Long-term impact of the COVID-19 pandemic on Inflammatory Bowel Disease healthcare utilization: A two-year nationwide update

Background: The COVID-19 pandemic has profoundly impacted utilization of inflammatory bowel disease (IBD) healthcare, with a large reduction in scheduled procedures in the early phase of the pandemic, as shown in our previous study1. In this current nationwide study, we aimed to determine the impact of consecutive COVID-19 waves on IBD healthcare utilization including IBD-related diagnoses and procedures during the first two years of the COVID-19 pandemic. Method(s): We conducted a search in the Dutch nationwide pathology databank (PALGA) to identify IBD patients who underwent an IBDrelated procedure between March 1, 2018 and February 28, 2022. We determined the incidence of IBD-related endoscopic and surgical procedures, new IBD diagnoses and neoplasia diagnoses (indefinite (IND), low-grade (LGD), high-grade dysplasia (HGD) and colorectal cancer (CRC)) during the first two years of the COVID-19 pandemic in the Netherlands (March 2020 - February 2022). The mean incidence of the previous two years (March 2018 - February 2020) served as a comparator. Result(s): Our search yielded 89,401 (94.2%) endoscopic and 5,462 (5.8%) surgical procedures. We calculated a net reduction of 2.9% (1,391 IBD procedures) after the first two years of the COVID-19 pandemic compared to the two pre-pandemic years (endoscopic procedures: -3.1%, n=1,409;surgical procedures: +0.7%, n=18, figure 1). For both endoscopic and surgical procedures, an initial net decrease after the first pandemic year was followed by a net increase after the second year (-6.2% (n=1,413) versus +0.02% (n=4) and -1.3% (n=18) versus +2.7% (n=36), respectively). A net reduction of 0.9% (n=54) in new IBD diagnoses was observed over the first two years of the COVID-19 pandemic (first year: -0.8%, n=24;second year: -1.0%, n=30). A net reduction of 1.9% (n=74) in IND/LGD diagnoses was observed after the two-year pandemic period (first year: -10.9%, n=213: Second year: +7.1%, n=139). No net decrease was seen for HGD and CRC diagnoses. Conclusion(s): In this nationwide cohort study covering the first two pandemic years, we observed a mitigation of the initial reduction of IBDrelated procedures after the first COVID-19 wave. This illustrates the rapid adaptation of the national IBD healthcare system during subsequent COVID-19 peaks.

Impact of Delayed Screening Invitations Due to Covid-19 on Outcomes of the Dutch Fit-Based Colorectal Cancer Screening Programme: Individual-Level Data Analysis

Introduction: Many countries were forced to temporarily suspend their cancer screening programme due to the COVID-19 pandemic;in the Netherlands, the colorectal cancer (CRC) screening programme was suspended for two months in 2020 (1-3). To clear the backlog after restarting, it was decided to delay the invitation interval from 24 months up to a maximum of 30 months (4). This study assessed the individual impact of the extended invitation interval due to COVID-19 pandemic on the key performance indicators of the Dutch CRC screening programme. Aims & Methods: All participants eligible for FIT screening in 2019 and 2020 were included in the study. Individual-level data were retrieved from the national information system (ScreenIT) for CRC screening. Multivariable logistic regression analyses were used to assess the association between either the different time periods (before, during,orafterthe first COVID-19 wave) or the invitation interval on the key performance indicators (i.e. participation FIT and follow-up colonoscopy, FIT positivity, positive predicted value (PPV) and FIT interval cancers), adjusted for confounding factors age, sex and invitation round. Result(s): FIT and follow-up colonoscopy participation were lower duringthe first COVID-19 wave, both for the first (OR: 0.80, 95%CI: 0.78-0.82)) and subsequent invitation rounds (OR: 0.73, 95%CI: 0.72-0.74). FIT positivity was slightly higher during,but for first-round participants only (OR: 1.04, 95%CI: 0.97-1.12). PPV for CRC and advanced neoplasia (AN) was lower during and after the first COVID-19 wave for the first (OR: 0.85, 95%CI: 0.71-0.98 and OR: 0.92, 95%CI: 0.85-0.98) and subsequent invitation rounds (OR: 0.95, 95%CI: 0.86-0.96 and OR: 0.95, 95%CI: 0.92-0.98). Models including invitation interval, showed higher participation for FIT and follow-up colonoscopy with extended invitation intervals >26 months. No relevant differences were observed for FIT positivity, PPV for CRC and AN, and interval cancers for the different invitation intervals. Conclusion(s): The impact of the first COVID-19 wave as well as the associated extended invitation interval on the key performance indicators was small, with the highest negative impact on participation rates in the first screening round during and after the first wave. In case of future unexpected bottlenecks, emphasizes might be placed on invitation strategies and public awareness for CRC screening, especially for first screening round invitees.

No decrease in number of new Inflammatory Bowel Disease diagnoses in children in the Netherlands during the Covid-19 pandemic: A nationwide retrospective cohort study

Background: The COVID-19 pandemic has had a large impact on regular healthcare provision in the Netherlands. During the first wave, healthcare in children was strongly reduced due to safety regulations and reduced hospital capacity for non-COVID care. This, and fear of COVID-19 could have led to delayed inflammatory bowel disease (IBD) healthcare, and delayed or even missed diagnoses. This has already been demonstrated in adult IBD patients in the Netherlands1, but not yet in the paediatric population. This is of importance, as in children, diagnostic delay is associated with higher rates of strictures, fistulising complications, and growth delay2. Therefore, this study aims to determine the impact of COVID-19 on IBD-related procedures and new IBD diagnoses in children in the Netherlands. Methods: In this nationwide retrospective cohort study, a search was conducted in the nationwide pseudonymized pathology registry of the Netherlands (PALGA), with complete national coverage. Using retrieval terms for ulcerative colitis, Crohn's disease, IBD unclassified and corresponding synonyms, all IBD related pathology reports (resection specimens or intestinal biopsies) from January 2018 to December 2020 in children age 1-18 were selected. Patients with a recognized diagnosis of IBD were eligible for inclusion, which was scored independently by two authors based on all reports. All IBD-related procedures (endoscopies and intestinal resections) were identified. Monthly frequencies of procedures and new IBD diagnoses during the COVID-19 pandemic in the Netherlands (March 11, 2020 - December 31, 2020) were compared to the average monthly frequencies of 2018-2019. Results: After exclusion of non-IBD related reports, 2161 IBD-related procedures were identified between January 2018 and December 2020. The average number of monthly IBD procedures in 2018-2019 was 59.8, whereas in 2020 this was 60.6 procedures per month, reflecting a 0.8% increase (Figure 1). In 2020, the number of new IBD diagnoses was 456, similar to the 458 new IBD diagnoses in 2018-2019. During the COVID-19 pandemic the weekly number of new diagnoses was 8.8, while between January 2018 and March 2020 this was 8.5 (Figure 2). A slight reduction in monthly IBD-related resections was observed (2.7 vs. 3.5). Conclusion: Despite the reduction in regular healthcare in children in the Netherlands due to the COVID-19 pandemic, no reduction was observed in IBD-related endoscopies and surgeries during the pandemic in the Netherlands. This reassuring evidence demonstrates that pediatric IBD healthcare remained unchanged, thus not delaying diagnosis of new IBD patients or treatment of severe disease flares.

OPTIMAL USE OF LIMITED COLONOSCOPY CAPACITY IN A FIT-BASED CRC SCREENING PROGRAM DURING COVID-19 PANDEMIC

Background During the first wave of the COVID-19 pandemic, many colorectal cancer (CRC) screening programs worldwide were disrupted. At restart of screening programs, the backlog is to be caught up while at the same time the regular invitations are to be sent out, straining colonoscopy capacity. At this time, our country is hit by a second wave of the pandemic, forcing many health care providers to downscale their services again. In this study, we assessed the best method to deal with these temporary shortages in colonoscopy capacity in the Dutch FIT-based CRC screening program while retaining optimal preventive effect of the screening program. Methods Using the well-calibrated and validated MIcrosimulation SCreening ANalysis for CRC model (MISCAN-Colon), we simulated the Dutch national CRC screening program in which individuals are biennially invited to perform a faecal immunochemical test (FIT) from age 55-75, including the three-month disruption of the program in the first half of 2020. For the second half of 2020 and 2021, we simulated three different interventions to temporarily reduce the required colonoscopy capacity in the Dutch national CRC screening program: 1) increase in FIT cut-off value (from 47 to 50, 55, 60, 70 μg Hb/g feces), 2) excluding specific age-groups for screening (youngest age-group (age 55) or age-groups testing negative in previous two screening rounds (age 63 and/or 65), and 3) extension of the screening interval (from 24 to 28, 30, 32, 34 or 36 months). For each scenario, we estimated the impact on required colonoscopy capacity in 2020-2021 as well as long-term outcomes such as CRC incidence, mortality and life years (LYs) lost. Outcomes were compared to a reference scenario without colonoscopy restrictions. Results In 2020 and 2021, the required colonoscopy capacity without restrictions was 100,300 colonoscopies in total. Increasing the cut-off, excluding age-groups and extending the screening interval resulted in a reduction of 11,600-27,000 (11.6% - 26.9%), 10,800-27,000 (10.8% - 26.9%) colonoscopies, and 16,100-49,500 (16.1% - 49.4%) colonoscopies, respectively (Table 1). Increasing the cut-off resulted in 400-900 excess CRC cases and 200-500 excess CRC-related deaths from 2020-2050, while excluding age-groups resulted in 200-600 excess CRC cases and 200-500 excess CRC-related deaths. Unexpectedly, extending the screening interval up to 34 months prevented 200-300 more CRC cases and 200-600 more CRC-related deaths, because screening occurred until slightly higher ages due to the initial delay. All measures resulted in LYs lost, but extending the screening interval up to 34 months had the smallest impact. Conclusion Based on modeling, temporarily extending the screening interval to accommodate reduced colonoscopy capacity due to the COVIDpandemic have the smallest impact on the CRC incidence, mortality and LYs lost. (Table Presented) The efficiency of measures to reduce colonoscopy demand predicted by MISCANColon. Abbreviations: CRC, colorectal cancer;LYs, Life Years;μg Hb/g feces, microgram Hemoglobin per gram feces.

Optimal use of limited colonoscopy capacity in a fit-based crc screening program duringCOVID-19 pandemic

Aims A second wave of the COVID-19 pandemic may force many health care providers to downscale their services again,including colonoscopies which may impact capacity for colorectal cancer (CRC) screening. This study aimed to determinethe optimal measure to handle these temporary shortages in colonoscopy capacity in the Dutch national CRC screeningprogram to retain as much of the preventive effect of the screening program as possible. Methods We used the MISCAN-Colon model to simulate the Dutch national CRC screening program, providing biennial FITto individuals aged 55-75, under three different scenarios to temporarily reduce required colonoscopy capacity in thesecond half of 2020 and 2021: increase in FIT cut-off value exclusion of specific age-groups, and extension of the screening interval For each scenario, we estimated the impact on required colonoscopy capacity in 2020-2021, long-term CRC incidence,mortality and life years (LYs) lost. Outcomes were compared to a reference scenario without colonoscopy restrictions. Results In 2020 and 2021, the required colonoscopy capacity without any restrictions was 100,300 colonoscopies.Increasing the cut-off, excluding age-groups and extending the screening interval resulted in a reduction of 11,600-27,000,10,800-17,500, and 16,100-49,500 colonoscopies, respectively (Table 1). Increasing the cut-off resulted in 400-900 excessCRC cases and 200-500 excess CRC-related deaths from 2020-2050, while excluding age-groups resulted in 200-600excess CRC cases and 200-500 excess CRC-related deaths. Unexpectedly, extending the screening interval up to 34 months prevented 200-300 more CRC cases and 200-600 more CRC-related deaths, because screening occurred until slightlyhigher ages due to the initial delay. All measures resulted in LYs lost, but extending the screening interval up to 34 monthshad the smallest impact. Abbreviations: CRC, colorectal cancer;LYs, Life Years;μg Hb/g feces, microgram Hemoglobin per gram feces.∗Number between brackets are negative numbers. Conclusions A temporary extension of the screening interval to accommodate reduction in available colonoscopy capacityresults in the smallest impact on the CRC incidence, mortality and LYs lost. (Table Presented).