services are delivered. During the initial stage of the pandemic in Britain, as well as a national lock down to reduce the spread of the virus, non-urgent care at hospitals was significantly reduced or stopped. JAG and BSG recommended that all but the most urgent endoscopic examination should be delayed. Most endoscopic examinations were postponed from the end of March 2020 to June 2020. On recommencement of endoscopic services, all patients who had had an endoscopic procedure delayed were invited to re-attend. This study explores the outcomes of those that deferred or cancelled their appointments. Aims & Methods: A retrospective observational study of patients referred for an endoscopic investigation at Sheffield Teaching Hospital NHS trust between March 2020 and June 2020. All patients who were referred for an endoscopy during the period of lockdown were reviewed. At resumption of endoscopic services, those patients that initially declined to attend for their endoscopy were included. A case note review of each patient was undertaken. Demographics, presentation, investigations performed and outcomes were obtained. The reason that the patient did not initially attend was recorded when available. Outcomes over the following 6 months were recorded including endoscopy investigation performed, radiological investigation performed and diagnosis of malignancy. Descriptive statistics were used to describe this cohort of patients. Results: At resumption of endoscopic services 66 patients initially declined an investigation. The median age was 65 with a range of 30-90 and an interquartile range 23. 55% of the cohort was male. Both upper and lower endoscopies had been requested for 22 patients, 29 had been referred for a colonoscopy and 15 had been referred for a gastroscopy. Over the following 6 months, 10 (13.6%) patients subsequently had an endoscopic investigation performed. The median days from resumption of endoscopic services to procedure was 60.5 with an interquartile range of 24.75 and a range of 45 to 190 days. A radiological investigation was performed in 28 (42.4%) patients. No endoscopic or radiological investigations were undertaken in 27 (41%) of patients. A malignant diagnosis was found in 4 (6%) patients. Of those patients not undertaking any investigations, 13/27 had resolution of their symptoms, 7/27 did not proceed due to concerns regarding the COVID 19 virus, 2/27 due to reasons unrelated the COVID 19 virus and in 5/27 no clear reason could be found. Conclusion: In this cohort of patients who were initially reluctant to attend for endoscopic examination, completion of investigations over the following 6 months occurred infrequently. Almost half of patients who delayed their endoscopy also did not have a radiological investigation. Although a significant proportion of patients' symptoms resolved, without s further investigation the prevalence of underlying malignant diagnosis is unknown. Although there is patient concern regarding COVID 19 transmission, risk of infection acquired whilst attending for endoscopy appears to be very low. There may still be a further hidden human cost of COVID 19 caused by incomplete investigation.