The Impact of the SARS-CoV-2 Pandemic on Healthcare Provision in Italy to non-COVID Patients: a Systematic Review 

Gianmarco Lugli1,10,*, Matteo Maria Ottaviani2,10,*, Annarita Botta1,10,*, Guido Ascione3,10, Alessandro Bruschi4,10, Federico Cagnazzo5, Lorenzo Zammarchi1,6, Paola Romagnani7,8 and Tommaso Portaluri9,10.

1 Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.
2 Department of Neurosurgery, University Politecnica delle Marche, Ancona, Italy.
3 Department of Cardiac Surgery, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy.
4 Rizzoli Orthopaedic Institute, University of Bologna, Bologna, Italy.
5 Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier University Medical Center, 80, Avenue Augustin Fliche, Montpellier, France.
6 Unit of Infectious and Tropical Disease, University Hospital Careggi, Florence, Italy.
7 Nephrology and Dialysis Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy.
8 Department of Biomedical Experimental and Clinical Sciences "Mario Serio," University of Florence, Florence, Italy.
9 IN Srl, Udine, Italy.
10 CEST Centre for Excellence and Transdisciplinary Studies, Turin, Italy.  
* These authors contributed equally to this work.

Correspondence to: Annarita Botta. Department of Experimental and Clinical Medicine, Infectious and Tropical Disease Unit, Careggi University Hospital, University of Florence. E-mail: annarita.botta@unifi.it      
Published: January 1, 2022
Received: October 18, 2021
Accepted: December 16, 2021
Mediterr J Hematol Infect Dis 2022, 14(1): e2022012 DOI 10.4084/MJHID.2022.012

This is an Open Access article distributed under the terms of the Creative Commons Attribution License
(https://creativecommons.org/licenses/by-nc/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background: Italy has been one of the countries most affected by the SARS-CoV-2 pandemic, and the regional healthcare system has had to quickly adapt its organization to meet the needs of infected patients. This has led to a drastic change in the routine management of non-communicable diseases with a potential long-term impact on patient health care. Therefore, we investigated the management of non-COVID-19 patients across all medical specialities in Italy.
Methods: A PRISMA guideline-based systematic review of the literature was performed using PubMed, Embase, and Scopus, restricting the search to the main outbreak period in Italy (from February 20 to June 25 2020). We selected articles in English or Italian that detailed changes in the Italian hospital care for non-COVID-19 patients due to the pandemic. Our keywords included all medical specialities combined with our geographical focus (Italy) and COVID-19.
Results: Of the 4643 potentially eligible studies identified by the search, 247 were included. A decrease in the management of emergencies in non-COVID patients was found together with an increase in mortality. Similarly, non-deferrable conditions met a tendency toward decreased diagnosis. All specialities have been affected by the re-organization of healthcare provision in the hub-and-spoke system and have benefited from telemedicine.
Conclusions: Our work highlights the changes in the Italian public healthcare system to tackle the developing health crisis due to the COVID-19 pandemic.The findings of our review may be useful to analyse future directions for the healthcare system in the case of new pandemic scenarios.



Introduction

Since the first case of the novel coronavirus (COVID-19) was reported in Wuhan, China, in December 2019, a viral infection spread at an alarming rate worldwide. On January 30, 2020, the World Health Organization (WHO) described COVID-19 as a Public Health Emergency of International Concern, and by March 11, 2020, it was officially declared a pandemic.[1] Italy was the first European country to be affected by COVID-19, with the first case being diagnosed on February 20 in a man living in the province of Lodi (NorthWest Italy).[2] The epidemic went on to affect all regions in Italy, with higher incidence rates in the north. The peak of the COVID-19 epidemic in Italy was reached in the last week of March, with over 5500 new cases per day.
Since then, there has been a gradual decline due to strict containment measures that shaped the Italian lockdown phase. However, especially during the first phase of the epidemic, the outbreak put the Italian National Health System (Servizio Sanitario Nazionale, SSN) under unprecedented pressure.
In an attempt to direct the available resources at counteracting and limiting the effects of the pandemic, deferrable and non-urgent medical activities were suspended. On the other hand, patients with life-threatening conditions, such as myocardial infarction and stroke, or chronic conditions, such as diabetes, retained the right to their medical needs being met.
In these circumstances, several medical domains have been constrained by different resource allocations with unpredictable long-term consequences on patient health care.[3-5]
Here, we present a systematic review of the literature, which illustrates the direct and indirect effects of the COVID-19 pandemic on the management of non-COVID patients across all medical specialities.

Methods

This systematic review was performed in accordance with PRISMA guidelines.[6] The search was conducted on June 25 2020, on three databases: PubMed, Embase, and Scopus, without any date restriction. All the keywords were investigated within the title and abstract in both "AND" and "OR" combinations. Our keywords included all medical specialities (and potential synonyms) combined with our geographical focus (Italy or Italian) and COVID-19. The full search strategy is reported in Supplementary Material Table 1. Patients or the public were not involved in the design, or conduct, or reporting, or dissemination plans of our research.
Selection of the Studies. The literature search returned original papers published between 1979 and 2020 – especially for the keyword "coronavirus". Since our focus was the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the first positive case in Italy was detected on February 20, the literature search was restricted to the period from February 20 to June 25 2020. The databases were queried via an R script on their respective APIs, checked and cleaned for duplicates (via title, DOI and/or database id), and exported into Excel.
In the second stage, studies were selected based on their titles and abstracts: each study was independently evaluated by three different raters (AnB, GA, GL). When there was a lack of agreement among the screeners, ensemble majority voting was used for the final decision. The full texts of the selected papers were thus analyzed by two reviewers in terms of relevance and inclusion/exclusion criteria (MMO and GA). When these reviewers disagreed over the inclusion or exclusion of a paper, a third reviewer was responsible for the final decision (GL). In addition, the reference lists of selected papers were reviewed in order to find pertinent studies not identified during the initial search.
Inclusion and Exclusion Criteria. The simultaneous co-occurrence of the following characteristics was considered for the inclusion of articles: (i) articles focusing on the SARS-CoV-2 infection/COVID-19 disease; (ii) articles focusing on the impact on patients based in Italy or on the Italian hospital organization; (iii) articles detailing COVID-19-associated changes in the Italian hospital care for non-COVID-19 patients. All the investigated articles were published in English or Italian.
Type of Studies. Original papers, editorials, comments, research letters, case series, and studies focusing on non-COVID patients in Italy were included.
Data Extraction and Quality Assessment. Data were extracted from the papers by one of the investigators (TP) and were subsequently checked for accuracy by other reviewers (GL, AnB). Disagreements regarding data extraction among reviewers were solved by consensus. Extracted data included: type of medical specialty involved (surgical, medical, or public health), geographical location (north, south, centre or nationwide), type of patients (COVID/non-COVID), type of study (article or research letter/comment/editorial). Unfortunately, no quality assessment was possible as over 32% of entries were not articles but consisted of comments, research letters, opinions or editorials – for which no quality guidelines are available.
Investigated Outcomes. This systematic review investigated the impact of the COVID-19 pandemic on patients' healthcare provision and hospital organization in Italy since the day the country was put in lockdown.[7] Our primary goal was to identify potential short-term and long-term effects on the health of non-COVID patients. Our secondary goals were to identify: (i) organizational and/or clinical settings and decisions that were particularly effective (or counterproductive) during the pandemic; and (ii) similarities and differences across medical specialities and regional areas.

Results

The results are shown in Figure 1. After searching the databases, we identified 4643 papers from three different databases. Database merges and the removal of duplicates resulted in 1262 records, of which 100 were immediately removed as they were not related to COVID-19 (articles published before the pandemic in Italy). A total of 1162 records were then screened: 166 were removed as not relevant to Italy; 534 were removed as they referred to COVID-19 patients rather than non-COVID-19 patients. A total of 247 were deemed eligible, of which 81 consisted of comments/letters/opinions/editorials.
Oncology and radiotherapy were the most represented category (47 papers), followed by surgery (24 for general surgery, 9 for neurosurgery, 2 for cardio-surgery, 2 for vascular surgery, and 3 other types), cardiology (19), and dermatology 14. There was one paper each for rheumatology and microbiology.
Figure 1 Figure 1
Overall, 133 papers were related to clinical disciplines, 89 to surgery, and 24 to services. In terms of geographical distribution, many papers provided general recommendations without a specific geographical identification (75). Lombardy was the most represented region (72), followed by Lazio (21) and Emilia Romagna (15). In the south, Campania was the most represented region (11), followed by Puglia (4). Marche, Piedmont and Friuli Venezia Giulia  had 7 papers each, Tuscany and Veneto 9 each. Overall, 73 were general/nationwide, 105 pertained to northern regions, 54 to central regions, and 15 to southern regions and islands. The studies included are reported in Supplementary Material Table 2.
Management of Emergencies. In general, non-COVID patients admitted to emergency departments (ED) decreased and remained well below the standard levels.[8-11] The youngest age classes declined dramatically, while the oldest age classes progressively increased, remaining considerably above the standard rate of the local ED.[12]
Table 1 shows the most relevant data regarding cardiovascular emergencies, including stroke. In northern Italy, the emergency gradually took over most cardiology intensive care units (ICUs).[13] As expected, the net effect of this re-organization was a significant reduction in sites and staff committed to the treatment of cardiovascular diseases. [14-18] Comparing out-of-hospital cardiac arrests in the same period of the previous year, Baldi et al. found that the median arrival time of the emergency medical service was three minutes longer in 2020, and the proportion of patients who received cardiopulmonary resuscitation from bystanders was 15.6% lower. Among patients in whom resuscitation was attempted by emergency medical services, the incidence of out-of-hospital death was 14.9% higher in 2020 than in 2019.[9] This finding was confirmed by additional studies highlighting an unpredictable decrease in acute coronary syndrome-related hospitalization in high-volume centres[10,19,20-21] and pacemaker implantation during the weeks following the COVID-19 outbreak.[21-25]
Table 1.1 Table 1. Management of deferrable conditions and telemedicine during COVID-19 pandemic in Italy. 
Table 1.2
Of note, one study showed a 49% reduction in acute heart failure admission to the hospital.[26] The patients admitted had longer door-to-balloon and symptoms to PCI times, higher hs-cTnI levels at presentation, lower residual left ventricular function at discharge, and higher predicted late cardiovascular mortality on the GRACE score.19
Two studies[11,27] also reported fewer patients with minor strokes and transient ischemic attacks (TIAs), longer onset-to-door and door-to-treatment times for major strokes, and reduced transfers from spokes centres. As a result, the number of patients who underwent intravenous thrombolysis or bridging therapy (combined intravenous and thrombectomy) decreased by − 26% and −30%, respectively.
In addition, as a consequence of the reduction in the patient eligibility for bridging therapy, the number of primary thrombectomies (performed with all the necessary personal protective equipment owing to the risk of infection)[28] increased by 41%. Most of these patients had very serious strokes that would have benefited from early diagnoses.[11]
The decrease in hospital admissions, confirmed by a survey across multiple countries, including Italy,[29,30] resulted in increased door-to-needle times and missed therapeutic windows for patients suffering from severe strokes.[31]
The reduction in available Intensive Care Units (ICU) beds, massively dedicated to COVID-19 patients with acute respiratory failure, and the fear of infection resulted in the shrinkage of surgical activities in all fields[32-36] and a reduction in urgent endoscopic procedures in COVID-free hospitals.[37]
Each sub-speciality defined various non- deferrable surgical procedures that had to be guaranteed, causing a drop in consultations requested by emergency departments, as in the case of urgent urology.[38] The surgical community also faced a shortage of blood components derived from fewer donations due to lockdown and fear of infection.[39] To compensate for the initial fall (−10%) in blood donations in the first week of March, the government promoted a national media campaign on the importance and safety of blood donation as a priority to maintain basic healthcare services for non-COVID patients.[40] No blood-transmitted SARS-CoV-2 infection has been reported to date.[41]
Children's emergency departments also showed a substantial decrease in visits,[42] and that might reflect the scarcity of resources or the reluctance of parents and health care workers to expose children to the risk of viral infection in a healthcare setting, in addition to lower rates of acute infections and trauma.[43] However, this phenomenon has been detrimental to the health of non-COVID child patients: 12 cases of delayed access to hospital care were reported during the week of March 23–27 across five hospitals of an Italian Children's Hospital Research Network. Half of the children were admitted to an ICU, and four died, highlighting the high risk of delaying access to hospital care.[44] As a result, life-threatening conditions (i.e. abdominal pain, severe ketoacidosis) seemed to be more frequent, requiring, in some cases, an aggressive approach.[43]
The same phenomenon affected dermatology.[45] Tartari et al. compared two different weeks, before and after the outbreak of the COVID-19 pandemic in Italy, showing a decrease in unjustified referrals (93% reduction) in dermatological emergency services.[46]
Despite medical care for emergencies and urgent treatments being continuously provided throughout the pandemic, the lack of personnel, resources, and ICUs beds and the patients' fear of being infected in hospital affected patient management and substantially delayed the provision of ordinary medical activities. These initial data seem to show a decrease in emergencies and an increase in mortality.
Management of Non-Deferrable Conditions: the Hub-and-Spoke System. To tackle the massive impact of the overflow of SARS-CoV-2 infected patients, hospitals in Italy had to undergo a significant re-organization.[47-52] In order to manage conditions needing non-deferrable treatment while avoiding the risk of infection, hub-and-spoke centres were created and widely used throughout the country.[48,53-56] In the hub-and-spoke model, the main campus or hub supplies the most intensive medical services, while satellite campuses or spokes offer more limited services at sites distributed across the neighbouring area.[57]
Neurological surgery was particularly affected by the ICU re-organization, as it often requires a period of intensive monitoring in ICUs.[22,58-60] All the cases of elective neurological surgery were deferred, while urgent neurosurgical pathologies (above all traumas) and non-deferrable tumour cases were transferred to hubs.[27,29-33,61-63]
Some minimal activities were still performed at spoke centres, only for critical cases or when specific tools were required (i.e. gamma knife treatment of neoplastic lesions).[64-67]
This provided an unprecedented opportunity for transversal collaboration among different teams, representing real innovation in such a competitive setting.[56,62]
A hub-and-spoke system was also organized for vascular surgery and cardiac surgery units. All elective surgery was reduced, and urgent surgery (including aortic aneurysms, valvular diseases or severe coronary diseases) was performed only in hub centres, preferring the endovascular to the open surgical approach whenever possible.[68-70] A transcatheter approach was generally preferred, as it usually does not require an ICU bed or a ventilator.[69]
The limitation of all non-urgent surgical activities also applied to general surgery[71-76] and obstetrics.[76,77] In highly-infected areas (such as Lombardy), hub centres were created[78] to treat only advanced symptomatic tumours,[78-80] while elective oncological surgery procedures continued to be performed in less-affected regions.[78,81] This was an important issue for oncological patients, especially the older ones.[82-85]
Many possible ways of minimizing the risks were proposed: to postpone treatments or elective surgery for stable cancer in endemic areas, provide patients with greater personal protection, and offer more intensive surveillance or treatment.[86-88] For example, neoadjuvant treatments were recommended or increased to defer surgical admission for as long as possible.[78,81,89-90] For other medical conditions requiring surgery under particular circumstances, such as relapse of inflammatory bowel disease, dedicated hubs were identified.[91-93]
Interestingly, a tendency toward treatments to reduce hospitalization was also found in medical oncology.[94,95]
Some regions such as Tuscany created home care protocols to avoid exposure to hospital settings.[96] Oncological care delivery and cancer diagnosis[97-99] were dramatically reduced by the SARS-CoV-2 outbreak, even though suboptimal care and treatments may result in worse cancer‐related outcomes. Oncologists were thus asked to preserve patients' continuum of care while adopting mitigation strategies to reduce the likelihood of infection in all cancer patients.[100-109]
Arduino et al. described a worrying delay in diagnosing oral cancer in northwest Italy during the Covid pandemic.[110] Moreover, the cessation of elective activities, screening programs,[111] and the drastic reduction in services regarding breast cancer restricted evaluations to only clinical observations of palpable lesions with the elevated risk of missing new diagnoses.[112] Although not requiring a structural re-organization, palliative care was forced to find a new balance between family member visits and patients' needs.[113-116]
In orthopaedics, the re-organization led to the identification of poly-specialist major trauma centres and specialistic referral centres for minor trauma or non-deferrable orthopaedic surgeries (i.e. septic arthritis or malignant tumours).[117-124] There was a reduction in the number of proximal femur fractures in two centres, as well as a reduction in hip and knee arthroplasties.[125,126]
A similar re-organization was also carried out for plastic surgery: only post-traumatic, oncological and burn treatments were guaranteed.[127-129] A new approach based on enzymatic debridement was proposed for burns to reduce the need for burn surgery.[130]
In urology, only urgent, non-deferrable procedures (colicky flank pain, gross hematuria and acute urinary retention) were authorized after careful multidisciplinary evaluation, which led to a drop in urological surgical activities.[131-136] Whenever possible, alternative treatments not requiring general anaesthesia (i.e. radiotherapy for genitourinary cancers) were suggested as preferable.[131,133,137]
Oral and maxillofacial surgery, otolaryngology, and ophthalmology also suspended all non-urgent treatments, especially considering healthcare workers' high risk of infection while manipulating the upper airways and eyes.[138-145] Only the treatment of trauma, malignant neoplasms, and severe infections was guaranteed.[139,146-149]
In the context of radiotherapy, all follow-up visits involved a phone call in advance in order to postpone non-urgent cases.[150-153] The initial consultations of patients needing treatment for malignant tumours were conducted as normal, as were certain treatments such as bone metastases radiotherapy.[154-157] Specific approaches, such as short fractionated radiotherapy, were suggested.[158]
All non-urgent and deferrable radiation treatments were delayed, while therapies for patients with better prognoses (benign and functional diseases) were postponed.[159,160]
Dermatology departments were also involved in an extensive re-organization.[161-162] Dermatological anti-neoplastic treatments were provided in the dermatology clinics of many centres, such as Bologna, Naples, Modena and Ancona, which also maintained urgent dermatological procedures and consultations required by other hospital wards.[163-166] As awareness of the severity of the COVID-19 increased, some patients were concerned about continuing their medications; however, all centres followed specific recommendations and advised patients not to suspend these drugs without consultation.[167-170]
Lastly, microbiology labs underwent unprecedentedly high workloads with the increasing number of samples (swabs or serological tests) to analyze for the identification of Sar-Cov-2 infection. An extensive re-organization of the microbiology lab activities thus also occurred. In a large teaching hospital in Rome, the introduction of night shifts and the creation of a dedicated team significantly improved the number of samples processed without interfering with the daily laboratory routines.[171]
Replacement Therapies: Dialysis and Transplantation. Dialysis units experienced a profound change in their management with the introduction of COVID-19 isolation rooms and the identification of dedicated healthcare professionals.[172,173] Rombolà et al. proposed three actions to be taken in order to dialyze non-COVID patients safely: hygiene measures, the use of PPE to protect patients and the healthcare team, and the protection of the dialysis ward with an isolated area for testing patients suspected of infection.[174]
In general, all transplant programs were profoundly affected by the pandemic.[175-177] First of all, the wall-to-wall screening of donors and recipients was established to identify positive patients who would not be able to donate or receive blood, in view of the high mortality rates COVID-19 in immunocompromised patients.[177-180] Secondly, the widespread reduction in available ICU beds led to an estimated 15% drop in transplants compared with the last five years' average, such as liver transplantations.[177,181] transplantation was thus suggested only in true end-stage organ failure, preferring conservative treatments (maximizing pharmacological therapy) in all other patients.[181-184]
Management of Deferrable Conditions and Telemedicine. The management of chronic conditions also suffered.[185] Cesari et al. found that the integration of care services collapsed: admissions to post-acute/long-term care facilities were reduced, and several person-tailored interventions were suspended – e.g., physical therapists for mobilization.[183] Lasevoli et al. reinforced the view that the current pandemic has had dramatic consequences for the mental health of serious psychiatric patients.[186] All this inevitably led to a drastic reduction and a substantial re-organization of the clinical activity in many specialities (Table 1), postponing elective treatments and switching to telemedicine (TM) for consultation or not to leave vulnerable high-need patients without proper follow-up.[187-188]
The implementation of TM occurred in different ways and to varying degrees depending on the specific centre and specialty. An online questionnaire administered to the 176 Directors of Italian Radiation Oncology Departments revealed that to guarantee the continuity of care, in 78 centres (62.4%) activated telematic consultations for RT treatments.[152] A similar survey for RT centres in the Lombardy region revealed that 84% of RT facilities cancelled out-patient follow-up visits, 68% activated telematic consultation and 30% adopted working from home solutions.[153] Another survey administered to 122 medical oncology departments homogeneously distributed on the national territory revealed that in 72% of cases, alternative ways to get in touch with patients had been used, like telephonic interviews with the interpretation of laboratory and radiologic examination reports. According to Pietrantonio et al., WhatsApp turned out to be adequate to give a rapid answer to most queries from oncologic patients.[105] Brunasso et al. started a teledermatology service in smart working using phone calls and e-mails by which they could monitor almost 94% of their patients.[189] In a Department of Urology in Northern Italy, 55% of cases were screened undergoing telephone consultation.[190]
TM has been shown to have beneficial impacts on heart failure outcomes in a comparative analysis between 2020 and 2019 by Salzano et al.[191] Finally, TM positively impacted patients' life as documented by a survey in which 85% of patients were satisfied with the remote interview modality and the reduction of economic and time costs related to going to the clinic. Most of those subjects (90%) expressed their willingness to continue to be included in remote evaluation programs.[192] Almost all specialities benefited from TM during the pandemic. The results are summarized in Table 1. 

Discussion

On March 11 2020, the World Health Organisation (WHO) declared the COVID-19 pandemic.[1] However, Italy was already in lockdown, with decrees limiting mobility and strengthening the National Health System. On March 9, 2020, most outpatient services were temporarily suspended, except for a few treatments that were considered urgent and non-deferrable.[7] Clinical support for early isolation, treatment, and, where needed, intensive care of COVID-19 patients (or suspect cases) became the priority, with a massive allocation of dedicated resources.
A large increase in all-cause mortality was revealed during the epidemic, greater than the number of deaths attributed to COVID-19 cases. The possible causes of this increase include a large number of severe undiagnosed COVID-19 cases, reduced access to health services due to the disruption of normal working processes, or the fear of contamination of sick patients affected by other diseases and possibly other factors.[8]
We provided a snapshot, across all medical specialities, of how the provision of treatments to non-COVID patients in Italy has been impacted by the shortage of resources imposed by the pandemic.
Measures put in place to mitigate the outbreak, such as social distancing and confinement, contributed to discouraging access to the emergency department (E.D.) all over the country and those conditions requiring urgent care. As a result, there was a significant decrease in overall E.D. admissions and a substantial reduction in all-speciality surgical consultations.[9-11] More studies are needed to confirm these data and to evaluate the impact on death rates; however, recent reports from other countries seem to confirm this trend.[193,194] Cardiovascular emergencies paid significant tolls with a significant delay in time-sensitive emergency operations.[9-19] More recent evidence, consistent with our results, showed a significant decrease in the mean number of endovascular therapies per hospital performed before and after COVID-19 confinement along with a significant increase in mean stroke onset-to groin puncture time.[195] A delayed presentation of STEMI patients that may lead to worsened prognosis and unnecessary deaths has also been observed.[196] Moreover, an additional study confirmed that more in-hospital cardiovascular deaths occurred in March 2020 compared with March 2019, a finding due to late hospital presentations and consequent greater disease severity that affected eligibility and outcome of cardiovascular procedures[197]
As stated before, the hospitalisation system was remodelled to allocate appropriate resources to manage patients with COVID-19; consequently, hubs were identified for specialised medical activities. Hub-and-spoke centres represented an important change in care provision, especially in the most affected regions, involving almost all specialities. However, data on the efficacy of this reorganisation, measured in terms of health outcomes (such as mortality), are lacking. To date, only a few reports suggest a tendency toward a decrease in diagnosis for non-deferrable conditions despite the hub-and-spoke organisation.[98,100,111] Cautious and evidence-based studies are needed to properly assess the overall impact of this model on measurable outcomes. Nevertheless, the hub-and-spoke system seems to be a valid model, at least, in the management of ischemic emergencies.[198]
A pandemic is a dynamic scenario, requiring reorganisation and flexibility of healthcare delivery. T.M., which consists of distributing health-related services and information via telecommunication technologies, proved a pragmatic approach to managing deferrable conditions during the COVID-19 pandemic in Italy. Moreover, TM allows for more flexibility on the side of both the clinician and the patient, as consultations can easily be rescheduled, and meetings can be held from home.[199] Notably, when looking at the world scenario, T.M. is thought to play an important role in delivering digital health to the general population.[200]
Almost all specialities benefited from T.M. during the pandemic, with short-term results particularly encouraging in some cases. The pandemic has generally demonstrated that information technologies should be more promoted independently from this specific context.[153] However, a longer follow-up is needed to assess the efficacy of these measures on common health outcomes.[199-201] Avoiding face-to-face contact via T.M. has been one of the most effective measures to limit the spread of SARS-Cov-2 infection, although many issues have been raised, such as privacy management and the lack of clear guidelines.[202-206] We strongly encourage overcoming these limitations to promote further the multiple opportunities of T.M. in tune with its pivotal role during the second phase of the COVID-19 pandemic in Italy.[207] T.M. has deeply influenced non-COVID patient care, enabling the remote diagnosis and monitoring of patients and allowing clinical data sharing between patients and physicians.[208,209]
One limitation of this systematic review is the heterogeneity in publication type, which prevented the execution of a meta-analysis to summarise the findings together with a quality assessment. Another important issue is the potential underreporting, although the studies covered the whole country's experiences. Finally, while also providing a snapshot of the first modification during the pandemic, this work does not include more recent Italian studies.
Our work thus suggests that a public health crisis has resulted from the pandemic, a concern raised in other countries too, such as France and Denmark; indeed, a danish study demonstrated that mortality rates for patients admitted to hospitals with non-covid-19 diseases (such as respiratory disease, cancer, pneumonia and sepsis) were higher.[210,211] More detailed, nationwide population-based cohort studies are needed to assess whether emergency management benefited from the reorganisation adopted and evaluate hospital admissions and mortality rates for non-covid patients. Nevertheless, the system and telemedicine undoubtedly played – and continue to play – a crucial role in dealing with non-deferrable and deferrable conditions, respectively.

Contributions

T.P. and G.L. conceived and designed the study. T.P. collected the data. G.L, M.M.O, An.B, G.A., Al.B. analysed and selected the data. F.C. and T.P. supervised data analysis. G.L, M.M.O., An.B, G.A., Al.B., T.P., wrote the manuscript. M.M.O. and An.B. revised and edited the manuscript. L.Z. and P.R. revised the final version of the manuscript.

Funding

All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: the work was supported by the Center for Excellence and Transdisciplinary Studies (CEST) and C.R.T. Foundation, Turin. The funder of the study had no role in the study design, data collection, data analysis, data interpretation, or writing the report; no financial relationships with any organisations that might have an interest in the submitted work; no other relationships or activities that could appear to have influenced the submitted work. All authors had full access to all study data and had final responsibility for the decision to submit for publication. The authors are thankful to Professor Paolo Vineis for his critical assistance in writing the paper.

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Supplementary Material
Suppl Table 1.1 Table 1. Full search strategy adopted in three different databases.
Suppl Table 1.2

SupTable2.1 Table 2. Full search strategy adopted in three different databases.
SupTable2.2
SupTable2.3
SupTable2.4
SupTable2.5
SupTable 2.6
SupTable 2.7
SupTable 2.8
SupTable 2.9
SupTable 2.10
SupTable 2.11
SupTable 2.12
SupTable 2.13
SupTable 2.14
SupTable 2.15
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SupTable 2.17
SupTable 2.18
 

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