Impact of SARS on healthcare utilization by disease categories: implications for delivery of healthcare services

Impact of the First-Wave COVID-19 Pandemic on Medical Expenditure for Older Adults in China: Lessons from a Natural Experiment

Older adults' access to healthcare services may have been affected by the COVID-19 pandemic. This study explored the effect of the first wave pandemic on the medical expenditure of older adults in China. Difference-in-Difference models captured both temporal and geographical variation in COVID-19 exposure to estimate the impacts of the pandemic on medical expenditure through a quasi-natural experiment. Data derived from the China Family Panel Studies. Results indicate that exposure to the pandemic significantly decreased total medical expenditures, hospital expenditures, and non-hospital medical expenditures of Chinese older adults by 15% (95% CI 12%-17%), 5% (95% CI 2%-7%), and 15% (95% CI 13%-16%), respectively, for each standardized severity increment. Females, less well-educated people, and individuals without internet access were most susceptible to experiencing these reductions. This study revealed that COVID-19 exerted a detrimental influence on the medical expenditure of older adults in mainland China. The "hidden epidemic" of non-COVID-19 medical needs of older adults deserves more attention on the part of policymakers.

"It took so much of the humanness away": Health care professional experiences providing care to dying patients during COVID-19

COVID-19 has affected healthcare in profound and unprecedented ways, distorting the experiences of patients and healthcare professionals (HCPs) alike. One area that has received little attention is how COVID-19 affected HCPs caring for dying patients. The goal of this study was to examine the experiences of HCPs working with dying patients during the COVID-19 pandemic. Between July 2020-July 2021, we recruited HCPs (N = 25) across Canada. We conducted semi-structured interviews, using a qualitative study design rooted in constructivist grounded theory methodology. The core themes identified were the impact of the pandemic on care utilization, the impact of infection control measures on provision of care, moral distress in the workplace, impact on psychological wellbeing, and adaptive strategies to help HCPs manage emotions and navigate pandemic imposed changes. This is the first Canadian study to qualitatively examine the experiences of HCPs providing care to dying patients during the COVID-19 pandemic. Implications include informing supportive strategies and shaping policies for HCPs providing palliative care.

Characteristics and Outcomes of ICU Patients Without COVID-19 Infection—Pandemic Versus Nonpandemic Times: A Population-Based Cohort Study

Outcomes for critically ill COVID-19 are well described; however, the impact of the pandemic on critically ill patients without COVID-19 infection is less clear.

Methodology for restarting hospital activities after a pandemic: COVID-19 experience

In addition to the health responsibility of hospitals in managing this COVID-19 crisis, hospital managers must also ensure the financial viability of healthcare structures. This is why, at the dawn of a lockdown exit, managers must anticipate the identification of recovery scenarios. This point refers in particular to the selection and scale of progression of hospital activities, and also to the impacts this will have on staff and patients in the short and medium term. Unfortunately, there is a serious lack of literature on the subject. The aim of this document is therefore to propose a methodology for resuming the medical, economic and social activities of a healthcare network or hospital. In our approach, we identify 6 stages following the COVID-19 peak: assessment of the situation, Act 2, development of scenarios-criteria-conditions, restarting, continuous improvement, and transversal activities. The entirety of our developed methodology is supported by a pragmatic approach with, in particular, the creation of specific tools for each stage of the process. This strategy and these tools have been created with the operational players and adapted to meet the specific features of each hospital while respecting the coherence of the healthcare network's decisions. We are convinced that this approach can be exported on a larger scale to inspire other healthcare networks and other hospitals that have also found themselves without the weapons to prepare for the resumption of hospital activities.

Using Ambulatory Care Sensitive Conditions to Assess Primary Health Care Performance during Disasters: A Systematic Review

Ambulatory care sensitive conditions (ACSCs) are health conditions for which appropriate primary care intervention could prevent hospital admission. ACSC hospitalization rates are a well-established parameter for assessing the performance of primary health care (PHC). Although this indicator has been extensively used to monitor the performance of PHC systems in peacetime, its consideration during disasters has been neglected. The World Health Organization (WHO) has acknowledged the importance of PHC in guaranteeing continuity of care during and after a disaster for avoiding negative health outcomes. We conducted a systematic review to evaluate the extent and nature of research activity on the use of ACSCs during disasters, with an eye toward finding innovative ways to assess the level of PHC function at times of crisis. Online databases were searched to identify papers. A final list of nine publications was retrieved. The analysis of the reviewed articles confirmed that ACSCs can serve as a useful indicator of PHC performance during disasters, with several caveats that must be considered. The reviewed articles cover several disaster scenarios and a wide variety of methodologies showing the connection between ACSCs and health system performance. The strengths and weaknesses of using different methodologies are explored and recommendations are given for using ACSCs to assess PHC performance during disasters.

The Impact of COVID-19 on Pediatric Healthcare Utilization and Disease Dynamics: An Observational Study From Western Odisha

Introduction

Children were affected by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus during the first and second waves of the coronavirus disease 2019 (COVID-19 pandemic. Although the severity was less in children, the fear of contracting SARS-CoV-2 at the hospital might have led to a delayed health-seeking attitude. The objective of the study was tailored around emergency health care utilization affecting outcomes. The study was done to compare the trend concerning the utilization of pediatric healthcare and immunization services, changes in the profile of diseases, and the outcomes between the pre-COVID-19 period and the COVID-19 period in a tertiary care hospital.

Methods

This retrospective observational study was conducted in a tertiary care hospital in western Odisha. Data were collected retrospectively from different hospital registers (outpatient register, inpatient register, and immunization records) and analyzed between the pre-COVID-19 period (April 2019 to March 2020) and the COVID-19 period (April 2020 to March 2021) with appropriate statistical procedures.

Results

There was a 60%, 49.8%, 51.1%, and 25.5% reduction in outpatient attendance, indoor pediatric admissions, nutritional rehabilitation centre admissions, and newborn admissions, respectively in COVID-19 period as compared to the pre-COVID-19 period. The pediatric bed occupancy rate was reduced by 54.5%. Unfavourable outcomes (death, left against medical advice, and referral) were significantly high in hospitalized children (24% vs. 18.1%, p < 0.001). The reduction in hospitalization due to common conditions like acute respiratory tract infections, bronchiolitis and asthma, and acute gastroenteritis during COVID-19 was 76.5%, 86.2%, and 39.5%, respectively. A higher percentage of low birth weight and preterm (<34 weeks) babies were admitted to special neonatal care unit (SNCU) during the pandemic (61.8% vs. 58%, p < 0.05; 18.9% vs. 15.8%; p < 0.05 respectively).

Conclusion

The COVID-19 pandemic and the associated lockdown led to a significant decrease in pediatric and neonatal healthcare utilization. The impact of lower care-seeking and attendance resulting in poor patient-related outcomes (malnutrition, upsurge of vaccine-preventable diseases, disease-specific hospitalization, and mortality) post-pandemic is a real threat.

The Impact of COVID-19 Pandemic on Outpatient Visits for All-Cause and Chronic Diseases in Korea: A Nationwide Population-Based Study

This study explores the impact of the coronavirus disease 2019 (COVID-19) pandemic on outpatient visits for all-cause and chronic diseases in 2020. We extracted the data of patients who visited medical institutions over the past five years (2016-2020) from nationwide claims data and measured the number of monthly outpatient visits. A negative binomial regression model was fitted to monthly outpatient visits from 2016 to 2019 to estimate the numbers of 2020. The number of all-cause outpatient visits in 2020 was 12% lower than expected. However, this change was relatively stable in outpatient visits for chronic diseases, which was 2% lower than expected. Deficits in all-cause outpatient visits were observed in all months except January; however, deficits in outpatient visits for chronic diseases have rebounded since April 2020. The levels of change in healthcare utilization were observed differently among disease groups, which indicates that the impacts of the pandemic were disproportionate. This study calls for a policy response to emerging and reemerging infectious diseases, as the findings confirm that a health crisis, such as the COVID-19 pandemic, could disrupt the healthcare system. Assessing the mid-to long-term impacts of COVID-19 on healthcare utilization and health consequences will require further research.

Healthcare utilisation for elderly people at the onset of the COVID-19 pandemic in South Korea

BACKGROUND

At the onset of the coronavirus disease 2019 (COVID-19) pandemic, health care systems were severely disrupted in many countries and in particular, elderly people vulnerable to COVID-19 may have been reluctant to receive their medical treatment.

METHODS

We conducted interrupted time series analyses (ITSA) using nationwide medical claim data between January 2020 and July 2020, with focus on different disease categories for the patients of 65 to 84-year-olds, i.e., acute upper respiratory infections (AURIs) vs. chronic diseases.

RESULTS

AURIs and chronic diseases showed a sharp contrast with respect to the change in healthcare service utilisation. First, the utilisation rate for chronic diseases changed little whereas for AURIs it dropped by 20.4% year-over-year (yoy) at the onset of the pandemic (week 6, 2020). Second, as social distancing relaxed (week 17, 2020), the AURIs patients trended up and even reached to 7.8% above yoy whereas no significant change found for chronic diseases.

CONCLUSIONS

The uninterrupted treatment for chronic diseases in contrast to the AURIs implies that the governmental and public responses to the pandemic outbreak worked for efficient healthcare provision to patients in needs of regular check-ups and treatment in the middle of an infectious disease crisis.

How the coronavirus disease 2019 pandemic changed the patterns of healthcare utilization by geriatric patients and the crowding: a call to action for effective solutions to the access block

The geriatric population constitutes a large slice of the population of Western countries and a class of fragile patients, with greater deaths due to COVID-19. The patterns of healthcare utilization change during pandemic disease outbreaks. Identifying the patterns of changes of this particular fragile subpopulation is important for future preparedness and response. Overcrowding in the emergency department (ED) can occur because of the volume of patients waiting to be seen, delays in patient assessment or treatment in the ED, or impediments to leaving the ED once the treatment has been completed. Overcrowding has become a serious and growing issue globally, which represents a serious impediment to healthcare utilization. To estimate the rate of ED visits attributable to the outbreak and guide the planning of strategies for managing ED access or after the outbreak of transmittable respiratory diseases. This observational study was based on a retrospective review of the epidemiological and clinical records of patients aged > 75 years who visited the Foundation IRCCS Policlinic San Matteo during the first wave of COVID-19 outbreak (February 21 to May 1, 2020; pandemic group). The analysis methods included estimation of the changes in the epidemiological and clinical data from the annual baseline data after the start of the COVID-19 pandemic. Outcome measures and analysis: Primary objective is the evaluation of ED admission rate change and ED overcrowding. Secondary objectives are the evaluation of modes of ED access by reason and triage code, access types, clinical outcomes (such as admission and mortality rates). During the pandemic, ED crowding increased dramatically, although the overall number of patients decreased, in the face of a percentage increase in those with high-acuity conditions, because of changes in patient management that have prolonged length of stay (LOS) and increased rates of access block. Overcrowding during the COVID-19 pandemic can be attributed to the Access Block. Access Block solutions are hence required to prevent a recurrence of crowding to any new viral wave or new epidemic in the future.

Incidence and characteristics of rhegmatogenous retinal detachment during coronavirus-19 pandemic: A French study

Purpose

To assess the impact of the Covid-19 pandemic and subsequent lockdown on the number and clinical characteristics of patients with retinal detachment (RD) in a French public university eye hospital.

Methods

Single-center, retrospective non-interventional study. Patients consulting at the emergency room (ER) of Quinze-Vingts Hospital (France) for rhegmatogenous RD before and after instauration of the lockdown were reviewed. We compared the characteristics of patients with RD between the containment period (March17th - April27th,2020) and the period preceding the lockdown (February18th - March16th,2020). We compared the number of RD surgeries performed between the first month of lockdown (March17th - April19th,2020) and the corresponding period of 2019. Number of cases, delay between diagnosis and surgery, visual acuity was measured.

Results

During the first month of lockdown, 59 RDs were operated on, compared to 107 in the corresponding period in 2019 (-44,8%). Mean time from first symptoms to surgery was significantly higher during the lockdown 12.7 (11.3) days vs 7.6 (7.8) days (p = 0.031) before. During the lockdown, the mean BCVA was lower albeit the difference did not reach statistical significance (1.16 (0.9) during pre-containment vs 1.5 (0.9) during containment; p = 0.09). Reasonsfor delayed consultation were: fear of Covid-19 (31%; p = 0.0001), absence of referral doctor (31%; p = 0.003) and difficulties in getting to public transport (10.3%;p = 0.859).

Conclusion

Despite maintaining accessto emergency eye care facilitiesin our hospital, the lockdown affected visual health. Should the lockdown be reinstated, we postulate that a better information about eye care access for non-Covid emergencies may attenuate its effect on visual health.

The effect of Ebola virus disease on maternal health service utilisation and perinatal outcomes in West Africa: a systematic review

Background

Ebola outbreaks pose a major threat to global public health, especially in Sub-Saharan Africa. These outbreaks disrupt the already fragile maternal health services in West Africa. The aims of this study is to assess the effect of Ebola virus disease (EVD) on maternal health service utilisation and perinatal outcomes.

Methods

This systematic review was conducted in West Africa, and the databases used were Medline, PubMed, CINAHL, Scopus, EMBASE and African journals online. Studies that reported the effect of the Ebola outbreak on maternal health services in West Africa were eligible for this systematic review. The search was limited to articles written in the English language only and published between 2013 and 2020. Three authors independently appraised the articles, and the data were extracted using a standardised data extraction format. The findings were synthesised using a narrative summary, tables, and figures.

Results

Twelve studies met the inclusion criteria and were used for this systematic review synthesis. The results showed that antenatal care significantly decreased during Ebola virus disease and strove to recover post-Ebola virus disease. Women were less likely to have institutional childbirth during Ebola virus disease and struggled to recover post-Ebola virus disease. In addition, this review revealed a substantially higher rate of maternal mortality post EVD than those observed before or during the outbreak.

Conclusion

Based on our findings, antenatal care, institutional childbirth, and postnatal care are attempting to recover post-Ebola virus disease. We recommended that responsible bodies and stakeholders need to prepare locally tailored interventions to increase the number of women attending ANC, institutional childbirth, and PNC services post-EVD and future outbreaks including COVID-19. In order to build trust, creating community networks between health care providers and trusted community leaders may increase the number of women attending antenatal care (ANC), institutional childbirth and postnatal care (PNC) post-EVD and during future outbreaks. Further studies are needed to examine health centre and hospital availability and accessibility, and capacity to deliver maternal health services post-Ebola virus disease and future outbreaks.

Ebola virus disease (EVD) is a serious public health concern affecting the health of humans and other primates. These outbreaks disrupt the already fragile maternal health services in West Africa. There is limited data on the effect of EVD on maternal health service utilisation and perinatal outcomes in West Africa. This systematic review aims to synthesise evidence on maternal health service utilisation and perinatal outcomes before EVD, during EVD and post EVD.

This systematic review was conducted in West Africa, and the databases used were Medline, PubMed, CINAHL, Scopus, EMBASE and African journals online. Twelve studies met the inclusion criteria and were used for this systematic review synthesis. The results showed that antenatal care significantly decreased during the Ebola virus outbreak and strove to recover post-Ebola virus disease. This finding indicated that women were less likely to have an institutional birth during EVD and struggled to recover post-Ebola virus disease. Based on this finding, responsible bodies and stakeholders need to prepare locally tailored interventions to increase the number of women attending ANC, institutional childbirth, and PNC services post-EVD and future outbreaks.

Social Vulnerability and COVID-19: Changes in Trauma Activations at a Safety-Net Hospital

Introduction

Following the declaration of the COVID-19 pandemic, there were reports of decreased trauma hospitalizations, although violent crime persisted. COVID-19 has had the greatest impact on minoritized and vulnerable communities. Decreases in traumatic events may not extend to these communities, given pandemic-related socioeconomic and psychological burdens that increase the risk of exposure to trauma and violence.

Materials and methods

This was a retrospective cohort study (n = 1634) of all trauma activations presenting to our institution January 1, 2020 to May 31, 2020, and same time periods in 2018 and 2019. Census tracts and associated Social Vulnerability Index quartiles were determined from patient addresses. Changes in trauma activations pre and post Massachusetts’ state-of-emergency declaration compared to a historical control were analyzed using a difference-in-differences methodology.

Results

Weekly all-cause trauma activations fell from 26.44 to 8.25 (rate ratio = 0.36 [0.26, 0.50]) postdeclaration, with significant difference-in-differences compared to a historical control (P < 0.0001). Nonviolent trauma activations significantly decreased from 21.11 to 5.17 after the declaration (rate ratio = 0.27 [0.37, 0.91]; P < 0.0001), whereas there was no significant decrease in violent injury (5.33 to 3.08 rate ratio = 0.69 [0.39, 1.22]; P = 0.20). Stratified by vulnerability, the most vulnerable quartile had an increased proportion of all-cause trauma postdeclaration and had no decrease in violent trauma activations following the declaration compared to the historical control (rate ratio = 0.84 [0.38-1.86]; P = 0.67).

Conclusions

The state-of-emergency declaration was associated with significant decreases in overall trauma, to a greater extent in nonviolent injuries. Among those living in the most socially vulnerable communities, there was no decrease in violent trauma. These findings highlight the need for violence and injury prevention programs in vulnerable communities, particularly in times of crisis.

Short report: engagement with health services during the COVID-19 outbreak: the case of Israeli people with diabetes

Although continuing to utilize health services remains a key determinant of health, the association between the COVID-19 pandemic and engagement with health services among people with diabetes (PWD) remains unknown. This cross-sectional online survey examined factors associated with PWD's engagement with health services among 205 Israeli PWD during the subsiding of the first COVID-19 wave in Israel. Participants completed measures of perceived diabetes status, perceived risk, emotional reactions toward COVID-19, sense of mastery, engagement with health services (fear of contracting the virus in health services, canceling a medical appointment), and socio-demographic questionnaires. Most participants were women, their mean age was 40.18 years, and mean years since diagnosis was 15.70. Participants were recruited mainly via diabetes internet forums. Logistic and multiple hierarchical regressions were calculated. The odds of canceling appointment were higher for younger participants and for participants experiencing greater negative emotional reactions. Higher fear of contracting the virus in health services was related to higher perceived risk and experiencing greater negative emotional reactions. Findings suggest that in order to encourage PWD to utilize health services during a virus outbreak, clinical interventions should address PWD's perceived risk of contracting the virus and their emotional reactions toward COVID-19.

Impact of COVID-19 on non-COVID intensive care unit service utilization, case mix and outcomes: A registry-based analysis from India

Background: Coronavirus disease 2019 (COVID-19) has been responsible for over 3.4 million deaths globally and over 25 million cases in India. As part of the response, India imposed a nation-wide lockdown and prioritized COVID-19 care in hospitals and intensive care units (ICUs). Leveraging data from the Indian Registry of IntenSive care, we sought to understand the impact of the COVID-19 pandemic on critical care service utilization, case-mix, and clinical outcomes in non-COVID ICUs.  Methods: We included all consecutive patients admitted between 1 st October 2019 and 27 th September 2020. Data were extracted from the registry database and included patients admitted to the non-COVID or general ICUs at each of the sites. Outcomes included measures of resource-availability, utilisation, case-mix, acuity, and demand for ICU beds. We used a Mann-Whitney test to compare the pre-pandemic period (October 2019 - February 2020) to the pandemic period (March-September 2020). In addition, we also compared the period of intense lockdown (March-May 31 st 2020) with the pre-pandemic period. Results: There were 3424 patient encounters in the pre-pandemic period and 3524 encounters in the pandemic period. Comparing these periods, weekly admissions declined (median [Q1 Q3] 160 [145,168] to 113 [98.5,134]; p<0.001); unit turnover declined (median [Q1 Q3] 12.1 [11.32,13] to 8.58 [7.24,10], p<0.001), and APACHE II score increased (median [Q1 Q3] 19 [19,20] to 21 [20,22] ; p<0.001). Unadjusted ICU mortality increased (9.3% to 11.7%, p=0.015) and the length of ICU stay was similar (median [Q1 Q3] 2.11 [2, 2] vs. 2.24 [2, 3] days; p=0.151). Conclusion: Our registry-based analysis of the impact of COVID-19 on non-COVID critical care demonstrates significant disruptions to healthcare utilization during the pandemic and an increase in the severity of illness.

Effect of the COVID-19 pandemic on stress, anxiety, and depressive disorders in German primary care: A cross-sectional study

Several studies revealed that mental disorders' prevalence increased during the COVID-19 pandemic, particularly in young and female individuals. Such studies represent individuals' subjective perceptions and not the number of mental health cases treated in primary care. Thus, this study aimed to describe the changes in depression, anxiety, and stress disorder diagnoses in General Practitioner (GP) practices during the COVID-19 pandemic. More than three million patients of 757 German GP practices were included in this cross-sectional analysis. Descriptive statistics were used to assess changes in the number of incident depression, anxiety disorders, and reaction to severe stress and adjustment disorders documented by GPs in 2020 compared to the average of the years 2017-2019. There was a tremendous decrease in mental health diagnoses during the first lockdown that was only slightly compensated later. Overall populations and the entire year 2020, there was no change in documented depression (0%) and stress disorders (1%), but anxiety disorders were more often documented (+19%), especially for the elderly population (>80 years; +24%). This population group also received more frequently new depression (+12%) and stress disorder diagnoses (23%). The younger population was diagnosed more frequently at the end of 2020, nine months after the first lockdown. Anxiety disorders but not depression and stress diagnoses were elevated, which is not in line with previously published studies. We speculate that the elderly population was affected most by the pandemic immediately after the first lockdown was announced. The younger population has probably become more and more affected the longer the pandemic lasts.

Impact of the COVID-19 pandemic on unmet healthcare needs in Seoul, South Korea: a cross-sectional study

OBJECTIVES

This study investigated the factors influencing unmet healthcare needs of people during the early stage of the COVID-19 pandemic in Seoul, South Korea. The findings help to identify people who have difficulty accessing healthcare services during a pandemic situation.

DESIGN

We conducted a cross-sectional study using a proportionate quota sampling method according to five major districts, sex and age, using an online survey. We analysed the key characteristics of influencing factors of unmet healthcare needs based on the Andersen behavioural model of healthcare utilisation: predisposing factors (eg, sex, age), need factors (eg, health status, illness) and enabling factors (eg, income, efficacy belief).

SETTING

The questionnaire was sent via email and mobile text messages from the end of April to the beginning of May 2020 during the first wave of the COVID-19 pandemic.

PARTICIPANTS

A sample of 813 respondents was used, and the respondent information was anonymised in the analysis process.

RESULTS

For the predisposing factors, sex, age, education level and occupational cluster were associated with unmet needs for healthcare. Chronic diseases and mental health were the influencing factors as an enabling factor that exerted an influence on the unmet need for healthcare in South Korea. Women, younger persons, those with lower education and persons with white-collar jobs were more likely to experience unmet healthcare needs. In addition, the more chronic diseases people had, the more COVID-19 negatively affected them mentally; and the more people felt fear of COVID-19, the higher chances they experienced unmet healthcare needs.

CONCLUSION

Government and policymakers are guided to draw out measures such as health communication and telemedicine to reduce the unmet healthcare needs during the pandemic and to recognise the different influencing factors.

Comparison of emergency department utilization trends between the COVID-19 pandemic and control period

ABSTRACT

Infectious disease pandemics has a great impact on the use of medical facilities. The purpose of this study was to analyze the effects of coronavirus disease 2019 (COVID-19) on the use of emergency medical facilities in the Republic of Korea. This single-center, retrospective observational study was conducted in a tertiary teaching hospital located in Incheon Metropolitan City, Republic of Korea. We set the pandemic period as February 19, 2020 to April 18, 2020, and the control period was set to the same period in 2018 and 2019. All consecutive patients who visited the emergency department (ED) during the study period were included. Patients were divided into 3 groups according to age (pediatric patients, younger adult patients and older adult patients). The total number, demographics, clinical data, and diagnostic codes of ED patients were analyzed. The total number of ED patients in the pandemic period was lower than that in the control period, which was particularly pronounced for pediatric patients. The proportion of patients who used the 119 ambulances increased in all 3 groups (P  = .002, P < .001, and P = .001), whereas the proportion of patients who visited on foot was decreased (P  = .006, P < .001, and P = .027). In terms of diagnostic codes, a significant decrease was observed in the proportion of certain infectious or parasitic diseases (A00-B99), and respiratory diseases (J00-J99) in the pediatric and younger adult patient groups (P < .001 and P < .001, respectively). The COVID-19 pandemic reduced the number of ED patients; however, the proportion of patients using ambulances increased. In particular, the proportion of patients with diagnostic codes for infectious and respiratory diseases significantly decreased during the pandemic period.

Impact of Coronavirus Disease 2019 Pandemic on Crowding: A Call to Action for Effective Solutions to “Access Block”

Introduction

Healthcare patterns change during disease outbreaks and pandemics. Identification of modified patterns is important for future preparedness and response. Emergency department (ED) crowding can occur because of the volume of patients waiting to be seen, which results in delays in patient assessment or treatment and impediments to leaving the ED once treatment is complete. Therefore, ED crowding has become a growing problem worldwide and represents a serious barrier to healthcare operations.

Methods

This observational study was based on a retrospective review of the epidemiologic and clinical records of patients who presented to the Foundation IRCCS Policlinic San Matteo in Pavia, Italy, during the coronavirus disease 2019 (COVID-19) outbreak (February 21–May 1, 2020, pandemic group). The methods involved an estimation of the changes in epidemiologic and clinical data from the annual baseline data after the start of the COVID-19 pandemic.

Results

We identified reduced ED visits (180 per day in the control period vs 96 per day in the pandemic period; P < 0.001) during the COVID-19 pandemic, irrespective of age and gender, especially for low-acuity conditions. However, patients who did present to the ED were more likely to be hemodynamically unstable, exhibit abnormal vital signs, and more frequently required high-intensity care and hospitalization. During the pandemic, ED crowding dramatically increased primarily because of an increased number of visits by patients with high-acuity conditions, changes in patient management that prolonged length of stay, and increased rates of boarding, which led to the inability of patients to gain access to appropriate hospital beds within a reasonable amount of time. During the pandemic, all crowding output indices increased, especially the rates of boarding (36% vs 57%; P < 0.001), “access block” (24% vs 47%; P < 0.001), mean boarding time (640 vs 1,150 minutes [min]; P 0.001), mean “access block” time (718 vs 1,223 min; P < 0.001), and “access block” total time (650,379 vs 1,359,172 min; P < 0.001).

Conclusion

Crowding in the ED during the COVID-19 pandemic was due to the inability to access hospital beds. Therefore, solutions to this lack of access are required to prevent a recurrence of crowding due to a new viral wave or epidemic.

The indirect impact of COVID-19 large-scale containment measures on the incidence of community-acquired pneumonia in older people: a region-wide population-based study in Tuscany, Italy

OBJECTIVE

To evaluate the indirect effect of COVID-19 large-scale containment measures on the incidence of community-acquired pneumonia (CAP) in older people during the first epidemic wave of COVID-19 in Tuscany, Italy.

METHODS

A population-based study was carried out on data from the Tuscany healthcare system. The outcome measures were: hospitalization rate for CAP, severity of CAP hospitalizations, and outpatient consumption of antibacterials for CAP in people aged 65 and older. Outcomes were compared between corresponding periods in 2020 (week 1 to 27) and previous years.

RESULTS

Compared with the average of the corresponding periods in the previous 3 years, significant reductions in weekly hospitalization rates for CAP were observed from the week in which the national containment measures were imposed (week 10) until the end of the first COVID-19 wave in July (week 27). There was also a significant decrease in outpatient consumption in all antibacterial classes for CAP.

CONCLUSIONS

The implementation of large-scale COVID-19 containment measures likely reduced the incidence of CAP in older people during the first wave of the COVID-19 pandemic in Tuscany, Italy. Considering this indirect impact of pandemic containment measures on respiratory tract infections may improve the planning of health services during a pandemic in the future.

Impact of COVID-19 on non-COVID intensive care unit service utilization, case mix and outcomes: A registry-based analysis from India

Background: Coronavirus disease 2019 (COVID-19) has been responsible for over 3.4 million deaths globally and over 25 million cases in India. As part of the response, India imposed a nation-wide lockdown and prioritized COVID-19 care in hospitals and intensive care units (ICUs). Leveraging data from the Indian Registry of IntenSive care, we sought to understand the impact of the COVID-19 pandemic on critical care service utilization, case-mix, and clinical outcomes in non-COVID ICUs.  Methods: We included all consecutive patients admitted between 1 st October 2019 and 27 th September 2020. Data were extracted from the registry database and included patients admitted to the non-COVID or general ICUs at each of the sites. Outcomes included measures of resource-availability, utilisation, case-mix, acuity, and demand for ICU beds. We used a Mann-Whitney test to compare the pre-pandemic period (October 2019 - February 2020) to the pandemic period (March-September 2020). In addition, we also compared the period of intense lockdown (March-May 31 st 2020) with the pre-pandemic period. Results: There were 3424 patient encounters in the pre-pandemic period and 3524 encounters in the pandemic period. Comparing these periods, weekly admissions declined (median [Q1 Q3] 160 [145,168] to 113 [98.5,134]; p=0.00002); unit turnover declined (median [Q1 Q3] 12.1 [11.32,13] to 8.58 [7.24,10], p<0.00001), and APACHE II score increased (median [Q1 Q3] 19 [19,20] to 21 [20,22] ; p<0.00001). Unadjusted ICU mortality increased (9.3% to 11.7%, p=0.01519) and the length of ICU stay was similar (median [Q1 Q3] 2.11 [2, 2] vs. 2.24 [2, 3] days; p=0.15096). Conclusion: Our registry-based analysis of the impact of COVID-19 on non-COVID critical care demonstrates significant disruptions to healthcare utilization during the pandemic and an increase in the severity of illness.

The Impact of COVID-19 on Psychiatric Emergency and Inpatient Services in the First Month of the Pandemic in a Large Urban Mental Health Hospital in Ontario, Canada

The World Health Organization characterized COVID-19 (coronavirus disease 2019) as a pandemic on March 11, 2020 (WHO). Within a couple of days, all Canadian provinces announced the implementation of social distancing measures. We evaluated the immediate effect of COVID-19 on psychiatric emergency and inpatient services in Canada's largest psychiatric hospital in the first month of the pandemic. We extracted data from the electronic medical records of the Center for Addiction and Mental Health in Toronto, Canada. We compared emergency department visits, inpatient occupancy rates, and length of stay in March 2019 and March 2020, and during the first and second half of March 2020. There was a decrease in the number of emergency department visits and inpatient occupancy rates in March 2020 compared to March 2019. There was also a significant decrease in the number of emergency department visits and inpatient occupancy rates in the second half of March 2020 compared to the first half. Our findings suggest that the pandemic was followed by a rapid decrease in the usage of psychiatric emergency and inpatient services in a large mental health hospital. Future studies will need to assess whether this decrease will be followed by a return to baseline or an increase in need for these services.

The mechanisms between illness representations of COVID-19 and behavioral intention to visit hospitals for scheduled medical consultations in a Chinese general population

Testing the Common-Sense Model, this random telephone survey examined the associations between illness representations of COVID-19 and behavioral intention to visit hospitals for scheduled medical consultations (BI-VHSMC), and the mediations via coping and fear of nosocomial infection among 300 Chinese adults. The prevalence of BI-VHSMC was 62.3%. Mediation analysis found that maladaptive coping (rumination and catastrophizing) and fear of nosocomial infection mediated the associations between various dimensions of illness representations of COVID-19 (e.g. consequence and controllability) and BI-VHSMC, both indirectly and serially. Illness representations, coping, and fear should be considered when planning related health promotion during the COVID-19 pandemic.

The impact of the COVID-19 pandemic on health services utilization in China: Time-series analyses for 2016-2020

BACKGROUND

The aim of this study is to quantify the effects of the SARS-CoV-2 pandemic on health services utilization in China using over four years of routine health information system data.

METHODS

We conducted a retrospective observational cohort study of health services utilization from health facilities at all levels in all provinces of mainland China. We analyzed monthly all-cause health facility visits and inpatient volume in health facilities before and during the SARS-CoV-2 outbreak using nationwide routine health information system data from January 2016 to June 2020. We used interrupted time series analyses and segmented negative binomial regression to examine changes in healthcare utilization attributable to the pandemic. Stratified analyses by facility type and by provincial Human Development Index (HDI) - an area-level measure of socioeconomic status - were conducted to assess potential heterogeneity in effects.

FINDINGS

In the months before the SARS-CoV-2 outbreak, a positive secular trend in patterns of healthcare utilization was observed. After the SARS-CoV-2 outbreak, we noted statistically significant decreases in all indicators, with all indicators achieving their nadir in February 2020. The magnitude of decline in February ranged from 63% (95% CI 61-65%; p<0•0001) in all-cause visits at hospitals in regions with high HDI and 71% (95% CI 70-72%; p<0•0001) in all-cause visits at primary care clinics to 33% (95% CI 24-42%; p<0•0001) in inpatient volume and 10% (95% CI 3-17%; p = 0•0076) in all-cause visits at township health centers (THC) in regions with low HDI. The reduction in health facility visits was greater than that in the number of outpatients discharged (51% versus 48%; p<0•0079). The reductions in both health facility visits and inpatient volume were greater in hospitals than in primary health care facilities (p<0•0001) and greater in developed regions than in underdeveloped regions (p<0•0001). Following the nadir of health services utilization in February 2020, all indicators showed statistically significant increases. However, even by June 2020, nearly all indicators except outpatient and inpatient volume in regions with low HDI and inpatient volume in private hospitals had not achieved their pre-SARS-COV-2 forecasted levels. In total, we estimated cumulative losses of 1020.5 (95% CI 951.2- 1089.4; P<0.0001) million or 23.9% (95% CI 22.5-25.2%; P<0.0001) health facility visits, and 28.9 (95% CI 26.1-31.6; P<0.0001) million or 21.6% (95% CI 19.7-23.4%; P<0.0001) inpatients as of June 2020.

INTERPRETATION

Inpatient and outpatient health services utilization in China declined significantly after the SARS-CoV-2 outbreak, likely due to changes in patient and provider behaviors, suspension of health facilities or their non-emergency services, massive mobility restrictions, and the potential reduction in the risk of non-SARS-COV-2 diseases. All indicators rebounded beginning in March but most had not recovered to their pre-SARS-COV-2 levels as of June 2020.

FUNDING

The National Natural Science Foundation of China (No. 72042014).

Emergency general surgery utilization and disparities during COVID-19: an interrupted time-series analysis

Objective

We aimed to compare general surgery emergency (GSE) volume, demographics and disease severity before and during COVID-19.

Background

Presentations to the emergency department (ED) for GSEs fell during the early COVID-19 pandemic. Barriers to accessing care may be heightened, especially for vulnerable populations, and patients delaying care raises public health concerns.

Methods

We included adult patients with ED presentations for potential GSEs at a single quaternary-care hospital from January 2018 to August 2020. To compare GSE volumes in total and by subgroup, an interrupted time-series analysis was performed using the March shelter-in-place order as the start of the COVID-19 period. Bivariate analysis was used to compare demographics and disease severity.

Results

3255 patients (28/week) presented with potential GSEs before COVID-19, while 546 (23/week) presented during COVID-19. When shelter-in-place started, presentations fell by 8.7/week (31%) from the previous week (p<0.001), driven by decreases in peritonitis (β=−2.76, p=0.017) and gallbladder disease (β=−2.91, p=0.016). During COVID-19, patients were younger (54 vs 57, p=0.001), more often privately insured (44% vs 38%, p=0.044), and fewer required interpreters (12% vs 15%, p<0.001). Fewer patients presented with sepsis during the pandemic (15% vs 20%, p=0.009) and the average severity of illness decreased (p<0.001). Length of stay was shorter during the COVID-19 period (3.91 vs 5.50 days, p<0.001).

Conclusions

GSE volumes and severity fell during the pandemic. Patients presenting during the pandemic were less likely to be elderly, publicly insured and have limited English proficiency, potentially exacerbating underlying health disparities and highlighting the need to improve care access for these patients.

Level of evidence

III.

Effect of the COVID-19 lockdown on disease recognition and utilisation of healthcare services in the older population in Germany: a cross-sectional study

BACKGROUND

There is little evidence about the utilisation of healthcare services and disease recognition in the older population, which was urged to self-isolate during the COVID-19 lockdown.

OBJECTIVES

We aimed to describe the utilisation of physician consultations, specialist referrals, hospital admissions and the recognition of incident diseases in Germany for this age group during the COVID-19 lockdown.

DESIGN

Cross-sectional observational study.

SETTING

1,095 general practitioners (GPs) and 960 specialist practices in Germany.

SUBJECTS

2.45 million older patients aged 65 or older.

METHODS

The number of documented physician consultations, specialist referrals, hospital admissions and incident diagnoses during the imposed lockdown in 2020 was descriptively analysed and compared to 2019.

RESULTS

Physician consultations decrease slightly in February (-2%), increase before the imposed lockdown in March (+9%) and decline in April (-18%) and May (-14%) 2020 compared to the same periods in 2019. Volumes of hospital admissions decrease earlier and more intensely than physician consultations (-39 versus -6%, respectively). Overall, 15, 16 and 18% fewer incident diagnoses were documented by GPs, neurologists and diabetologists, respectively, in 2020. Diabetes, dementia, depression, cancer and stroke were diagnosed less frequently during the lockdown (-17 to -26%), meaning that the decrease in the recognition of diseases was greater than the decrease in physician consultations.

CONCLUSION

The data suggest that organisational changes were adopted quickly by practice management but also raise concerns about the maintenance of routine care. Prospective studies should evaluate the long-term effects of lockdowns on patient-related outcomes.

The dynamics of patient visits to traditional Chinese medicine during the 2019 coronavirus pandemic

Background

Large-scale epidemics have changed people’s medical behavior, and patients tend to delay non-urgent medical needs. However, the impact of the pandemic on the use of complementary and alternative medicine remains unknown.

Methods

This retrospective study aimed to analyze the changes in the number of traditional Chinese medicine (TCM) patients and examine the epidemic prevention policy during the coronavirus disease 2019 (COVID-19) pandemic. We analyzed the number of TCM patients in Taipei City Hospital from January 2017 to May 2020. We tallied the numbers of patients in each month and compared them with those in the same months last year. We calculated the percentage difference in the number of patients to reveal the impact of the COVID-19 pandemic on TCM utilization. We used the Mann–Whitney U test to examine whether there was a significant difference in the number of patients during the COVID-19 pandemic.

Results

We included a total of 1,935,827 TCM visits of patients from January 2017 to May 2020 in this study. During the COVID-19 pandemic, the number of patients decreased significantly, except in February 2020. The number of patients during the COVID-19 pandemic had fallen by more than 15% compared with those in the same months last year. March and April had the greatest number of patient losses, with falls of 32.8 and 40% respectively. TCM patients declined significantly during the COVID-19 pandemic, and mobile medicine provided to rural areas fell considerably. Among all the TCM specialties, pediatrics and traumatology, as well as infertility treatment, witnessed the most significant decline in the number of patients. However, the number of cancer patients has reportedly increased.

Conclusions

The COVID-19 pandemic decreased the utilization rate of TCM, especially for mobile healthcare in rural areas. We suggest that the government pay attention to the medical disparity between urban and rural areas, which are affected by the pandemic, as well as allocate adequate resources in areas deprived of medical care.

Managing cancer in context of pandemic: a qualitative study to explore the emotional and behavioural responses of patients with cancer and their caregivers to COVID-19

OBJECTIVES

Having to access life-sustaining treatment during the emerging COVID-19 outbreak has placed patients with cancer at an especially vulnerable position notwithstanding their immunocompromised condition. The present study aimed to elucidate cancer patients' and their caregivers' experiences during this outbreak.

DESIGN

Face-to-face semistructured interviews were conducted.

SETTING

A tertiary cancer care facility.

PARTICIPANTS

16 patients with cancer and 14 caregivers. Inclusions criteria were: (A) diagnosed with cancer, (B) receiving active treatment or follow-ups, (C) aged 21 years and above and (D) fluent in English or Mandarin.

RESULTS

Thematic analysis was conducted. Five themes were identified: heightened sense of threat, impact on healthcare experience, responsibility falls on oneself, striving for normalcy and sense of safety and trust. Heightened threat of COVID-19 was more pronounced in patients and linked to vulnerability and fear, uncertainty and actions of socially irresponsible others. Dominant in their healthcare experience was prioritising cancer and treatment amidst heightened threat and anticipatory worry about treatment disruptions. Both noted on the importance of taking responsibility for one's health, with caregivers reporting a reinforced sense of duty towards patients. They strived to maintain normalcy by viewing COVID-19 as beyond personal control, downplaying and living life as usual. Their resolve was supported by a sense of safety from the actions of authorities, hospitals and trust towards healthcare providers.

CONCLUSIONS

Cancer intensifies threat and the emotional impact of COVID-19 and may trigger specific concerns related to treatment. Psychoeducation interventions led by healthcare providers over digital platforms could help address cancer-specific concerns and support patients and caregivers during the pandemic.

Pediatric Emergency Department Utilization and Coronavirus Disease in Daegu, Korea

BACKGROUND

Limited data exist on children's utilization of the emergency department (ED) in the ongoing coronavirus disease 2019 (COVID-19) pandemic. Thus, we aimed to examine ED utilization among pediatric patients and the impact of COVID-19 in one large city affected by the outbreak.

METHODS

This retrospective study included data from six EDs in Daegu, Korea. We compared the demographic and clinical data of patients presenting to the ED during the COVID-19 pandemic (February 1st-June 30th 2020) with those of patients who visited the ED in this period during 2018 and 2019.

RESULTS

Fewer patients, particularly children visited the EDs during the study period in 2020 than those in the previous (2018/2019) year period: the number of adult patient decreased by 46.4% and children by 76.9%. Although the number of patients increased from the lowest point of the decrease in March 2020, the number of pediatric patients visiting the ED remained less than half (45.2%) in June 2020 compared with that of previous years. The proportion of patients with severe conditions increased in adults, infants, and school-aged children, and consequently resulted in increased ambulance use and higher hospitalization rates. Fewer infants and young children but more school-aged children visited the ED with febrile illnesses in 2020 than in 2018/2019.

CONCLUSION

The COVID-19 pandemic has led to a substantial decrease in pediatric ED utilization. These findings can help reallocate human and material resources in the EDs during infectious disease outbreaks.

Collateral Impact of the COVID-19 Pandemic on Acute Care of Non-COVID Patients: An Internet-based Survey of Critical Care and Emergency Personnel

Purpose

The impact of disruption to the care of non-coronavirus disease (COVID) patients (COVID collateral damage syndrome-CCDS) is largely unknown in resource-limited settings. We investigated CCDS as perceived by healthcare workers (HCWs) providing acute and critical care services in India.

Materials and methods

A clinician and nurse codesigned and validated an internet-based survey, which was disseminated to HCWs using a multiple frame sampling technique.

Results

Responses were received from 468 HCWs (completion rate 84%); at the time of the survey, 48% were working in critical care, 41% aged 30–40 years, and 53% represented public institutions. Respondents perceived a decrease in service utilization and disruption to time-sensitive acute interventions (60.1% and 40.8%, respectively), with fear of infection (score, 63.0; standard deviation (SD), 31.8) and restrictions due to lockdown (61.4; SD 32.5) being cited as the causes of service disruption. Being overwhelmed or lack of protective equipment was perceived to contribute less to CCDS. Insistence on COVID test results X² (p = 0.02) and duty-avoidance (p < 0.01) was perceived as significant causes for CCDS by HCWs from private hospitals and those in leadership roles, respectively.

Conclusions

Fear of infection and the effect of lockdown were perceived as important contributors to CCDS resulting in disruption to services and decreased service utilization. Perceptions were influenced by HCWs’ role and hospital organizational structure.

How to cite this article

Tripathy S, Vijayaraghavan BKT, Panigrahi MK, Shetty AP, Haniffa R, Mishra RC, et al. Collateral Impact of the COVID-19 Pandemic on Acute Care of Non-COVID Patients: An Internet-based Survey of Critical Care and Emergency Personnel. Indian J Crit Care Med 2021;25(4):374–381.

Where did the patients go? Changes in acute appendicitis presentation and severity of illness during the coronavirus disease 2019 pandemic: A retrospective cohort study

BACKGROUND

The coronavirus disease 2019 pandemic restricted movement of individuals and altered provision of health care, abruptly transforming health care-use behaviors. It serves as a natural experiment to explore changes in presentations for surgical diseases including acute appendicitis. The objective was to determine if the pandemic was associated with changes in incidence of acute appendicitis compared to a historical control and to determine if there were associated changes in disease severity.

METHODS

The study is a retrospective, multicenter cohort study of adults (N = 956) presenting with appendicitis in nonpandemic versus pandemic time periods (December 1, 2019-March 10, 2020 versus March 11, 2020-May 16, 2020). Corresponding time periods in 2018 and 2019 composed the historical control. Primary outcome was mean biweekly counts of all appendicitis presentations, then stratified by complicated (n = 209) and uncomplicated (n = 747) disease. Trends in presentations were compared using difference-in-differences methodology. Changes in odds of presenting with complicated disease were assessed via clustered multivariable logistic regression.

RESULTS

There was a 29% decrease in mean biweekly appendicitis presentations from 5.4 to 3.8 (rate ratio = 0.71 [0.51, 0.98]) after the pandemic declaration, with a significant difference in differences compared with historical control (P = .003). Stratified by severity, the decrease was significant for uncomplicated appendicitis (rate ratio = 0.65 [95% confidence interval 0.47-0.91]) when compared with historical control (P = .03) but not for complicated appendicitis (rate ratio = 0.89 [95% confidence interval 0.52-1.52]); (P = .49). The odds of presenting with complicated disease did not change (adjusted odds ratio 1.36 [95% confidence interval 0.83-2.25]).

CONCLUSION

The pandemic was associated with decreased incidence of uncomplicated appendicitis without an accompanying increase in complicated disease. Changes in individual health care-use behaviors may underlie these differences, suggesting that some cases of uncomplicated appendicitis may resolve without progression to complicated disease.

Impact of the COVID-19 Pandemic on Emergency Department Use: Focus on Patients Requiring Urgent Revascularization

Background

The novel coronavirus (2019-nCOV) appeared in China and precipitously extended across the globe. As always, natural disasters or infectious disease outbreaks have the potential to cause emergency department (ED) volume changes.

Objective

We aimed to assess the influence of the Coronavirus Disease 2019 (COVID-19) pandemic on ED visits and the impact on the handling of patients requiring urgent revascularization.

Methods

We reviewed the charts of all patients presenting to the ED of Hospital Sainte Anne (Toulon, France) from March 23 to April 5, 2020 and compared them with those of the same period in 2019. Then we analyzed complementary data on acute coronary syndrome (ST-elevation myocardial infarction [STEMI] and non-ST-elevation myocardial infarction [NSTEMI]) and neurovascular emergencies (strokes and transient ischemic attacks).

Results

The total number of visits decreased by 47%. The number of people assessed as triage level 2 was 8% lower in 2020. There were five fewer cases of NSTEMI in 2020, but the same number of STEMI. The number of neurovascular emergencies increased (27 cases in 2019 compared with 30 in 2020). We observed a reduction in the delay between arrival at the ED and the beginning of coronary angiography for STEMI cases (27 min in 2019 and 22 min in 2020). In 2020, 7 more stroke patients were admitted.

Conclusion

The COVID-19 pandemic probably dissuaded “non-critical” patients from coming to the hospital, whereas the same number of patients with a critical illness attended the ED as attended prior to the pandemic. There does not seem to have been any effect of the pandemic on patients requiring reperfusion therapy (STEMI and stroke).

Understanding the Psychological Impact of COVID-19 Pandemic on Patients With Cancer, Their Caregivers, and Health Care Workers in Singapore

PURPOSE

The coronavirus disease 2019 (COVID-19) pandemic has had a global impact, and Singapore has seen 33,000 confirmed cases. Patients with cancer, their caregivers, and health care workers (HCWs) need to balance the challenges associated with COVID-19 while ensuring that cancer care is not compromised. This study aimed to evaluate the psychological effect of COVID-19 on these groups and the prevalence of burnout among HCWs.

METHODS

A cross-sectional survey of patients, caregivers, and HCWs at the National Cancer Centre Singapore was performed over 17 days during the lockdown. The Generalized Anxiety Disorder-7 and Maslach Burnout Inventory were used to assess for anxiety and burnout, respectively. Self-reported fears related to COVID-19 were collected.

RESULTS

A total of 624 patients, 408 caregivers, and 421 HCWs participated in the study, with a response rate of 84%, 88%, and 92% respectively. Sixty-six percent of patients, 72.8% of caregivers, and 41.6% of HCWs reported a high level of fear from COVID-19. The top concern of patients was the wide community spread of COVID-19. Caregivers were primarily worried about patients dying alone. HCWs were most worried about the relatively mild symptoms of COVID-19. The prevalence of anxiety was 19.1%, 22.5%, and 14.0% for patients, caregivers, and HCWs, respectively. Patients who were nongraduates and married, and caregivers who were married were more anxious. The prevalence of burnout in HCWs was 43.5%, with more anxious and fearful HCWs reporting higher burnout rates.

CONCLUSION

Fears and anxiety related to COVID-19 are high. Burnout among HCWs is similar to rates reported prepandemic. An individualized approach to target the specific fears of each group will be crucial to maintain the well-being of these vulnerable groups and prevent burnout of HCWs.

Healthcare utilization among breast cancer patients during the COVID-19 outbreak

OBJECTIVE

Continuing to utilize healthcare as needed during an epidemic outbreak is significant, in general, and especially for cancer patients. Therefore, this study aimed to explore factors associated with health services utilization among breast cancer patients during the coronavirus disease (COVID-19) outbreak.

METHOD

A cross-sectional online survey was conducted among 151 women with breast cancer. Participants completed measures of perceived health status, perceived susceptibility to COVID-19, anxiety, coping resources, health services utilization (contact with healthcare professionals and cancellation of an appointment to the oncology/hematology clinic), and socio-demographic questionnaires. A multiple hierarchical regression was calculated; contact with healthcare professionals was the dependent variable. In addition, a logistic regression was calculated; cancellation of an appointment to the oncology/hematology clinic because of the COVID-19 was the dependent variable.

RESULTS

Breast cancer patients' contact with healthcare professionals was lower than their contact prior to the pandemic. A higher extent of contact with healthcare professionals was related to patients' perception of health as bad/reasonable, lower perceived susceptibility, a lower sense of mastery, and higher social support. In addition, the odds of cancelling an appointment to the oncology/hematology clinic were higher in the presence of additional chronic illnesses and a higher sense of mastery.

SIGNIFICANCE OF RESULTS

The results could provide public health agencies with a more complete picture of the impact of the COVID-19 epidemic among breast cancer patients. This is significant because, in the event that COVID-19 re-emerges, the findings of the current study could help guide public health officials and possibly prevent the future avoidance of health services' use among this high-risk population.

Neurosurgical Procedures and Safety During the COVID-19 Pandemic: A Case-Control Multicenter Study

Objective

Quantitative documentation of the effects of outbreaks, including the coronavirus disease 2019 (COVID-19) pandemic, is limited in neurosurgery. Our study aimed to evaluate the effects of the COVID-19 pandemic on neurosurgical practice and to determine whether surgical procedures are associated with increased morbidity and mortality.

Methods

A multicenter case-control study was conducted, involving patients who underwent neurosurgical intervention in the Kingdom of Saudi Arabia during 2 periods: pre-COVID-19 and during the COVID-19 pandemic. The surgical intervention data evaluated included diagnostic category, case priority, complications, length of hospital stay, and 30-day mortality.

Results

A total of 850 procedures were included, 36% during COVID-19. The median number of procedures per day was significantly lower during the COVID-19 period (5.5 cases) than during the pre-COVID-19 period (12 cases; P < 0.0001). Complications, length of hospital stay, and 30-day mortality did not differ during the pandemic. In a multivariate analysis comparing both periods, case priority levels 1 (immediate) (odds ratio [OR], 1.82; 95% confidence interval [CI], 1.24–2.67), 1 (1–24 h) (OR, 1.63; 95% CI, 1.10–2.41), and 4 (OR, 0.28; 95% CI, 0.19–0.42) showed significant differences.

Conclusions

During the early phase of the COVID-19 pandemic, the overall number of neurosurgical procedures declined, but the load of emergency procedures remained the same, thus highlighting the need to allocate sufficient resources for emergencies. More importantly, performing neurosurgical procedures during the pandemic in regions with limited effects of the outbreak on the health care system was safe. Our findings may aid in developing guidelines for acute and long-term care during pandemics in surgical subspecialties.

Connecting During COVID-19: A Protocol of a Volunteer-Based Telehealth Program for Supporting Older Adults' Health

Introduction: Social-distancing due to COVID-19 has led to social isolation, stress, and mental health issues in older adults, while overwhelming healthcare systems worldwide. Telehealth involving phone calls by trained volunteers is understudied and may be a low-cost, scalable, and valuable preventive tool for mental health. In this context, from patient participatory volunteer initiatives, we have adapted and developed an innovative volunteer-based telehealth intervention program for older adults (TIP-OA). Methods and analysis: To evaluate TIP-OA, we are conducting a mixed-methods longitudinal observational study. Participants: TIP-OA clients are older adults (age ≥ 60) recruited in Montreal, Quebec. Intervention: TIP-OA volunteers make weekly friendly phone calls to seniors to check in, form connections, provide information about COVID-19, and connect clients to community resources as needed. Measurements: Perceived stress, fear surrounding COVID-19, depression, and anxiety will be assessed at baseline, and at 4- and 8-weeks. Semi-structured interviews and focus groups will be conducted to assess the experiences of clients, volunteers, and stakeholders. Results: As of October 15th, 2020, 150 volunteers have been trained to provide TIP-OA to 305 older clients. We will consecutively select 200 clients receiving TIP-OA for quantitative data collection, plus 16 volunteers and 8 clinicians for focus groups, and 15 volunteers, 10 stakeholders, and 25 clients for semi-structured interviews. Discussion: During COVID-19, healthcare professionals' decreased availability and increased needs related to geriatric mental health are expected. If successful and scalable, volunteer-based TIP-OA may help prevent and improve mental health concerns, improve community participation, and decrease healthcare utilization. Clinical Trial Registration: ClinicalTrials.gov NCT04523610; https://clinicaltrials.gov/ct2/show/NCT04523610?term=NCT04523610&draw=2&rank=1.

The impact of global budgeting in Taiwan on inpatients with unexplained fever

Unexplained fever is one of the most common and difficult diagnostic problems faced daily by clinicians. This study evaluated the differences in health service utilization, health care expenditures, and quality of care provided to patients with unexplained fever before and after global budget (GB) implementation in Taiwan.The National Health Insurance Research Database was used for analyzing the health care expenditures and quality of care before and after implementation of the GB system. Patients diagnosed as having unexplained fever during 2000-2001 were recruited; their 2000-2001 and 2004-2005 data were considered baseline and postintervention data, respectively.Data of 259 patients with unexplained fever were analyzed. The mean lengths of stay (LOSs) before and after GB system implementation were 4.22 ± 0.35 days and 5.29 ± 0.70 days, respectively. The mean costs of different health care expenditures before and after implementation of the GB system were as follows: the mean diagnostic, drug, therapy, and total costs increased respectively from New Taiwan Dollar (NT$) 1440.05 ± NT$97.43, NT$3249.90 ± NT$1108.27, NT$421.03 ± NT$100.03, and NT$13,866.77 ± NT$2,114.95 before GB system implementation to NT$2224.34 ± NT$238.36, NT$4272.31 ± NT$1466.90, NT$2217.03 ± NT$672.20, and NT$22,856.41 ± NT$4,196.28 after implementation. The mean rates of revisiting the emergency department within 3 days and readmission within 14 days increased respectively from 10.5% ± 2.7% and 8.3% ± 2.4% before implementation to 6.3% ± 2.2% and 4.0% ± 1.7% after implementation.GB significantly increased LOS and incremental total costs for patients with unexplained fever; but improved the quality of care.

Impact of the 2015 Middle East Respiratory Syndrome Outbreak on Emergency Care Utilization and Mortality in South Korea

PURPOSE

In May 2015, South Korea experienced an epidemic of Middle East respiratory syndrome (MERS). This study investigated the impacts of MERS epidemic on emergency care utilization and mortality in South Korea.

MATERIALS AND METHODS

A natural experimental study was conducted using healthcare utilization and mortality data of the entire Korean population. The number of monthly emergency room (ER) visits was investigated to identify changes in emergency care utilization during the MERS epidemic; these trends were also examined according to patients' demographic factors, disease severity, and region. Deaths within 7 days after visiting an ER were analyzed to evaluate the impact of the reduction in ER visits on mortality.

RESULTS

The number of ER visits during the peak of the MERS epidemic (June 2015) decreased by 33.1% compared to the average figures from June 2014 and June 2016. The decrease was observed in all age, sex, and income groups, and was more pronounced for low-acuity diseases (acute otitis media: 53.0%; upper respiratory infections: 45.2%) than for high-acuity diseases (myocardial infarctions: 14.0%; ischemic stroke: 16.6%). No substantial changes were detected for the highest-acuity diseases, with increases of 3.5% for cardiac arrest and 2.4% for hemorrhagic stroke. The number of deaths within 7 days of an ER visit did not change significantly.

CONCLUSION

During the MERS epidemic, the number of ER visits decreased in all age, sex, and socioeconomic groups, and decreased most sharply for low-acuity diseases. Nonetheless, there was no significant change in deaths after emergency care.

What happened to health service utilization, health care expenditures, and quality of care in patients with acute pancreatitis after implementation of global budgeting in Taiwan?

AIM

Acute pancreatitis is associated with significant morbidity and mortality. In the United States, more than 3,00,000 patients are admitted and about 20,000 die from acute pancreatitis per year. In Taiwan, the incidence rate of acute pancreatitis is 0.03% and the mortality rate among severe acute pancreatitis is 16.3%. The aim of the study was to evaluate the impact of the global budgeting system on health service utilization, health care expenditures, and quality of care among patients with acute pancreatitis in Taiwan.

MATERIALS AND METHODS

The National Health Insurance Research Database (NHIRD) was used for analysis. Data on patients with acute pancreatitis diagnosed during the period 2000 and 2001 were used as baseline data, and data from 2004 and 2005 were used as post-intervention data. The length of stay (LOS), diagnostic costs, drug cost, therapy costs, total costs, risk of readmission within 14 days, and risk of revisiting the emergency department (ED) within 3 days of discharge before and after implementation of the global budgeting system were compared and analyzed.

RESULTS

Data on 2810 patients with acute pancreatitis were analyzed in this study. There was a significant difference in mean LOS before and after introduction of the global budget system (7.34 ± 0.22 days and 7.82 ± 0.22 days, respectively; P < .001)). The mean total costs before and after implementation of the global budget system were Taiwan dollars (NT$) 28,290.66 ± 1576.32 and NT$ 42,341.83 ± 2285.23, respectively. The mean rate of revisiting the ED within 3 days decreased from 9.9 ± 0.9% before adoption of global budgeting to 7.2 ± 0.6% after implementation of the system. The mean 14-day re-admission rates before and after introduction of global budgeting were 11.6 ± 1.0% and 7.9 ± 0.7%, respectively.

CONCLUSION

The global budget system was associated with significantly longer length of stay, higher health care expenditures, and better quality of care in patients treated for acute pancreatitis.

Health care utilization and health outcomes: a population study of Taiwan

Facing escalating health care expenditures, the governments of countries with national health insurance programs are trying to control or even to reduce health care utilization. Little research has examined the effects of decreased health care utilization on health outcomes. Applying a natural experiment design to the Taiwan population between 2000 and 2004, which includes the 2003 SARS epidemic when an average 20% decline in health care utilization occurred, this study examines the association between a decline in health care utilization and health outcomes measured by cause-specific mortality rates. We analyse the monthly mortality rates caused by infectious diseases, cancer, diabetes mellitus, nervous system diseases, cerebrovascular diseases, heart and other vascular diseases, respiratory system diseases, digestive system diseases, genitourinary system diseases and accidents. Models control for age, sex, month and year effects. Results show the heterogeneous effect of reduced health care utilization on health outcomes. Patients with diabetes mellitus or cerebrovascular diseases are vulnerable to short-term reductions in health care; compared with the non-SARS period, mortality caused by diabetes mellitus and cerebrovascular diseases significantly increased during the SARS epidemic by 8.4% and 6.2%, respectively. No significant change in mortality rates caused by the other diseases or accidents is found. This study suggests that governments of countries where health care utilization and spending are similar to or inferior to those in Taiwan should carefully evaluate the impact of policies that attempt to reduce health care utilization. Furthermore, when an area encounters an epidemic, governments should be aware of the negative consequences of voluntary restraints on access to health care that accompany decreases in utilization.

Population-based post-crisis psychological distress: an example from the SARS outbreak in Taiwan

BACKGROUND/PURPOSE

As a result of the severe acute respiratory syndrome (SARS) pandemic, the World Health Organization placed Taiwan on the travel alert list from May 21 to July 5, 2003. The aim of this study was to explore the post-crisis psychological distress among residents in Taiwan after the SARS epidemic.

METHODS

The target population consisted of a nationwide representative sample of residents aged > or = 18 years. Data were collected using computer assisted telephone interview systems by stratified random sampling according to geographic area. The survey (n = 1278) was conducted in November 2003, about 4 months after resolution of the SARS crisis in Taiwan. The maximum deviation of sampling error at the 95% confidence level was +/- 2.74%. Psychological distress was measured by a question related to subject's changes in perception of life, plus the five-item Brief Symptom Rating Scale. Multivariate logistic regression was used to examine the correlation of psychological distress.

RESULTS

About 9.2% of the participants reported that their perceptions of life became more pessimistic following the SARS crisis. The prevalence of psychiatric morbidity was 11.7%. Major predictors of higher levels of pessimism after the SARS epidemic included demographic factors, perception of SARS and preparedness, knowing people or having personal experiences of SARS-related discrimination, and individual worries and psychiatric morbidity. The correlates of symptomatic cases, as indicated by the five-item Brief Symptom Rating Scale, included age > or = 50 years, senior high school graduate, and worries about recurrence of SARS.

CONCLUSION

Psychological distress was significantly correlated with demographic factors and perception regarding the SARS epidemic. It is suggested that marketing of mental health education should be segmented according to age and education level, which should enhance crisis communication for newly emerging infectious diseases among community populations.

The impact of matching vaccine strains and post-SARS public health efforts on reducing influenza-associated mortality among the elderly

Public health administrators do not have effective models to predict excess influenza-associated mortality and monitor viral changes associated with it. This study evaluated the effect of matching/mismatching vaccine strains, type/subtype pattern changes in Taiwan's influenza viruses, and the impact of post-SARS (severe acute respiratory syndrome) public health efforts on excess influenza-associated mortalities among the elderly. A negative binomial model was developed to estimate Taiwan's monthly influenza-associated mortality among the elderly. We calculated three winter and annual excess influenza-associated mortalities [pneumonia and influenza (P&I), respiratory and circulatory, and all-cause] from the 1999-2000 through the 2006-2007 influenza seasons. Obtaining influenza virus sequences from the months/years in which death from P&I was excessive, we investigated molecular variation in vaccine-mismatched influenza viruses by comparing hemagglutinin 1 (HA1) of the circulating and vaccine strains. We found that the higher the isolation rate of A (H3N2) and vaccine-mismatched influenza viruses, the greater the monthly P&I mortality. However, this significant positive association became negative for higher matching of A (H3N2) and public health efforts with post-SARS effect. Mean excess P&I mortality for winters was significantly higher before 2003 than after that year [mean +/- S.D.: 1.44+/-1.35 vs. 0.35+/-1.13, p = 0.04]. Further analysis revealed that vaccine-matched circulating influenza A viruses were significantly associated with lower excess P&I mortality during post-SARS winters (i.e., 2005-2007) than during pre-SARS winters [0.03+/-0.06 vs. 1.57+/-1.27, p = 0.01]. Stratification of these vaccine-matching and post-SARS effect showed substantial trends toward lower elderly excess P&I mortalities in winters with either mismatching vaccines during the post-SARS period or matching vaccines during the pre-SARS period. Importantly, all three excess mortalities were at their highest in May, 2003, when inter-hospital nosocomial infections were peaking. Furthermore, vaccine-mismatched H3N2 viruses circulating in the years with high excess P&I mortality exhibited both a lower amino acid identity percentage of HA1 between vaccine and circulating strains and a higher numbers of variations at epitope B. Our model can help future decision makers to estimate excess P&I mortality effectively, select and test virus strains for antigenic variation, and evaluate public health strategy effectiveness.

Hospitalization for ambulatory-care-sensitive conditions in Taiwan following the SARS outbreak: a population-based interrupted time series study

BACKGROUND/PURPOSE

In 2003, the severe acute respiratory syndrome (SARS) outbreak resulted in 8096 probable cases and 774 deaths in 26 countries. The purpose of this study was to explore the effect of the SARS outbreak on hospitalization for chronic ambulatory-care-sensitive conditions (ACSCs) in Taiwan.

METHODS

We applied a population-based interrupted time series study design and used the time series auto-regressive integrated moving-average model to compare the actual and predicted admission rates of seven selected chronic ACSCs. The analyses were based on National Health Insurance hospital inpatient claims data from 1997 to 2003.

RESULTS

The impact of SARS on ACSCs after the outbreak varied among seven selected chronic conditions. Hospitalization for respiratory conditions was significantly lower than the predicted values, whereas hospitalization for diabetes was significantly higher than the predicted values after the outbreak.

CONCLUSION

Admission rates for most ACSCs, except for diabetes, did not change in the post-SARS period. The reductions in outpatient utilization during the SARS outbreak did not appear to affect adversely admissions for most ACSCs.