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Unanticipated Consequences of COVID-19 Pandemic Policies on Pediatric Acute Appendicitis Surgery

      Highlights

      • What is currently known about this topic? The COVID-19 pandemic caused hospitals to alter protocols to reserve resources for COVID-19-positive patients, impacting all aspects of healthcare and potentially, access to time-sensitive interventions.
      • What new information is contained in this article? This study highlights changes in healthcare access as a secondary consequence of the COVID-19 pandemic and related policies through the increased rate of complicated appendicitis.

      Summary

      Background

      Global pandemics may limit access to specialized care, delaying diagnosis and treatment of common acute surgical diseases. We analyzed the impact of the novel coronavirus disease 2019 (COVID-19) pandemic on acute appendicitis at an urban tertiary care center. We hypothesize that pandemics are associated with delayed presentation and worsened clinical sequelae, specifically, higher incidences of perforation in children.

      Methods

      We retrospectively assessed patients admitted to our institution with acute appendicitis in pre-pandemic control (February 2018-June 2019) and COVID-19 (February 2020-June 2021) cohorts. Primary outcomes included complicated appendicitis rates (perforation/abscess/bowel obstruction), COVID-19 status, complications and travel distance to our institution. 1,107 patients met inclusion criteria: 491 (44.4%) during the control period and 616 (55.6%) in the COVID-19 cohort. Statistical analysis involved t-tests, contingency tables and logistic regression modelling for key variables.

      Results

      A larger proportion of complicated appendicitis occurred during COVID-19 compared to controls (28.3% vs 38.8%, p<0.001). Symptom duration at presentation and length of stay were not significantly different. Duration of antibiotic treatment, surgery length, readmission rate and travel distances were significantly higher during COVID-19. The pre-pandemic cohort had a significantly younger age distribution.

      Conclusion

      Pediatric appendicitis was significantly impacted during COVID-19, demonstrated by increased rates of complicated appendicitis, surgery duration and antibiotic duration. This may be an unintended secondary consequence of patients avoiding healthcare facilities for non-pandemic related illnesses or lockdown policies. Government policies directing all provincial pediatric appendicitis cases to pediatric institutions increased travel distances for our patients and had unanticipated consequences and resource requirements on tertiary healthcare.

      Keywords

      Abbreviations

      COVID-19
      Novel coronavirus disease 2019
      IQR
      Inter-quartile range
      SD
      Standard deviation

      Conflict of Interest Disclosures

      The authors have no conflicts of interest to disclose.

      Funding/Support

      Phases of this study were supported by the Hospital for Sick Children Perioperative Services Summer Student Scholarship. The Hospital for Sick Children Perioperative Services had no role in the design and conduct of the study.

      Previous communication

      Presented as an oral podium presentation at the Canadian Association of Paediatric Surgeons (CAPS) 2022 Annual Meeting in Victoria, British Columbia, Canada, September 2022. Accepted by CAPS as a Societal Manuscript.

      Introduction

      Acute appendicitis is the most frequent acute care surgical disease in the pediatric population [
      • Kulik D.M.
      • Uleryk E.M.
      • Maguire J.L.
      Does this child have appendicitis? A systematic review of clinical prediction rules for children with acute abdominal pain.
      ]. It can be classified as uncomplicated or complicated/perforated appendicitis, with abscess or intestinal obstruction. Strong correlations have been reported between complicated appendicitis and worsened outcomes, more frequent postoperative complications, longer in-hospital stays, higher risk of readmission and higher hospital and healthcare costs [
      • Yousef Y.
      • Youssef F.
      • Dinh T.
      • Pandya K.
      • Stagg H.
      • Homsy M.
      • et al.
      Risk stratification in pediatric perforated appendicitis: Prospective correlation with outcomes and resource utilization.
      ,
      • Cameron D.B.
      • Anandalwar S.P.
      • Graham D.A.
      • Melvin P.
      • Serres S.K.
      • Dunlap J.L.
      • et al.
      Development and Implications of an Evidence-based and Public Health-relevant Definition of Complicated Appendicitis in Children.
      ].
      A global pandemic may limit access to specialized care, which can delay diagnosis and definitive treatment of common acute surgical diseases such as acute appendicitis in the pediatric population [
      • Boutis K.
      • Stephens D.
      • Lam K.
      • Ungar W.J.
      • Schuh S.
      The impact of SARS on a tertiary care pediatric emergency department.
      ,
      • Snapiri O.
      • Rosenberg Danziger C.
      • Krause I.
      • Kravarusic D.
      • Yulevich A.
      • Balla U.
      • et al.
      Delayed diagnosis of paediatric appendicitis during the COVID-19 pandemic.
      ,
      • Lazzerini M.
      • Barbi E.
      • Apicella A.
      • Marchetti F.
      • Cardinale F.
      • Trobia G.
      Delayed access or provision of care in Italy resulting from fear of COVID-19.
      ]. In response to the novel coronavirus disease 2019 (COVID-19) pandemic, Canadian provincial and federal governments issued travel restrictions, safety guidelines and stay-at-home orders to help limit the spread of the COVID-19 virus, similar to or potentially more stringent than other countries. Some places in North America had limited lockdown restrictions or policies [

      Ligo AK, Mahoney E, Cegan J, et al. Relationship among state reopening policies, health outcomes and economic recovery through first wave of the COVID-19 pandemic in the U.S. Ndeffo Mbah ML, ed. PLoS One [Internet]. 2021 [cited 2022 Oct 6];16 (11):e0260015. Available from: https://doi.org/10.1371/journal.pone.0260015

      ,
      • Elitzur M.
      • Kaplan S.
      • Ivezić Ž.
      • Zilberman D.
      The impact of policy timing on the spread of COVID-19.
      ,
      • Walensky R.P.
      • Walke H.T.
      • Fauci A.S.
      SARS-CoV-2 Variants of Concern in the United States—Challenges and Opportunities.
      ,
      • Colloca L.
      • Thomas S.
      • Yin M.
      • Haycock N.R.
      • Wang Y.
      Pain experience and mood disorders during the lockdown of the COVID-19 pandemic in the United States: an opportunistic study.
      ,

      Canadian Institute for Health Information. COVID-19 Intervention Scan — Data Tables. Ottawa; 2022 [last accessed October 7 2022]. Available from: https://www.cihi.ca/en/covid-19-intervention-timeline-in-canada#info

      ]. These social distancing/isolation policies and fear of exposure to pathogens in healthcare facilities may have restricted access to care [
      • Lazzerini M.
      • Barbi E.
      • Apicella A.
      • Marchetti F.
      • Cardinale F.
      • Trobia G.
      Delayed access or provision of care in Italy resulting from fear of COVID-19.
      ]. In addition, strategies to mitigate spread of and exposure to infectious diseases may have resulted in increased resource utilization, secondary to increased admissions, length of stay and more complicated cases [
      • Boutis K.
      • Stephens D.
      • Lam K.
      • Ungar W.J.
      • Schuh S.
      The impact of SARS on a tertiary care pediatric emergency department.
      ,
      • Snapiri O.
      • Rosenberg Danziger C.
      • Krause I.
      • Kravarusic D.
      • Yulevich A.
      • Balla U.
      • et al.
      Delayed diagnosis of paediatric appendicitis during the COVID-19 pandemic.
      ,
      • Lazzerini M.
      • Barbi E.
      • Apicella A.
      • Marchetti F.
      • Cardinale F.
      • Trobia G.
      Delayed access or provision of care in Italy resulting from fear of COVID-19.
      ,
      • Fisher J.C.
      • Tomita S.S.
      • Ginsburg H.B.
      • Gordon A.
      • Walker D.
      • Kuenzler K.A.
      Increase in Pediatric Perforated Appendicitis in the New York City Metropolitan Region at the Epicenter of the COVID-19 Outbreak.
      ,
      • Gerall C.D.
      • DeFazio J.R.
      • Kahan A.M.
      • Fan W.
      • Fallon E.M.
      • Middlesworth W.
      • et al.
      Delayed presentation and sub-optimal outcomes of pediatric patients with acute appendicitis during the COVID-19 pandemic.
      ].
      Literature emerging from pediatric centers in New York City, France and Israel began assessing appendicitis rates and severity as a secondary effect of the pandemic [
      • Snapiri O.
      • Rosenberg Danziger C.
      • Krause I.
      • Kravarusic D.
      • Yulevich A.
      • Balla U.
      • et al.
      Delayed diagnosis of paediatric appendicitis during the COVID-19 pandemic.
      ,
      • Fisher J.C.
      • Tomita S.S.
      • Ginsburg H.B.
      • Gordon A.
      • Walker D.
      • Kuenzler K.A.
      Increase in Pediatric Perforated Appendicitis in the New York City Metropolitan Region at the Epicenter of the COVID-19 Outbreak.
      ,
      • Gerall C.D.
      • DeFazio J.R.
      • Kahan A.M.
      • Fan W.
      • Fallon E.M.
      • Middlesworth W.
      • et al.
      Delayed presentation and sub-optimal outcomes of pediatric patients with acute appendicitis during the COVID-19 pandemic.
      ,
      • Montalva L.
      • Haffreingue A.
      • Ali L.
      • Clariot S.
      • Julien-Marsollier F.
      • el Ghoneimi A.
      • et al.
      The role of a pediatric tertiary care center in avoiding collateral damage for children with acute appendicitis during the COVID-19 outbreak.
      ]. Toronto has one specialized free-standing pediatric hospital to treat 7.1 million children in the broad geographical region of Toronto and the greater metropolitan area. Thus, offering us a unique perspective on the immediate and latent effects of the pandemic on the regional and provincial pediatric population. Other major cities, such as New York City, typically have multiple specialized pediatric centers. Toronto’s experience with SARS in 2003 produced similar intensity lockdowns, however of shorter duration and less extensive (just regional and not provincial) [
      • Boutis K.
      • Stephens D.
      • Lam K.
      • Ungar W.J.
      • Schuh S.
      The impact of SARS on a tertiary care pediatric emergency department.
      ]. We therefore aimed to study the impact of pandemics, specifically COVID-19, on the presentation, management and overall outcomes of acute appendicitis in the pediatric population, in our urban tertiary care center. We hypothesized that pandemics are associated with delayed presentation and consequently worsened clinical sequelae, specifically, a higher incidence of complicated appendicitis in children.

      1. Methods

      1.1 Patient selection

      We included all pediatric patients (less than 18 years old) who were admitted or transferred to our pediatric academic tertiary care centre for acute appendicitis. We excluded those who presented for an interval appendectomy (8-12 weeks after initial presentation and non-operative management) or incidental appendectomy (removal due to another illness/operation). We excluded those who were COVID-19-positive, as institutional protocol required them to receive an interval appendectomy, thereby not meeting our inclusion criteria, and were treated non-operatively while COVID-19-positive and later returned for appendectomy. We reviewed all records for patients meeting inclusion criteria over two time periods: a pre-pandemic control period (February 2018 to June 2019) and the COVID-19 pandemic period (February 2020 to June 2021). We defined the start of the pandemic period as a midpoint between the first case in Ontario in January 2020 and the World Health Organization declaration of the COVID-19 pandemic on March 11, 2020 [

      World Health Organization. World Health Organization Director-General’s Opening Remarks at the Media Briefing on COVID-19–11 March 2020. Geneva; 2020 [last accessed June 28 2022]. Available from: https://www.who.int/director-general/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19–-11-march-2020

      ]. Provincial government mandates effective April 12, 2021, required all pediatric appendicitis cases in the province be directed to pediatric institutions to redirect resources for adults with COVID-19 [

      Ontario Supporting Health System Response During Third Wave of COVID-19. Government of Ontario NewsRoom. Published 2021. Accessed July 6, 2022. https://news.ontario.ca/en/release/61094/ontario-supporting-health-system-response-during-third-wave-of-covid-19

      ]. The care team at our institution who managed appendicitis patients followed a standardized protocol for assessment and management over both time periods, the only difference being the type of antibiotic used for complicated appendicitis cases (intravenous (IV) ampicillin, tobramycin and metronidazole/oral amoxicillin and clavulanic acid during the control period versus IV ceftriaxone and metronidazole/oral ciprofloxacin and metronidazole during the COVID-19 period). The study was approved by our institution’s Research Ethical Board (REB#1000076098).

      1.2 Patient variables and data collection

      Patient demographics and baseline characteristics were retrospectively collected from electronic medical records and included age, sex, weight and comorbidities. The primary objective of this study was to determine disease severity, as the proportion of complicated to uncomplicated appendicitis. The secondary objective was to assess clinical characteristics including duration of symptoms at presentation, length of stay and antibiotic treatment duration. Duration of symptoms was identified as documented in consultation notes taken by surgeons and/or Emergency Department physicians during admission. Clinical data to assess primary and secondary outcomes include appendicitis diagnosis (uncomplicated or complicated), diagnostic imaging used, antibiotic use and duration, type of treatment and associated variables, length of stay, complications and rate of readmission. Complicated appendicitis is defined as perforation, abscess and/or bowel obstruction as determined by surgeon, radiologist and/or pathology reports. Surgical length was identified as documented in surgical reports from the surgical team. Our institution calculates operative time as the time from incision to dressing placement after closure and is documented in our electronic medical records.
      The first 3 digits of patient postal codes (A2A 2A2 format) were collected to determine travel distance to our institution. This information was visualized by constructing maps using ArcGIS® software by Esri. ArcGIS® and ArcMap™ are the intellectual property of Esri and used herein under license/©Esri (www.esri.com). We excluded patients travelling from outside of Ontario as these were extraordinary and rare cases beyond the scope of this analysis, but still required our care and resources.

      1.3 Statistical analysis

      Statistical analysis was completed using SPSS 28.0 (IBM, Armonk, NY), with a significance level of a=0.05. Normality for continuous variables was tested using normality plots, to determine test use. Continuous data was analyzed using independent samples t-test for parametric data, Mann-Whitney U test for non-parametric data and logistic regression. Contingency tables were used for binary data. Parametric data is reported as mean (standard deviation (SD)) and non-parametric data as median (inter-quartile range (IQR)). Levene’s test for equality of variances was used prior to t-test. Variables with a significant p-value (i.e., unequal variance) are reported using the Satterthwaite p-value. Complicated appendicitis subgroup analyses followed these same methods. The final logistic regression model included the independent variables that showed a significant association in the unadjusted analysis.

      2. Results

      A total of 1260 patients were identified with the diagnosis of appendicitis within the study periods. Of these, 1,107 patients met the inclusion criteria (defined in Methods 1.1), with 491 (44.4%) presenting during the control period and 616 (55.6%) in the COVID-19 pandemic period, with exclusion of 153 interval and incidental appendectomies. Our institution treated two COVID-19-positive patients with appendicitis during the study period. They were excluded from this study as they were treated by interval appendectomy. Patient admission can be visualized by Fig. 1 for monthly changes in acute appendicitis. The COVID-19 cohort was significantly older and heavier (p<0.001) than controls, but not significantly different in sex distribution (p=0.634) (Table 1). The duration of symptoms at presentation was also not significantly different between study groups (p=0.612). Comparing the complicated appendicitis subgroups from both groups showed similar demographic trends (Table 2).
      Fig. 1
      Fig. 1Number of acute appendicitis patients admitted to our institution per month, separated by appendicitis outcome (uncomplicated – grey, complicated – black). Red line indicates the start of the COVID-19 pandemic (February 2020).
      Table 1Demographics and Clinical Characteristics.
      Pre-pandemic control (2018-2019)

      (n=491)
      COVID-19 pandemic group (2020-2021)

      (n=616)
      p-value
      Age (years)
      data presented as mean (SD).
      8.6 (3.4)9.7 (3.8)<0.001
      Weight (kg)
      data presented as median (IQR).
      30.9 (19.4)34.2 (25.7)<0.001
      Females
      data presented as n (%).
      195 (39.7%)236 (38.3%)0.634
      Duration of symptoms at presentation (days)
      data presented as median (IQR).
      1.0 (2.0)2.0 (2.0)0.538
      Complicated appendicitis
      data presented as n (%).
      139 (28.3%)239 (38.8%)<0.001
      Diagnostic Imaging
      Ultrasound
      data presented as n (%).
      450 (91.6%)543 (88.1%)0.044
      Ultrasound and CT
      data presented as n (%).
      18 (3.7%)30 (4.9%)0.332
      Ultrasound and X-ray
      data presented as n (%).
      11 (2.2%)26 (4.2%)0.070
      Ultrasound and MRI
      data presented as n (%).
      9 (1.8%)6 (1.0%)0.218
      CT
      data presented as n (%).
      0 (0%)6 (1.0%)0.028
      Interventions Required
      Appendectomy
      data presented as n (%).
      428 (87.2%)535 (86.9%)0.807
      Non-operative
      data presented as n (%).
      36 (7.3%)44 (7.1%)0.896
      Percutaneous drain
      data presented as n (%).
      12 (2.4%)19 (3.1%)0.525
      Appendectomy and percutaneous drain
      data presented as n (%).
      6 (1.2%)11 (1.8%)0.451
      Secondary Outcomes
      Length of stay (days)
      data presented as median (IQR).
      2.0 (4.0)2.0 (3.0)0.137
      Total antibiotic treatment duration (days)
      data presented as median (IQR).
      2.0 (8.0)2.0 (11.0)0.033
      Surgery length (min)
      data presented as median (IQR).
      105 (30)115 (10)<0.001
      Readmission related to appendicitis
      data presented as n (%).
      21 (4.3%)50 (8.1%)0.010
      Abbreviations: CT – Computed tomography, MRI – Magnetic resonance imaging.
      a data presented as mean (SD).
      b data presented as median (IQR).
      c data presented as n (%).
      Table 2Demographics and Clinical Characteristics for complicated appendicitis subgroups.
      Pre-pandemic -Complicated appendicitis subgroup (n=139)COVID-19 pandemic - Complicated appendicitis subgroup (n=239)p-value
      Age (years)
      data presented as mean (SD).
      7.9 (3.6)9.5 (3.9)<0.001
      Weight (kg)
      data presented as median (IQR).
      27.8 (21.2)33.9 (26.6)0.007
      Females
      data presented as n (%).
      51 (36.7%)102 (42.7%)0.253
      Duration of symptoms at presentation (days)
      data presented as median (IQR).
      2.0 (3.0)2.0 (3.0)0.511
      Complications
      Perforation
      data presented as n (%).
      139 (100%)239 (100%)
      Abscess
      data presented as n (%).
      47 (33.8%)69 (28.9%)0.315
      Obstruction
      data presented as n (%).
      4 (2.9%)7 (2.9%)0.977
      Diagnostic Imaging
      Ultrasound
      data presented as n (%).
      119 (85.6%)199 (83.3%)0.547
      Ultrasound and CT
      data presented as n (%).
      11 (7.9%)15 (6.3%)0.544
      Ultrasound and X-ray
      data presented as n (%).
      7 (5.0%)18 (7.5%)0.347
      Ultrasound and MRI
      data presented as n (%).
      2 (1.4%)3 (1.3%)0.880
      CT
      data presented as n (%).
      0 (0%)3 (1.3%)0.185
      Interventions Required
      Appendectomy
      data presented as n (%).
      99 (71.2%)186 (77.8%)0.151
      Non-operative
      data presented as n (%).
      18 (12.9%)22 (9.2%)0.254
      Percutaneous drain
      data presented as n (%).
      12 (8.6%)19 (7.9%)0.815
      Appendectomy and percutaneous drain
      data presented as n (%).
      5 (3.6%)10 (4.2%)0.778
      Secondary Outcomes
      Length of stay (days)
      data presented as median (IQR).
      6.0 (4.0)5.0 (5.0)0.019
      Total antibiotic treatment duration (days)
      data presented as median (IQR).
      12.0 (8.0)12.0 (7.0)0.487
      Surgery length (min)
      data presented as median (IQR).
      105 (110)115 (15)0.002
      Readmission related to appendicitis
      data presented as n (%).
      10 (7.2%)33 (13.8%)0.051
      a data presented as mean (SD).
      b data presented as median (IQR).
      c data presented as n (%).
      Complicated appendicitis accounted for 139 (28.3%) cases during the control period and 239 (38.8%) cases during the COVID-19 period (p<0.001). The COVID-19 cohort demonstrated worsened secondary outcomes, summarized in Table 1. Children in the COVID-19 cohort required a longer median surgery time and overall duration of antibiotic treatment. They also had a higher rate of readmission, 8.1% vs 4.3% for controls (p=0.010). Surgery duration remained significantly longer (p=0.002) for the complicated appendicitis subgroups. The trend of readmission rate also increased, although did not meet the significance limit (p=0.51). Secondary outcomes for the complicated appendicitis subgroups are summarized in Table 2.
      The rates of various intervention methods (appendectomy, non-operative management, percutaneous drain, or appendectomy followed by percutaneous drain) did not differ between study groups or complicated subgroups (Table 1, 2). Surgical management was the most common intervention method, followed by non-operative/antibiotic management for both control and pandemic periods, 71.2% vs 77.8% (p=0.151) and 12.9% vs 9.2% (p=0.254).
      Binomial logistic regression was done for each predictor variable and those with significant p-values, indicating significant contribution to the model, were included in the final model (Table 3). The final model included study group, age, sex and duration of symptoms before presentation as predictor variables. This model demonstrated that, when holding all other predictor variables constant, the odds of complicated appendicitis increased by 81% (OR 1.81; 95% CI 1.38, 2.37) when presenting during the pandemic, compared to the control period. Younger age and increasing duration of symptoms were also associated with increased risk of complicated appendicitis in this model.
      Table 3Final adjusted logistic regression model values assessing risk of complicated appendicitis outcomes for each predictor variable.
      Predictor VariableOdds Ratio95% Confidence Interval for ORp-value
      Lower LimitUpper Limit
      COVID-19 cohort (control cohort = reference)1.811.382.37<0.001
      Increasing age (years)0.940.910.980.002
      Increasing duration of symptoms at presentation (days)1.261.181.34<0.001
      Distance to surgical care was calculated using postal codes from patient residences to our institution using both straight line “as-the-crow-flies” and road driving distances (Fig. 2, Fig. 3). The COVID-19 cohort experienced greater median travel distances by both measures; 18.8 km vs 17.7 km (p=0.042) by “as-the-crow-flies” and 24.7 km vs 20.7 km (p=0.044) by driving distance. The COVID-19 complicated appendicitis subgroup had greater travel distances than the control subgroup, but it did not reach statistical significance. We excluded patients living outside of Ontario from this analysis.
      Fig. 2
      Fig. 2Maps of travel distances to our institution. Travel distance measured by “as-the-crow-flies” (blue) and driving (red) distances for Ontario patients in (A) the pre-pandemic cohort and (B) the COVID-19 cohort.
      Fig. 3
      Fig. 3Density maps of patient residence, by postal code area. Shown for (A) the pre-pandemic cohort and (B) the COVID-19 cohort, wherein a deeper red color indicates more patients in that area.

      3. Discussion

      The immediate effects of COVID-19/SARS-CoV-2 infection are continuously being assessed however, little is known about latent and collateral effects of the pandemic, specifically in pediatric populations. This study uncovers implications of policy changes to healthcare access as a secondary consequence of the COVID-19 pandemic and related enacted policies on the pediatric population, in the context of a government-controlled universal healthcare system. Such changes may unintentionally impede access to care or delay treatments for other diagnoses, resulting in secondary consequences and ultimately increased use of healthcare resources. Compared to the same period in prior years, our institution treated 1.25 times more acute appendicitis cases during the first 17 months of the COVID-19 pandemic, with the proportion of complicated appendicitis also significantly increasing from 28.3% in controls to 38.8%. Geographical analysis highlighted further impacts on care, as patients during the pandemic traveled significantly further to our institution. Our data suggests an indirect relationship between COVID-19 and acute appendicitis, specifically complicated appendicitis. We did not have enough COVID-19-positive appendicitis patients during the study period to evaluate direct relationships.
      The Canadian universal healthcare system places policy changes and resource allocation under provincial government jurisdiction. As a result of increasing adult COVID-19 cases and hospitalizations, and need for additional adult inpatient capacity at non-free-standing pediatric hospitals, our provincial government recommended limiting pediatric surgical care at integrated hospitals throughout the pandemic, and eventually implemented a province-wide policy in April 2021 directing all pediatric appendicitis cases to pediatric hospitals, while our institution covered the entire Greater Toronto Area. These policy changes can, at least partially, explain the great increase in number of patients with acute and complicated appendicitis treated at our institution.
      No reports have been made of a direct biological impact of COVID-19 on the development or severity of appendicitis to date. Our institution did not have enough COVID-19-positive appendicitis patients during the study period to evaluate direct relationships between these two conditions.
      As the designated pediatric hospital for the region, and with minimal COVID-19-positive patients being treated at our institution, we did not change acute appendicitis standard-of-care protocols, unlike many other institutions which opted for non-operative management to preserve resources and minimize length of stay [
      • Barie P.S.
      Non-Operative Management of Appendicitis: Evolution, not Revolution.
      ]. Literature suggests that non-operative management has high failure rates (upwards of 30%), which would later require patient re-admission [
      • Minneci P.C.
      • Hade E.M.
      • Lawrence A.E.
      • Sebastião Y.v.
      • Saito J.M.
      • Mak G.Z.
      • et al.
      Association of Nonoperative Management Using Antibiotic Therapy vs Laparoscopic Appendectomy With Treatment Success and Disability Days in Children With Uncomplicated Appendicitis.
      ]. While this policy addressed the immediate issue of treating COVID-19-positive patients, latent effects of this policy were not considered. As a result, our institution treated more patients with acute appendicitis, shifting resources towards acute care surgery without additional support to meet this demand. Sufficient medical evaluation for children suspected of having surgical conditions should be prioritized, even during a pandemic.
      Children are more likely to have perforated/complicated appendicitis than adults and this risk increases linearly with duration of symptoms prior to appendectomy, especially prior to hospital admission [
      • Papandria D.
      • Goldstein S.D.
      • Rhee D.
      • Salazar J.H.
      • Arlikar J.
      • Gorgy A.
      • et al.
      Risk of perforation increases with delay in recognition and surgery for acute appendicitis.
      ,
      • Narsule C.K.
      • Kahle E.J.
      • Kim D.S.
      • Anderson A.C.
      • Luks F.I.
      Effect of delay in presentation on rate of perforation in children with appendicitis.
      ]. We anticipated the pandemic and stay-at-home orders would increase reluctancy to visit hospitals, thereby seeing acute appendicitis cases present later in the disease course. While no significant increase in the median duration of symptoms in the COVID-19 (2 days) versus control cohorts (1 day) was observed, it seems to be of clinical significance. In accordance with current literature, our logistic regression showed the odds of complicated appendicitis increased by 26% for every 1-day increase in symptom duration, holding all other predictors constant. The COVID-19 group also had a significantly increased risk of complicated appendicitis, regardless of age or symptom duration. The duration of symptoms for complicated appendicitis subgroups suggests the government protocol may not have impeded access to care, but patients/families may still have been hesitant to seek hospital care due to fear of COVID-19 exposure. Symptoms could be subjective and not fully acknowledged when patients’ families struggle with significant fear of an ongoing pandemic.
      Moreover, greater duration of antibiotics, surgery length and proportion of readmissions in the COVID-19 group indicate more severe disease and worsened secondary outcomes compared to controls. These factors resulted in greater resource utilization and increased burden on our institution and healthcare system.
      The COVID-19 cohort had significantly greater median travel distances to our institution, measured by “as-the-crow-flies” and driving distances. This is likely due to the provincial mandate, as older children and those living further from Toronto were required to travel to our institution to receive care. Prior to the pandemic, older patients would be treated by general surgery teams at community hospitals. Our hospital had an increased catchment area, as no pediatric hospital is located North of Toronto. This likely contributed to the increased mean age and median weight in the pandemic cohort.
      Similar studies were conducted in Italy, the United States of America and France early in the pandemic and reported comparable results. Pediatric emergency department visits in Italy decreased by up to 88% at the March 2020 peak of the initial wave of the COVID-19 pandemic, when compared to the same period in 2018 and 2019 [
      • Lazzerini M.
      • Barbi E.
      • Apicella A.
      • Marchetti F.
      • Cardinale F.
      • Trobia G.
      Delayed access or provision of care in Italy resulting from fear of COVID-19.
      ]. Parents of these pediatric patients reported delaying hospital visits due to fear of being infected by SARS-CoV-2. Moreover, the patients that presented during this peak period had worse overall outcomes than the control period. Gerall et al. found similar results in New York City with patients presenting with more severe cases, higher rates of perforation, greater antibiotic use, longer length of hospital stay and more frequent complications [
      • Gerall C.D.
      • DeFazio J.R.
      • Kahan A.M.
      • Fan W.
      • Fallon E.M.
      • Middlesworth W.
      • et al.
      Delayed presentation and sub-optimal outcomes of pediatric patients with acute appendicitis during the COVID-19 pandemic.
      ]. An additional New York City study found an increased rate of perforation and duration of symptoms at presentation, highlighting obstacles to care during the pandemic [
      • Fisher J.C.
      • Tomita S.S.
      • Ginsburg H.B.
      • Gordon A.
      • Walker D.
      • Kuenzler K.A.
      Increase in Pediatric Perforated Appendicitis in the New York City Metropolitan Region at the Epicenter of the COVID-19 Outbreak.
      ]. A study in Paris, France saw an increase in the number of pediatric acute appendicitis cases and greater travel distances during the pandemic [
      • Montalva L.
      • Haffreingue A.
      • Ali L.
      • Clariot S.
      • Julien-Marsollier F.
      • el Ghoneimi A.
      • et al.
      The role of a pediatric tertiary care center in avoiding collateral damage for children with acute appendicitis during the COVID-19 outbreak.
      ]. However, this study did not see any differences in clinical outcomes including length of stay, rate of abscess or readmissions.
      This data can be used to create an ethical framework to help guide government- and institution-based protocols on resource allocation and consideration of its latent and potentially long-term effects for future waves of the COVID-19 pandemic and future pandemics/health crises. This data and the importance of upholding adequate medical evaluation of children suspected of having surgical conditions must be kept in mind to maintain quality care, avoid excess resource use and unanticipated consequences, even during a pandemic.
      Limitations of our study include those inherent to its retrospective nature. Our use of a historical control group was necessary due to the nature of the posed question and our methodology. The changes in our appendicitis protocols for antibiotics between study periods is an uncontrolled variable that may impact these results; however, this change did not affect any other part of the treatment process and the required duration of antibiotic treatment was not changed between these times. Surgeons followed institutional pathways to determine antibiotic use and duration with high adherence (>99%), including IV antibiotics until oral tolerance and then transition to oral antibiotics for a total of 7 days in complicated appendicitis with improvement of symptoms. In non-perforated appendicitis, the patients did not receive any additional antibiotic therapy unless they developed symptoms suggesting abscess formation (recurrent pain, fevers, anorexia). As well, reported duration of symptoms is a subjective measure and is particularly difficult to determine in younger children as they may not be able to easily explain their pain/symptoms. This is a potential source of bias as it varies between patients based on pain thresholds, parent interpretation of symptoms and recall.
      While differences in surgery duration are likely due to the increased number of complicated appendicitis cases, the identity of the surgeon may also influence surgery duration. Most of our appendectomy cases are done by pediatric surgery fellows with staff as back up/assistance, or more rarely by staff surgeons themselves. Surgeon identity was not assessed in the present study, however very similar between the two cohorts.
      Future analysis with this cohort involves extracting socio-economic status (SES) and mean income information from federal census data for patient postal code areas to assess potential correlations between outcomes, rate of complicated appendicitis or symptom duration with SES. Minority and lower SES groups have been disproportionately impacted by the pandemic and may experience greater barriers accessing healthcare [
      • Little C.
      • Alsen M.
      • Barlow J.
      • Naymagon L.
      • Tremblay D.
      • Genden E.
      • et al.
      The Impact of Socioeconomic Status on the Clinical Outcomes of COVID-19; a Retrospective Cohort Study.
      ,
      • Palacio A.
      • Tamariz L.
      Social Determinants of Health Mediate COVID-19 Disparities in South Florida.
      ,
      • Patel J.A.
      • Nielsen F.B.H.
      • Badiani A.A.
      • Assi S.
      • Unadkat V.A.
      • Patel B.
      • et al.
      Poverty, inequality and COVID-19: the forgotten vulnerable.
      ]. We anticipate a single-payer healthcare system could minimize these disparities and we plan to explore the impact of SES on healthcare access within this universal healthcare system.

      Conclusion

      Overall, our institution saw significantly more children with acute appendicitis and a higher proportion of complicated appendicitis during the COVID-19 pandemic. The provincial government’s surgical mandate was an ethical strategy to save resources and allocate them to more urgent cases, however it impacted pediatric healthcare with downstream effects on time-sensitive procedures, resulting in unanticipated secondary consequences and increased resource use at our institution to keep up with the influx of patients with acute appendicitis.

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