Collateral damage of the COVID-19 outbreak: expression of concern

Influence of practice location on prescribing, diabetes care, and colorectal cancer screening among Czech general practitioners during the COVID-19 pandemic

OBJECTIVES

The provision of primary health care was not interrupted during the coronavirus disease 2019 (COVID-19) pandemic in Czechia, although the capacity and resources of providers changed. We examined how the pandemic affected individual general practices throughout 2017-2021, focusing on differences between urban and rural practices.

METHODS

We analysed data from the largest health insurance company in Czechia, which provides care to 4.5 million people (60% of the population). We evaluated the prescription volume, diabetes care procedures, and faecal immunochemical test (FIT) in preventive care and new pandemic-related procedures (remote consultations, testing, and vaccinations). For the spatial distribution of practices, we adapted the Organisation for Economic Cooperation and Development typology.

RESULTS

We observed minimal declines in 2020 in the rate of prescribing (-1.0%) and diabetes care (-5.1%), with a rapid resumption in 2021, but a substantial decline in FIT (-17.8% in 2020) with slow resumption. Remote consultations were used by 94% of all practices regardless of location, with testing and vaccinations more commonly performed by rural general practitioners (GPs).

CONCLUSIONS

Primary care in Czechia rose to the challenge of the COVID-19 pandemic, as shown by the finding that the volume of healthcare services provided through primary care did not decrease across most of the monitored parameters. This study also confirmed that rural GPs provide more care in-house, both in terms of prescribing and procedures performed in their practices. Future studies will need to focus on preventive care, which the pandemic has dampened in GP practices in Czechia.

Open data for monitoring COVID-19 in Spain: Descriptive study

BACKGROUND

The indicators of the pandemic have been based on the total number of diagnosed cases of COVID-19, the number of people hospitalized or in intensive care units, and deaths from the infection. The aim of this study is to describe the available data on diagnostic tests, health service used for the diagnosis of COVID-19, case detection and monitoring.

METHOD

Descriptive study with review of official data available on the websites of the Spanish health councils corresponding to 17 Autonomous Communities, 2 Autonomous cities and the Ministry of Health. The variables collected refer to contact tracing, technics for diagnosis, use of health services and follow-up.

RESULTS

All regions of Spain show data on diagnosed cases of COVID-19 and deaths. Hospitalized cases and intensive care admissions are shown in all regions except the Balearic Islands. Diagnostic tests for COVID-19 have been registered in all regions except Madrid region and Extremadura, with scarcely information on what type of test has been performed (present in 7 CCAA), requesting service and study of contacts.

CONCLUSIONS

The information available on the official websites of the Health Departments of the different regions of Spain are heterogeneous. Data from the use of health service or workload in Primary Care, Emergency department or Out of hours services are almost non-existent.

COVID-19 Pandemic Brings Challenges to the Management of Stroke-The Differences Between Stroke Cases Admitted to a Tertiary Hospital Before and During COVID-19 Pandemic in China

Background

An international public health emergency has resulted from the emergence of the new coronavirus-2. Both direct and indirect influences have been felt on the treatment of acute stroke. However, no conclusive link between COVID-19 and the alleged decline in admissions for stroke-related reasons has been established, and the findings of recent studies are contentious. Most of those researches are not made use of authentic data. Therefore, the goal of this study is to examine how the COVID-19 pandemic has affected hospital admissions for stroke patients, to provide a basis for managing stroke patients in hospitals during COVID-19 pandemic.

Methods

This retrospective study took place at the People's Hospital of Peking University in Beijing, China. For each patient, interventions such as the application of tissue plasminogen activator (tPA) were examined. We recorded each patient's outcomes. The stroke patients' hospital admissions were compared to the average of the prior year. As the time span of interest, we selected the epidemic period (January 2020 to December 2020).

Results

When compared to the previous year in the pre-COVID period, mean monthly stroke hospitalizations decreased during the pandemic by 54.42% (P<0.001); average lengths of stay (ALOS) increased; and non-emergency admissions decreased by 78.8% (P<0.001). The monthly volume of stroke patients exceeding the intravenous thrombolysis (IVT) window decreased by 25% and 59.73%, respectively (P <0.001). There was a 5.3% increase in the percentage of IVT or within IVT time window in male stroke patients (p=0.019; p=0.049). During COVID-19, the proportion of non-local patients among male stroke patients decreased by 10% compared with the previous year (p=0.006).

Conclusion

The COVID-19 epidemic has had a negative impact on stroke management in China, healthcare systems must work to assess and adapt to the new reality.

The association of the COVID-19 outbreak with in-hospital mortality: A single-centre study from Indonesia

Objective

The early outbreak period of Coronavirus Disease (COVID-19) has affected the emergency department (ED) and hospital services in many countries. This study aimed to investigate the association between COVID-19 outbreak and in-hospital mortality in Jakarta, Indonesia.

Methods

This retrospective cohort study was conducted in a single-centre referral hospital in Jakarta, Indonesia. Data were collected between May and October 2020. All patients who visited the ED and required inpatient care during the early COVID-19 outbreak period at the study location (March to April 2020) were included in the exposure group. All patients who visited the ED and required inpatient care during the non-outbreak period (March to April 2019) were included in the non-exposure group. In-hospital mortality was the primary outcome, whereas other variables, such as sex, age, triage categories, trauma cases, referral cases, and ED length of stay (LOS), were measured to identify confounding and effect modifications. Multivariate logistic regression analysis was performed to assess this association.

Results

A total of 2,808 patients during the outbreak period and 2,423 patients during the non-outbreak period participated in the study. The odds of in-hospital mortality increased during the outbreak period compared to that during the non-outbreak period (odds ratio [OR], 1.41; 95%CI 1.04-1.91; p = 0.01) after adjusting for age, sex, triage categories, trauma case, ED LOS, and interaction between the outbreak period and ED LOS.

Conclusion

COVID-19 outbreaks have been associated with an increased risk of in-hospital mortality in referral hospitals in Jakarta, Indonesia.

Short-Term Effectiveness of Oral Nirmatrelvir/Ritonavir Against the SARS-CoV-2 Omicron Variant and Culture-Positive Viral Shedding

BACKGROUND

Information on the effectiveness of nirmatrelvir/ritonavir against the omicron is limited. The clinical response and viral kinetics to therapy in the real world need to be evaluated.

METHODS

Mild to moderate coronavirus disease 2019 (COVID-19) patients with risk factors for severe illness were prospectively enrolled as a treatment group with nirmatrelvir/ritonavir therapy versus a control group with supportive care. Serial viral load and culture from the upper respiratory tract were evaluated for seven days, and clinical responses and adverse reactions were evaluated for 28 days.

RESULTS

A total of 51 patients were analyzed including 40 in the treatment group and 11 in the control group. Faster symptom resolution during hospitalization (P = 0.048) was observed in the treatment group. Only minor adverse reactions were reported in 27.5% of patients. The viral load on Day 7 was lower in the treatment group (P = 0.002). The viral culture showed a positivity of 67.6% (25/37) vs. 100% (6/6) on Day 1, 0% (0/37) vs. 16.7 (1/6) on Day 5, and 0% (0/16) vs. 50.0% (2/4) on Day 7 in the treatment and control groups, respectively.

CONCLUSIONS

Nirmatrelvir/ritonavir against the omicron was safe and resulted in negative viral culture conversion after Day 5 of treatment with better symptomatic resolution.

Unexpected Repercussions of the COVID-19 Pandemic on Total Hip Arthroplasty with Cemented Hip Prosthesis versus Cementless Implants

(1) Background: Total hip arthroplasty (THA) is one of the most common procedures used for adult hip reconstruction, employing mainly two types of prostheses: cemented (CHP) and cementless (CLHP). This study aims to analyze the impact of the COVID-19 pandemic on THA with CHP and CLHP, in terms of the benefit/cost ratio. (2) Methods: This article represents a retrospective analysis of the differences concerning the benefit/cost ratio between THA with the two types of prostheses in 2950 patients admitted for THA in the two orthopedic clinics of our hospital between 1 January 2015-1 March 2020 in comparison with 1005 THA subjects seen between 1 April 2020-31 December 2022. (3) Results: In the first period, THA with CHP was performed in 45.83% of cases, while CLHP was used in 54.16% of patients. During the COVID-19 period, CHP was inserted in 52% of THA patients, while the other 48% had CLHP inserted, with a hospitalization duration reduced by over 50% for both types of implants (p ˂ 0.001). (4) Conclusions: CHP offered good outcomes, with quicker mobilization, and shorter hospitalization duration, compared to CLHP, but optimization of the patients' management can be achieved mainly by reducing the length of hospitalization through an appropriate preoperative patient evaluation through a multidisciplinary approach, an aspect that was proven during the COVID-19 pandemic.

The Organization of Outreach Work for Vulnerable Patients in General Practice during COVID-19: Results from the Cross-Sectional PRICOV-19 Study in 38 Countries

The COVID-19 pandemic disproportionately affected vulnerable populations' access to health care. By proactively reaching out to them, general practices attempted to prevent the underutilization of their services. This paper examined the association between practice and country characteristics and the organization of outreach work in general practices during COVID-19. Linear mixed model analyses with practices nested in countries were performed on the data of 4982 practices from 38 countries. A 4-item scale on outreach work was constructed as the outcome variable with a reliability of 0.77 and 0.97 at the practice and country level. The results showed that many practices set up outreach work, including extracting at least one list of patients with chronic conditions from their electronic medical record (30.1%); and performing telephone outreach to patients with chronic conditions (62.8%), a psychological vulnerability (35.6%), or possible situation of domestic violence or a child-rearing situation (17.2%). Outreach work was positively related to the availability of an administrative assistant or practice manager (p < 0.05) or paramedical support staff (p < 0.01). Other practice and country characteristics were not significantly associated with undertaking outreach work. Policy and financial interventions supporting general practices to organize outreach work should focus on the range of personnel available to support such practice activities.

The Response of Emergency Departments (EDs) to the COVID-19 Pandemic: The Experience of 5 EDs in a Paris-Based Academic Hospital Trust

The coronavirus disease-2019 (COVID-19) pandemic has imposed unforeseen and unprecedented constraints on emergency departments (EDs). In this study, we detail the organizational and managerial tools recently implemented among 5 academic EDs in a French region particularly affected by COVID-19 and analyze how EDs responded to the COVID-19-related disease burden during different phases of the epidemic. Initially, they focused on the early detection of suspected cases by identifying 3 predominant COVID-19 syndromes. During this diagnostic process, patients were placed in respiratory isolation (facial mask before triage) and droplet isolation (ED rooms). A 3-level strategy for triage, clinical pathways in the EDs, and the organization of hospital spaces was based on the real-time polymerase chain reaction (RT-PCR) COVID-19 positivity rate, with ED strategies adapted to the exigencies of each level. This crisis demonstrated hospitals' adaptability and capacity to mobilize in the face of new risks, with hospitals and EDs coordinating their management to reallocate resources, optimize interoperability, and rethink patient pathways. This report on their processes may assist hospitals and EDs in areas currently spared by the new variants.

Impact of the COVID-19 pandemic on perceived access and quality of care in German people with parkinsonism

Due to the heterogeneous clinical presentation, people with Parkinsonism (PwP) develop individual healthcare needs as their disease progresses. However, because of limited health resources during the COVID-19 pandemic, many patients were put at risk of inadequate care. All this occurred in the context of inequitable healthcare provision within societies, especially for such vulnerable populations. This study aimed to investigate factors influencing satisfaction and unmet need for healthcare among PwP during the COVID-19 pandemic in Germany. Analyses relied on an anonymous online survey with a 49-item questionnaire. We aimed at describing access to health services before and during the early stages of the pandemic. To this end, a generalized linear model was used to derive significant predictors and a stepwise regression to subsummarize the main factors of perceived inadequate care. In total, 551 questionnaires showed that satisfaction with Parkinsonism-related care decreased significantly during the pandemic (p < 0.001). In particular, factors such as lower educational level, lower perceived expertise of healthcare providers, less confidence in remote care, difficulties in obtaining healthcare, and restricted access to care before the pandemic but also lower densities of neurologists at residence and less ability to overcome barriers were indicative of higher odds to perceive unmet needs (p < 0.05). The results unveil obstacles contributing to reduced access to healthcare during the COVID-19 pandemic for PwP. These findings enable considerations for improved provision of healthcare services to PwP.

The impact of the COVID-19 pandemic on healthcare access and utilisation in South Sudan: a cross-sectional mixed methods study

BACKGROUND

Indirect effects of the COVID-19 pandemic on communities in fragile and conflict-affected settings may be severe due to reduced access and use of healthcare, as happened during the 2015 Ebola Virus Disease outbreak. Achieving a balance between short-term emergency response and addressing long-term health needs is particularly challenging in fragile and conflict-affected settings such as South Sudan, given the already significant barriers to accessing healthcare for the population. This study sought to characterise the effect of COVID-19 on healthcare access and South Sudan's healthcare response. This can inform efforts to mitigate the potential impacts of COVID-19 or other epidemiological threats, and contribute to understanding how these may be balanced for greater health system resilience in fragile contexts.

METHODS

We conducted a mixed methods study in three of South Sudan's states, combining data from a cross-sectional quantitative household survey with qualitative interviews and Focus Group Discussions.

RESULTS

Even though some fears related to COVID-19 were reported, we found these did not greatly dissuade people from seeking care and do not yield significant consequences for health system programming in South Sudan. The pillars of the response focused on risk communication and community engagement were effective in reaching communities through different channels. Respondents and participants reported behaviour changes that were in line with public health advice. We also found that the implementation of COVID-19 response activities sometimes created frictions between the national government and international health actors, and that COVID-19 caused a greater reliance on, and increased responsibility for, international donors for health planning.

CONCLUSIONS

Given the fact that global priorities on COVID-19 are greatly shifting, power dynamics between international health agencies and the national government may be useful to consider in further COVID-19 planning, particularly for the vaccine roll-out. South Sudan must now navigate a period of transition where COVID-19 vaccine roll-out continues and other domestic health burdens are re-prioritised.

The impact of COVID-19 on an Irish Emergency Department (ED): a cross-sectional study exploring the factors influencing ED utilisation prior to and during the pandemic from the patient perspective

BACKGROUND

The collateral damage of SARS-CoV-2 is a serious concern in the Emergency Medicine (EM) community, specifically in relation to delayed care increasing morbidity and mortality in attendances unrelated to COVID-19. The objectives of this study are to describe the profile of patients attending an Irish ED prior to, and during the pandemic, and to investigate the factors influencing ED utilisation in this cohort.

METHODS

This was a cross-sectional study with recruitment at three time-points prior to the onset of COVID-19 in December 2019 (n = 47) and February 2020 (n = 57) and post-Lockdown 1 in July 2020 (n = 70). At each time-point all adults presenting over a 24 h period were eligible for inclusion. Clinical data were collected via electronic records and a questionnaire provided information on demographics, healthcare utilisation, service awareness and factors influencing the decision to attend the ED. Data analysis was performed in SPSS and included descriptive and inferential statistics.

RESULTS

The demographic and clinical profile of patients across time-points was comparable in terms of age (p = 0.904), gender (p = 0.584) and presenting complaint (p = 0.556). Median length of stay in the ED decreased from 7.25 h (IQR 4.18-11.22) in February to 3.86 h (IQR 0.41-9.14) in July (p ≤ 0.005) and differences were observed in disposition (p ≤ 0.001). COVID-19 influenced decision to attend the ED for 31% of patients with 9% delaying presentation. Post-lockdown, patients were less likely to attend the ED for reassurance (p ≤ 0.005), for a second opinion (p ≤ 0.005) or to see a specialist (p ≤ 0.05).

CONCLUSIONS

Demographic and clinical presentations of ED patients prior to the first COVID-19 lockdown and during the reopening phase were comparable, however, COVID-19 significantly impacted health-seeking behaviour and operational metrics in the ED at this phase of the pandemic. These findings provide useful information for hospitals with regard to pandemic preparedness and also have wider implications for planning of future health service delivery.

Long-Term Impact of COVID-19 on Hospital Visits of Rural Residents in Guangdong, China: A Controlled Interrupted Time Series Study

To date, there is a lack of comprehensive understanding regarding the effect of coronavirus disease 2019 (COVID-19) on the healthcare-seeking behavior and utilization of health services in rural areas where healthcare resources are scarce. We aimed to quantify the long-term impact of COVID-19 on hospital visits of rural residents in China. We collected data on the hospitalization of all residents covered by national health insurance schemes in a county in southern China from April 2017 to March 2021. We analyzed changes in residents' hospitalization visits in different areas, i.e., within-county, out-of-county but within-city, and out-of-city, via a controlled interrupted time series approach. Subgroup analyses based on gender, age, hospital levels, and ICD-10 classifications for hospital visits were examined. After experiencing a significant decline in hospitalization cases after the COVID-19 outbreak in early 2020, the pattern of rural residents' hospitalization utilization differed markedly by disease classification. Notably, we found that the overall demand for hospitalization utilization of mental and neurological illness among rural residents in China has been suppressed during the pandemic, while the utilization of inpatient services for other common chronic diseases was redistributed across regions. Our findings suggest that in resource-poor areas, focused strategies are urgently needed to ensure that people have access to adequate healthcare services, particularly mental and neurological healthcare, during the COVID-19 pandemic.

[Open data for monitoring COVID-19 in Spain: descriptive study]

BACKGROUND

The indicators of the pandemic have been based on the total number of diagnosed cases of COVID-19, the number of people hospitalized or in intensive care units, and deaths from the infection. The aim of this study is to describe the available data on diagnostic tests, health service used for the diagnosis of COVID-19, case detection and monitoring.

METHOD

Descriptive study with review of official data available on the websites of the Spanish health councils corresponding to 17 Autonomous Communities, 2 Autonomous cities and the Ministry of Health. The variables collected refer to contact tracing, technics for diagnosis, use of health services and follow-up.

RESULTS

all regions of Spain show data on diagnosed cases of COVID-19 and deaths. Hospitalized cases and intensive care admissions are shown in all regions except the Balearic Islands. Diagnostic tests for COVID-19 have been registered in all regions except Madrid region and Extremadura, with scarcely information on what type of test has been performed (present in 7 CCAA), requesting service and study of contacts.

CONCLUSIONS

The information available on the official websites of the Health Departments of the different regions of Spain are heterogeneous. Data from the use of health service or workload in Primary Care, Emergency department or Out of hours services are almost non-existent.

Long-term spill-over impact of COVID-19 on health and healthcare of people with non-communicable diseases: a study protocol for a population-based cohort and health economic study

INTRODUCTION

The COVID-19 pandemic has a significant spill-over effect on people with non-communicable diseases (NCDs) over the long term, beyond the direct effect of COVID-19 infection. Evaluating changes in health outcomes, health service use and costs can provide evidence to optimise care for people with NCDs during and after the pandemic, and to better prepare outbreak responses in the future.

METHODS AND ANALYSIS

This is a population-based cohort study using electronic health records of the Hong Kong Hospital Authority (HA) CMS, economic modelling and serial cross-sectional surveys on health service use. This study includes people aged ≥18 years who have a documented diagnosis of diabetes mellitus, hypertension, cardiovascular disease, cancer, chronic respiratory disease or chronic kidney disease with at least one attendance at the HA hospital or clinic between 1 January 2010 and 31 December 2019, and without COVID-19 infection. Changes in all-cause mortality, disease-specific outcomes, and health services use rates and costs will be assessed between pre-COVID-19 and-post-COVID-19 pandemic or during each wave using an interrupted time series analysis. The long-term health economic impact of healthcare disruptions during the COVID-19 pandemic will be studied using microsimulation modelling. Multivariable Cox proportional hazards regression and Poisson/negative binomial regression will be used to evaluate the effect of different modes of supplementary care on health outcomes.

ETHICS AND DISSEMINATION

The study was approved by the institutional review board of the University of Hong Kong, the HA Hong Kong West Cluster (reference number UW 21-297). The study findings will be disseminated through peer-reviewed publications and international conferences.

Collateral impact of the COVID−19 pandemic on the use of healthcare resources among people with disabilities

Objective

We assessed the collateral impact of the COVID−19 pandemic on healthcare service use among people with disabilities.

Methods

We utilized the COVID−19 database from the Korean National Health Insurance Service claims from 2015 until June 2020. We included 5,850 people with disabilities and matched 5,850 without disabilities among those who were neither tested nor diagnosed with COVID−19. We used a quasi–experimental setting with a COVID−19 outbreak as an external event in a difference–difference estimation with matching controls.

Results

Participants with disabilities recorded a larger decrease in the number of claims for total services (2.1 claims per 5 months) upon the COVID−19 pandemic's onset compared to those without disabilities (1.6 claims), and the difference–in–difference estimates were statistically significant (0.46 claims). The decline was driven by outpatient and emergency visits. The extent of the decline was large for the severe disability group overall. By disability type, those with a physical disability showed a statistically significant decline in the number of claims.

Conclusion

The COVID−19 pandemic has had a collateral impact on people with disabilities' use of healthcare services. Continued assessment is needed regarding whether the collateral impact has been sustained or is following a different path.

Unmet Healthcare Needs Predict Depression Symptoms among Older Adults

Risk factors for depression in older adults include significant interpersonal losses, increasing social isolation, and deteriorating physical abilities and health that require healthcare. The effects of unmet healthcare needs on depression in older adults are understudied. This study aimed to analyze the association between unmet healthcare needs and symptoms of depression, sleep, and antidepressant medication while controlling for other significant factors among older adults. For this study, we used a multinational database from The Survey of Health, Ageing and Retirement in Europe (SHARE), containing data of individuals aged 50 and older. The final sample used in this research consisted of 39,484 individuals from 50 to 100 years (mean − 71.15, SD ± 9.19), 42.0 percent of whom were male. Three path models exploring relationships between symptoms of depression at an older age and unmet healthcare needs were produced and had a good model fit. We found that unmet healthcare needs were directly related to depression, activity limitations were related to depression directly and through unmet healthcare needs, whereas financial situation mostly indirectly through unmet healthcare needs. We discuss how depression itself could increase unmet healthcare needs.

The Spill-Over Impact of the Novel Coronavirus-19 Pandemic on Medical Care and Disease Outcomes in Non-communicable Diseases: A Narrative Review

Objectives: The coronavirus-19 (COVID-19) pandemic has claimed more than 5 million lives worldwide by November 2021. Implementation of lockdown measures, reallocation of medical resources, compounded by the reluctance to seek help, makes it exceptionally challenging for people with non-communicable diseases (NCD) to manage their diseases. This review evaluates the spill-over impact of the COVID-19 pandemic on people with NCDs including cardiovascular diseases, cancer, diabetes mellitus, chronic respiratory disease, chronic kidney disease, dementia, mental health disorders, and musculoskeletal disorders. Methods: Literature published in English was identified from PubMed and medRxiv from January 1, 2019 to November 30, 2020. A total of 119 articles were selected from 6,546 publications found. Results: The reduction of in-person care, screening procedures, delays in diagnosis, treatment, and social distancing policies have unanimously led to undesirable impacts on both physical and psychological health of NCD patients. This is projected to contribute to more excess deaths in the future. Conclusion: The spill-over impact of COVID-19 on patients with NCD is just beginning to unravel, extra efforts must be taken for planning the resumption of NCD healthcare services post-pandemic.

Experiences and concerns of health workers throughout the first year of the COVID-19 pandemic in the UK: A longitudinal qualitative interview study

OBJECTIVE

To identify the experiences and concerns of health workers (HWs), and how they changed, throughout the first year of the COVID-19 pandemic in the UK.

METHODS

Longitudinal, qualitative study with HWs involved in patient management or delivery of care related to COVID-19 in general practice, emergency departments and hospitals. Participants were identified through snowballing. Semi-structured telephone or video interviews were conducted between February 2020 and February 2021, audio-recorded, summarised, and transcribed. Data were analysed longitudinally using framework and thematic analysis.

RESULTS

We conducted 105 interviews with 14 participants and identified three phases corresponding with shifts in HWs' experiences and concerns. (1) Emergency and mobilisation phase (late winter-spring 2020), with significant rapid shifts in responsibilities, required skills, and training, and challenges in patient care. (2) Consolidation and preparation phase (summer-autumn 2020), involving gradual return to usual care and responsibilities, sense of professional development and improvement in care, and focus on learning and preparing for future. (3) Exhaustion and survival phase (autumn 2020-winter 2021), entailing return of changes in responsibilities, focus on balancing COVID-19 and non-COVID care (until becoming overwhelmed with COVID-19 cases), and concerns about longer-term impacts of unceasing pressure on health services. Participants' perceptions of COVID-19 risk and patient/public attitudes changed throughout the year, and tiredness and weariness turned into exhaustion.

CONCLUSIONS

Results showed a long-term impact of the COVID-19 pandemic on UK HWs' experiences and concerns related to changes in their roles, provision of care, and personal wellbeing. Despite mobilisation in the emergency phase, and trying to learn from this, HWs' experiences seemed to be similar or worse in the second wave partly due to many COVID-19 cases. The findings highlight the importance of supporting HWs and strengthening system-level resilience (e.g., with resources, processes) to enable them to respond to current and future demands and emergencies.

Forgoing healthcare during the COVID-19 pandemic in Geneva, Switzerland - A cross-sectional population-based study

BACKGROUND

Health systems around the world continue to navigate through operational challenges surfaced by the coronavirus disease 2019 (COVID-19) pandemic; these have implications for access to healthcare. In this study, we estimate the prevalence and reasons for forgoing healthcare during the pandemic in Geneva, Switzerland; a country with a universal and mandatory private health insurance coverage.

METHODS

Participants from a randomly selected population-based sample of the adult population living in the Canton of Geneva completed an online socio-demographic and lifestyle questionnaire between November 2020 and January 2021. The prevalence and reasons for forgoing healthcare since the beginning of the COVID-19 pandemic were examined descriptively, and logistic regression models were used to assess determinants for forgoing healthcare.

RESULTS

The study included 5397 participants, among which 8.0% reported having forgone healthcare since the beginning of the COVID-19 pandemic; participants with a disadvantaged financial situation (OR = 2.04; 95% CI: 1.56-2.65), and those reporting an average (OR = 2.54; 95% CI: 1.94-3.31) or poor health (OR = 4.40; 95% CI: 2.39-7.67) were more likely to forgo healthcare. The most common reasons to forgo healthcare were appointment cancellations by healthcare providers (53.9%), fear of infection (35.3%), and personal organizational issues (11.1%).

CONCLUSION

Our paper highlights the effects of the COVID-19 pandemic on access to healthcare and identifies population sub-groups at-risk for forgoing healthcare. These results necessitate public health efforts to ensure equitable and accessible healthcare as the COVID-19 pandemic continues.

How did general practices organize care during the COVID-19 pandemic: the protocol of the cross-sectional PRICOV-19 study in 38 countries

BACKGROUND

General practitioners (GPs) play a crucial role in the fight against the COVID-19 pandemic as the first point of contact for possibly infected patients and are responsible for short and long-term follow-up care of the majority of COVID-19 patients. Nonetheless, they experience many barriers to fulfilling this role. The PRICOV-19 study investigates how GP practices in 38 countries are organized during the COVID-19 pandemic to guarantee safe, effective, patient-centered, and equitable care. Also, the shift in roles and tasks and the wellbeing of staff members is researched. Finally, PRICOV-19 aims to study the association with practice- and health care system characteristics. It is expected that both characteristics of the GP practice and health care system features are associated with how GP practices can cope with these challenges. This paper describes the protocol of the study.

METHODS

Using a cross-sectional design, data are collected through an online questionnaire sent to GP practices in 37 European countries and Israel. The questionnaire is developed in multiple phases, including a pilot study in Belgium. The final version includes 53 items divided into six sections: patient flow (including appointments, triage, and management for routine care); infection prevention; information processing; communication; collaboration and self-care; and practice and participant characteristics. In the countries where data collection is already finished, between 13 and 636 GP practices per country participated in the study. Questionnaire data are linked with OECD and HSMR data regarding national policy responses to the pandemic and analyzed using multilevel models considering the system- and practice-level.

DISCUSSION

To the best of our knowledge, the PRICOV-19 study is the largest and most comprehensive study that examines how GP practices function during the COVID-19 pandemic. Its results can significantly contribute to better preparedness of primary health care systems across Europe for future major outbreaks of infectious diseases.

Lockdown and non-COVID-19 deaths: cause-specific mortality during the first wave of the 2020 pandemic in Norway: a population-based register study

OBJECTIVE

To explore the potential impact of the first wave of COVID-19 pandemic on all cause and cause-specific mortality in Norway.

DESIGN

Population-based register study.

SETTING

The Norwegian cause of Death Registry and the National Population Register of Norway.

PARTICIPANTS

All recorded deaths in Norway from March to May from 2010 to 2020.

MAIN OUTCOME MEASURES

Rate (per 100 000) of all-cause mortality and causes of death in the European Shortlist for Causes of Death from March to May 2020. The rates were age standardised and adjusted to a 100% register coverage and compared with a 95% prediction interval (PI) from linear regression based on corresponding rates for 2010-2019.

RESULTS

113 710 deaths were included, of which 10 226 were from 2020. We did not observe any deviation from predicted total mortality. There were fewer than predicted deaths from chronic lower respiratory diseases excluding asthma (11.4, 95% PI 11.8 to 15.2) and from other non-ischaemic, non-rheumatic heart diseases (13.9, 95% PI 14.5 to 20.2). The death rates were higher than predicted for Alzheimer's disease (7.3, 95% PI 5.5 to 7.3) and diabetes mellitus (4.1, 95% PI 2.1 to 3.4).

CONCLUSIONS

There was no significant difference in the frequency of the major causes of death in the first wave of the 2020 COVID-19 pandemic in Norway compared with corresponding periods 2010-2019. There was an increase in diabetes mellitus and Alzheimer's deaths. Reduced mortality due to some heart and lung conditions may be linked to infection control measures.

Trends in presentations to a private emergency department during the first and second waves of the COVID-19 pandemic in Australia

Objective The COVID-19 pandemic in Australia coincided with an early trend of reduced visits to the emergency department (ED), but to determine which patients presented less requires closer evaluation. Identifying which patient groups are presenting less frequently will provide a better understanding of health care utilisation behaviours during a pandemic and inform healthcare providers of the potential challenges in managing these groups. Methods This single-centre retrospective study examined trends in presentations in 2020 to a private, mixed paediatric and adult ED in an inner city suburb within the state of Victoria that treats both COVID-19 and non-COVID-19 patients. The 2019 dataset was used as a reference baseline for comparison. All analyses were performed using baseline characteristics and triage data. Results The total number of visits to the ED dropped from 24 775 in 2019 to 22 754 in 2020, representing an overall reduction of 8%. Significant reductions in daily presentations and admissions from the ED were observed in the months immediately following the peak of the two COVID-19 waves in the state of Victoria. Visits by those in the 0- to 17-year age group, triage categories 4 and 5 and musculoskeletal presentations were also reduced for most of 2020. Gastrointestinal/abdominal and urological/renal presentations were reduced immediately after the first COVID-19 wave, whereas infectious diseases visits were reduced during and after the second COVID-19 wave. Conclusions These findings add to the growing body of evidence regarding emergency care underutilisation during the COVID-19 pandemic. Reduced private ED presentations were observed overall and in paediatric patients, lower acuity triage categories, musculoskeletal, abdominal/gastrointestinal and urological/renal presentations during the first wave, whereas infectious disease cases were reduced during the second wave. What is known about the topic? During the first and second waves of COVID-19 in Victoria, ED visits were reduced in the public sector across all diagnostic categories and all triage categories. The effect of the COVID-19 pandemic on private ED attendance is less well known. What does this paper add? Total visits to the private ED during the first and second waves of COVID-19 were reduced across all major diagnostic categories except cardiac presentations. During this same period, visits for triage categories 4 and 5 were significantly reduced. What are the implications for practitioners? ED underutilisation during the initial two waves of the COVID-19 pandemic is apparent in both the private and public sector. Patients should be encouraged not to delay seeking urgent medical care during the pandemic.

Effect of the First Wave of the Belgian COVID-19 Pandemic on Physician-Provided Prehospital Critical Care in the City of Antwerp (Belgium)

INTRODUCTION

There is evidence to suggest that patients delayed seeking urgent medical care during the first wave of the coronavirus disease 2019 (COVID-19) pandemic. A delay in health-seeking behavior could increase the disease severity of patients in the prehospital setting. The combination of COVID-19-related missions and augmented disease severity in the prehospital environment could result in an increase in the number and severity of physician-staffed prehospital interventions, potentially putting a strain on this highly specialized service.

STUDY OBJECTIVE

The aim was to investigate if the COVID-19 pandemic influences the frequency of physician-staffed prehospital interventions, prehospital mortality, illness severity during prehospital interventions, and the distribution in the prehospital diagnoses.

METHODS

A retrospective, multicenter cohort study was conducted on prehospital charts from March 14, 2020 through April 30, 2020, compared to the same period in 2019, in an urban area. Recorded data included demographics, prehospital diagnosis, physiological parameters, mortality, and COVID-status. A modified National Health Service (NHS) National Early Warning Score (NEWS) was calculated for each intervention to assess for disease severity. Data were analyzed with univariate and descriptive statistics.

RESULTS

There was a 31% decrease in physician-staffed prehospital interventions during the period under investigation in 2020 as compared to 2019 (2019: 644 missions and 2020: 446 missions), with an increase in prehospital mortality (OR = 0.646; 95% CI, 0.435 - 0.959). During the study period, there was a marked decrease in the low and medium NEWS groups, respectively, with an OR of 1.366 (95% CI, 1.036 - 1.802) and 1.376 (0.987 - 1.920). A small increase was seen in the high NEWS group, with an OR of 0.804 (95% CI, 0.566 - 1.140); 2019: 80 (13.67%) and 2020: 69 (16.46%). With an overall decrease in cases in all diagnostic categories, a significant increase was observed for respiratory illness (31%; P = .004) and cardiac arrest (54%; P < .001), combined with a significant decrease for intoxications (-58%; P = .007). Due to the national test strategy at that time, a COVID-19 polymerase chain reaction (PCR) result was available in only 125 (30%) patients, of which 20 (16%) were positive.

CONCLUSION

The frequency of physician-staffed prehospital interventions decreased significantly. There was a marked reduction in interventions for lower illness severity and an increase in higher illness severity and mortality. Further investigation is needed to fully understand the reasons for these changes.

Delays in Presentation Time Under the COVID-19 Epidemic in Patients With Transient Ischemic Attack and Mild Stroke: A Retrospective Study of Three Hospitals in a Japanese Prefecture

Background: Coronavirus Disease 2019 (COVID-19) has spread worldwide with collateral damage and therefore might affect the behavior of stroke patients with mild symptoms seeking medical attention.

Methods: Patients with ischemic stroke who were admitted to hospitals within 7 days of onset were retrospectively registered. The clinical characteristics, including onset-to-door time (ODT), of patients with a transient ischemic attack (TIA)/mild stroke (National Institutes of Health Stroke Scale [NIHSS] score of ≤ 3 on admission) or moderate/severe stroke were compared between those admitted from April 2019 to March 2020 (pre-COVID-19 period) and from April to September 2020 (COVID-19 period). Multivariable regression analysis was performed to identify factors associated with the ODT.

Results: Of 1,100 patients (732 men, median age, 73 years), 754 were admitted during the pre-COVID-19 period, and 346 were admitted during the COVID-19 period. The number and proportion of patients with TIA/minor stroke were 464 (61.5%) in the pre-COVID-19 period and 216 (62.4%) during the COVID-19 period. Among patients with TIA/mild stroke, the ODT was longer in patients admitted during the COVID-19 period compared with that of the pre-COVID-19 period (median 864 min vs. 508 min, p = 0.003). Multivariable analysis revealed the COVID-19 period of admission was associated with longer ODT (standardized partial regression coefficient 0.09, p = 0.003) after adjustment for age, sex, route of arrival, NIHSS score on admission, and the presence of hypertension, diabetes mellitus, and wake-up stroke. No significant change in the ODT was seen in patients with moderate/severe stroke.

Conclusions: The COVID-19 epidemic might increase the ODT of patients with TIA/mild stroke.

The Impact of the COVID-19 Pandemic on Medical Imaging Case Volumes in Aseer Region: A Retrospective Study

COVID-19 has had a significant impact on global health systems. The aim of this study was to evaluate how imaging volumes and imaging types in radiology departments have been affected by the COVID-19 pandemic across different locations. Methods: Imaging volumes in the Aseer region (in the south of Saudi Arabia) across main hospitals were reviewed retrospectively including all cases referred from different locations (outpatient, inpatient and emergency departments). Data for years 2019 and 2020 were compared. The mean monthly cases were compared using a t-test. Results: The total imaging volumes in 2019 were 205,805 compared to 159,107 in 2020 with a 22.7% overall reduction. A substantial decline was observed in both the April to June and the July to September periods of approximately 42.9% and 44.4%, respectively. With respect to location, between April and June, the greatest decline was observed in outpatient departments (76% decline), followed by emergency departments (25% decline), and the least impact was observed in inpatient departments, with only 6.8% decline over the same period. According to modality type, the greatest decreases were reported in nuclear medicine, ultrasound, MRI, and mammography, by 100%, 76%, 74%, and 66%, respectively. Our results show a statistically significant (p-value ≤ 0.05) decrease of cases in 2020 compared to 2019, except for mammography procedures. Conclusion: There has been a significant decline in radiology volumes due to COVID-19. The overall reduction in radiology volumes was dependent on the stage/period of lockdown, location, and imaging modality.

Coronavirus Disease 2019

In this article, the authors review manifestations of COVID-19 in older adults, normal physiologic changes and frequent comorbidities of aging that increase pathogenicity, factors contributing to overwhelming viral spread among seniors, negative effects on health and well-being resulting from measures to control the virus, and health-system improvements necessary to protect and care for this vulnerable population.

Resuming Dental and Craniomaxillofacial Surgical Missions During the COVID-19 Pandemic: Guidelines and Recommendations

Study Design

Descriptive review article.

Objective

The purpose of this article is to provide guidelines and recommendations for how to safely resume dental and craniomaxillofacial STSMs. The following considerations will be discussed: the need for extensive collaboration between organizations and local leadership, the importance of COVID-19 testing, use and management of personal protective equipment, team selection and training, social distancing protocols, and criteria for patient and case selection.

Methods

A literature review was completed, identifying resources and current data regarding the safe resumption clinical activities during the COVID-19 pandemic.

Results

At this time, there are no protocols developed regarding the safe resumption of STSMs. Primary resources, including the CDC, WHO, and FDA should be closely monitored so that developed protocols from these recommendations reflect the latest information.

Conclusion

This paper outlines general considerations and recommendations for dentists, oral health specialists, and craniomaxillofacial surgeons seeking to safely resume STSMs. These recommendations are designed to minimize the risk of exposure to COVID-19 by reinforcing social distancing protocols, reviewing criteria for patient and case selections, encouraging collaboration between organizations and local leadership, and team training. These guidelines should be tailored to fit the needs of each individual mission while keeping the safety as the main objective.

The impact of the COVID-19 pandemic on paediatric emergency service

AIMS

The aims of this research were to review patients visiting the paediatric emergency department over a 6-month period 1 year before and during the pandemic, to review paediatric emergency department referral ratios and to determine whether there were any significant decreases in mortality and morbidity.

METHODS

All patients from the ages of 0 to 18 years visiting the University of Health Sciences, Ankara Research and Training Hospital, paediatric emergency service from April-October 2019 to April-October 2020 with no missing information in their records were involved in this retrospective cross-sectional study.

RESULTS

The total number of paediatric emergency service consultations was 74 739; the number of emergency visits from April to October 2019 was 55 678, whereas it was 19 061 from April to October 2020 in the midst of the COVID-19 pandemic period. There was a 67.7% decrease in consultations during the pandemic period. The mean age of participants from April to October 2019 was 8.11 ± 5.31 years, and 52.4% of cases were male. The mean age from April to October 2020 was 8.58 ± 5.93 years, and 51% of cases were male. COVID-19-related symptoms were higher during the pandemic period (P < .05), with fever and gastroenteritis being the most frequently received diagnosis in both periods. During the pandemic period, the newborn consultation ratio was higher (P > .05), there was a decrease in consultation ratios related to suicide attempts (P < .05), and a threefold increase in death rates was observed (P < .05).

CONCLUSION

In Turkey, where emergency consultation rates are quite high, these decreases look fearsome for secondary injuries that can develop in children. For this reason, families should be made aware of the importance of bringing their children to the hospital during emergencies, and that all necessary health precautions are being taken to decrease the spread of infection in hospitals.

Vulnerable patients forgo health care during the first wave of the Covid-19 pandemic

During the first wave of the Covid-19 pandemic, access to health care was limited, and patients encountered important delays for scheduled appointments and care. Empirical data relying on patients' reports of forgoing health care are scarce. This study investigated Covid-19-related self-reports of forgoing health care in a sample of vulnerable outpatients in Geneva, Switzerland. We collected data from 1167 adult outpatients, including clinically vulnerable patients (with chronic diseases), geriatric patients (involved in a health care network for people aged 60 or older), and socially vulnerable patients (involved in a migrant health program or a mobile outpatient community care center) in June 2020. Data on sociodemographic factors, forgoing health care, and anti-SARS-CoV-2 antibodies were collected. Of the patients, 38.5% reported forgoing health care. Forgoing health care was more frequent for younger patients, women, patients with a low level of education, and patients with a chronic disease (p < .001). There was no significant association between the presence of anti-SARS-CoV-2 antibodies and forgoing health care (p = .983). As the decrease in routine management of patients might have important and unpredictable adverse health consequences, avoiding delayed health care is crucial.

Impact of COVID-19 on ischemic stroke care in Hungary

Data about the coronavirus disease 2019 (COVID-19) pandemic’s collateral damage on ischemic stroke (IS) care during the second epidemic wave in Central Europe are limited. We sought to evaluate the impact of the COVID-19 outbreak on Hungarian IS care during the two epidemic waves. This retrospective observational study was based on a nationwide reimbursement database that encompasses all IS admissions and all reperfusion interventions, i.e., intravenous thrombolysis (IVT) and endovascular therapy (EVT) from 2 January 2017 to 31 December 2020 in Hungary. COVID-19 pandemic’s effect on the number of IS admissions and reperfusion interventions were analyzed using different statistics: means, medians, trends, relative rates, and linear relationships. The mean and median values of IS admissions and reperfusion interventions decreased only in some measure during the COVID-periods. However, trend analysis demonstrated a significant decline from the trends. The decline’s dynamic and amplitude have differed for each variable. In contrast to IVT, the number of IS admissions and EVTs negatively correlated with the epidemic waves’ amplitude. Besides, the decrease in the number of IS admissions was more pronounced than the decrease in the number of reperfusion interventions. Our study demonstrated a significant disruption in IS care during the COVID-19 epidemic in Hungary, in which multiple different factors might play a role. The disproportionate reduction of IS admission numbers could partially be explained by the effect of health emergency operative measures and changes in patients’ social behavior. Further studies are needed to evaluate the causes of our observations.

Trends of follow-up clinic visits and admissions three-months before and during COVID-19 pandemic at Tikur Anbessa specialized hospital, Addis Ababa, Ethiopia: an interrupted time series analysis

BACKGROUND

Following the first report of the COVID-19 case in Ethiopia on March 13, 2020, the country promptly adopted a lockdown policy to contain the virus's spread. Responding to the healthcare burden imposed by the COVID-19 pandemic had to be coupled with ensuring essential health care services. This study assessed the impact of COVID-19 on the trends in hospital visits and admissions at Tikur Anbessa Specialized Hospital by comparing the rate of follow-up clinic visits and admissions for the 3 months before and after the first report of the COVID-19 case.

METHODS

A retrospective, time-series study examined the trend in follow-up visits and admissions between December 11, 2019, to June 7, 2020, with the 1st case of the COVID-19 report in Ethiopia (March 13, 2020) as a reference time. To control seasonal effects and random fluctuation, we have compared health care utilization to its equivalent period in 2018/19. A data extraction tool was used to collect secondary data from each unit's electronic medical recordings and logbooks.

RESULTS

A total of 7717 visits from eight follow-up clinics and 3310 admissions were collected 3 months before the onset of COVID-19. During the following 3 months after the onset of the pandemic, 4597 visits and 2383 admissions were collected. Overall, a 40.4% decrease in follow-up visits and a 28% decline in admissions were observed during the COVID-19 pandemic. A drop in the daily follow-up visits was observed for both genders. The number of visits in all follow-up clinics in 2019/2020 decreased compared to the same months in 2018/19 (p < 0.05). Follow-up visits were substantially lower for renal patients (- 68%), patients with neurologic problems (- 53.9%), antiretroviral treatment clinics (- 52.3%), cardiac patients (- 51.4%). Although pediatric emergency admission was significantly lower (- 54.1%) from the baseline (p = 0.04), admissions from the general pediatric and adult wards did not show a significant difference.

CONCLUSIONS

A decline in follow-up clinic visits and emergency admissions was observed during the first months of the COVID-19 pandemic. This will increase the possibility of avoidable morbidity and mortality due to non-COVID-19-related illnesses. Further studies are needed to explore the reasons for the decline and track the pandemic's long-term effects among non-COVID-19 patients.

Assessment of Referrals and Hospitalizations in the Hospital Transformed into COVID-19 Facility in Poland during the "Spring Wave" of the Epidemic in 2020-A Cross-Sectional Study

The study aimed to evaluate hospitalizations in a COVID-dedicated facility during the "spring wave" of the epidemic in 2020 in Poland and analyze changes in access to hospital treatment in the country in the early phase of the pandemic. We investigated all referrals and admissions to the Ministry of Interior and Administration hospital in Białystok from 14 April to 14 August 2020. A total of 238 patients were referred to the hospital (with a median age of 64.5 years; IQR, 44-78), most commonly with fever (n = 151; 63.5%). Only 135 (56.7%) were admitted (5.5% of the number hospitalized in the same period in 2019). SARS-CoV-2 was confirmed in 42 (17.7%) cases. Older people with concomitant diseases and disabilities dominated. Seventeen patients (12.6%) required ICU treatment, and 19 (14%) died. Based on the National Health Fund data, we also examined changes in the rate of hospitalizations in Poland and in selected Polish COVID/ and non-COVID hospitals between February and August 2019 and 2020. The number of hospitalizations in Poland decreased dramatically in comparison to 2019. A very low hospitalization rate, significantly lower than in structurally similar non-COVID hospitals, was observed in transformed hospitals. Better use of hospital resources was observed when the hospital was semi-transformed and had the flexibility to adapt to epidemiological needs. The study seems to confirm that the system of transformed COVID hospitals resulted in unused healthcare resources and limited patient access to medical services in the early period of the epidemic. As a consequence, systemic modifications allowing the maximization and adequate use of the Polish healthcare system's limited resources have been implemented.

How Can Health Systems Better Prepare for the Next Pandemic? Lessons Learned From the Management of COVID-19 in Quebec (Canada)

The magnitude of the COVID-19 pandemic challenged societies around our globalized world. To contain the spread of the virus, unprecedented and drastic measures and policies were put in place by governments to manage an exceptional health care situation while maintaining other essential services. The responses of many governments showed a lack of preparedness to face this systemic and global health crisis. Drawing on field observations and available data on the first wave of the pandemic (mid-March to mid-May 2020) in Quebec (Canada), this article reviewed and discussed the successes and failures that characterized the management of COVID-19 in this province. Using the framework of Palagyi et al. on system preparedness toward emerging infectious diseases, we described and analyzed in a chronologically and narratively way: (1) how surveillance was structured; (2) how workforce issues were managed; (3) what infrastructures and medical supplies were made available; (4) what communication mechanisms were put in place; (5) what form of governance emerged; and (6) whether trust was established and maintained throughout the crisis. Our findings and observations stress that resilience and ability to adequately respond to a systemic and global crisis depend upon preexisting system-level characteristics and capacities at both the provincial and federal governance levels. By providing recommendations for policy and practice from a learning health system perspective, this paper contributes to the groundwork required for interdisciplinary research and genuine policy discussions to help health systems better prepare for future pandemics.

Nationwide study on trends in unplanned hospital attendance and deaths during the 7 weeks after the onset of the COVID-19 pandemic in Denmark

BACKGROUND

The impact of a pandemic on unplanned hospital attendance has not been extensively examined. The aim of this study is to report the nationwide consequences of the COVID-19 pandemic on unplanned hospital attendances in Denmark for 7 weeks after a 'shelter at home' order was issued.

METHODS

We merged data from national registries (Civil Registration System and Patient Registry) to conduct a study of unplanned (excluding outpatient visits and elective surgery) hospital-based healthcare and mortality of all Danes. Using data for 7 weeks after the 'shelter at home' order, the incidence rate of unplanned hospital attendances per week in 2020 was compared with corresponding weeks in 2017-2019. The main outcome was hospital attendances per week as incidence rate ratios. Secondary outcomes were general population mortality and risk of death in-hospital, reported as weekly mortality rate ratios (MRRs).

RESULTS

From 2 438 286 attendances in the study period, overall unplanned attendances decreased by up to 21%; attendances excluding COVID-19 were reduced by 31%; non-psychiatric by 31% and psychiatric by 30%. Out of the five most common diagnoses expected to remain stable, only schizophrenia and myocardial infarction remained stable, while chronic obstructive pulmonary disease exacerbation, hip fracture and urinary tract infection fell significantly. The nationwide general population MRR rose in six of the recorded weeks, while MRR excluding patients who were COVID-19 positive only increased in two.

CONCLUSION

The COVID-19 pandemic and a governmental national 'shelter at home' order was associated with a marked reduction in unplanned hospital attendances with an increase in MRR for the general population in two of 7 weeks, despite exclusion of patients with COVID-19. The findings should be taken into consideration when planning for public information campaigns.

Impact of COVID-19 Pandemic on the Implantation of Intra-Cardiac Devices in Diabetic and Non-Diabetic Patients in the Western of Romania

Background and Objectives: COVID-19 pandemic severely impacted public health services worldwide, determining a significant decrease of elective cardiovascular (CV) procedures, especially in patients with associated chronic diseases such as diabetes mellitus (DM). Materials and Methods: This study was first started in 2019 in the western of Romania, to analyze the differences regarding the implantations of intra-cardiac devices such as permanent pacemakers (PPM), cardiac resynchronization therapy (CRT), or implantable cardioverter-defibrillators (ICD) in 351 patients with and without DM and the situation was reanalyzed at the end of 2020. Results: of the first 351 patients with and without DM. 28.20% of these patients had type 2 DM (p = 0.022), exceeding more than twice the prevalence of DM in the general population (11%). Patients with DM were younger (p = 0.022) and required twice as often CRT (p = 0.002) as non-diabetic patients. The state of these procedures was reanalyzed at the end of 2020, a dramatic decrease of all new device implantations being observed, both in non-diabetic and in patients with type 2 DM (79.37%, respectively 81.82%). Conclusions: COVID-19 pandemic determined a drastic decrease, with around 75% reduction of all procedures of new intra-cardiac devices implantation, both in non-diabetics, this activity being reserved mostly for emergencies.

Medical Care Disruptions During the First Six-Months of the COVID19 Pandemic: The Experience of Older Breast Cancer Survivors

Purpose.

Older cancer survivors required medical care during the COVID-19 pandemic despite infection risks, but there are limited data on medical care in this age group.

Methods.

We evaluated care disruptions in a longitudinal cohort of non-metastatic breast cancer survivors ages 60–98 from five US regions (n=321). Survivors completed a web-based or telephone survey from May 27, 2020 to September 11, 2020. Care disruptions included self-reported interruptions in ability to see doctors, receive treatment or supportive therapies, or fill prescriptions. Logistic regression models evaluated bivariate and multivariate associations between care disruptions and education, medical, psychosocial and COVID-19-related factors. Multivariate models included age, county COVID-19 rates, comorbidity and post-diagnosis time.

Results.

There was a high response rate (n=262, 81.6%). Survivors were 32.2 months post-diagnosis (SD 17.5, range 4–73). Nearly half (48%) reported a medical disruption. The unadjusted odds of care disruptions were significantly higher with more education (OR 1.23 per one-year increase, 95% CI 1.09–1.39, p =0.001) and greater depression (OR 1.04 per one-point increase in CES-D score, CI 1.003–1.08, p=0.033); tangible support decreased the odds of disruptions (OR 0.99, 95% CI 0.97–0.99 per one-point increase, p=0.012). There was a trend for associations between disruptions and comorbidity (unadjusted OR 1.13 per 1 added comorbidity, 95% CI 0.99–1.29, p=0.07). Adjusting for covariates, only higher education (p=0.001) and tangible social support (p=0.006) remained significantly associated with having care disruptions.

Conclusions.

Older breast cancer survivors reported high rates of medical care disruptions during the COVID-19 pandemic and psychosocial factors were associated with care disruptions.

Care for the chronically ill in Germany - The challenges during the COVID-19 pandemic

The COVID-19 pandemic is posing major challenges to the health care sector. This scoping review compiles evidence concerning changes to health care service availability and utilisation as well as possible impacts on health for selected groups of chronically ill people in Germany. The focus is on cancer, cardiovascular diseases, diabetes mellitus and mental disorders. Most empirical data available concerned inpatient care and showed a clear decline in the utilisation of inpatient treatments in March and April 2020 in the areas of oncology and cardiology as well as in mental health. For cardiovascular emergencies such as heart attack and stroke, a decline was observed especially regarding less serious cases. Although there were indications of treatment delays, there was no evidence thus far that emergency care had been generally compromised due to adjustments to inpatient care capacities. In the outpatient setting, extensive adjustments to health care services availability were observed for all disease groups considered. Overall, very limited empirical data were available. In particular, hardly any data were available on how changes in care impacted population health. There is an urgent need for continuous surveillance and evaluation based on health care and epidemiological data.

Development of a Model to Estimate the Association Between Delay in Cancer Treatment and Local Tumor Control and Risk of Metastases

IMPORTANCE

The coronavirus disease 2019 (COVID-19) pandemic has led to treatment delays for many patients with cancer. While published guidelines provide suggestions on which cases are appropriate for treatment delay, there are no good quantitative estimates on the association of delays with tumor control or risk of new metastases.

OBJECTIVES

To develop a simplified mathematical model of tumor growth, control, and new metastases for cancers with varying doubling times and metastatic potential and to estimate tumor control probability (TCP) and metastases risk as a function of treatment delay interval.

DESIGN, SETTING, AND PARTICIPANTS

This decision analytical model describes a quantitative model for 3 tumors (ie, head and neck, colorectal, and non-small cell lung cancers). Using accepted ranges of tumor doubling times and metastatic development from the clinical literature from 2001 to 2020, estimates of tumor growth, TCP, and new metastases were analyzed for various treatment delay intervals.

MAIN OUTCOMES AND MEASURES

Risk estimates for potential decreases in local TCP and increases in new metastases with each interval of treatment delay.

RESULTS

For fast-growing head and neck tumors with a 2-month treatment delay, there was an estimated 4.8% (95% CI, 3.4%-6.4%) increase in local tumor control risk and a 0.49% (0.47%-0.51%) increase in new distal metastases risk. A 6-month delay was associated with an estimated 21.3% (13.4-30.4) increase in local tumor control risk and a 6.0% (5.2-6.8) increase in distal metastases risk. For intermediate-growing colorectal tumors, there was a 2.1% (0.7%-3.5%) increase in local tumor control risk and a 2.7% (2.6%-2.8%) increase in distal metastases risk at 2 months and a 7.6% (2.2%-14.2%) increase in local tumor control risk and a 24.7% (21.9%-27.8%) increase in distal metastases risk at 6 months. For slower-growing lung tumors, there was a 1.2% (0.0%-2.8%) increase in local tumor control risk and a 0.19% (0.18%-0.20%) increase in distal metastases risk at 2 months, and a 4.3% (0.0%-10.6%) increase in local tumor control risk and a 1.9% (1.6%-2.2%) increase in distal metastases risk at 6 months.

CONCLUSIONS AND RELEVANCE

This study proposed a model to quantify the association of treatment delays with local tumor control and risk of new metastases. The detrimental associations were greatest for tumors with faster rates of proliferation and metastasis. The associations were smaller, but still substantial, for slower-growing tumors.

Inégalités sociales de santé et médecine d’urgence

En France, le système de santé est basé sur un principe d’universalité et les indicateurs macroscopiques y sont satisfaisants. Toutefois, des inégalités de santé persistent touchant particulièrement les populations vulnérables. Celles-ci peuvent voir s’ériger des barrières financières, institutionnelles ou cognitives qui entravent leur accès aux soins et participent à l’altération de leur état de santé. L’exercice de la médecine d’urgence n’est pas exempté des problématiques soulevées par ces inégalités sociales de santé qu’il s’agisse : du rôle des services d’urgence dans la sanctuarisation de l’accès aux soins ; des pathologies urgentes plus fréquentes ou plus graves observées parmi les populations les plus vulnérables ; de la qualité des soins administrés qui est parfois suboptimale. La première partie de cet article indique ce qui définit la vulnérabilité d’une population puis il présente les spécificités des prises en charge aux urgences. Il détaille ensuite les barrières à l’accès aux soins qui persistent ainsi que les répercussions du renoncement sur le recours aux services d’urgence. Enfin, l’exemple du contexte actuel de la pandémie du Sars-Cov2 permet de mettre en lumière les nombreuses interactions qui existent entre vulnérabilité et état de santé. Les questions de l’organisation de l’offre de soins en amont des urgences et des conditions réelles de son accessibilité pour tous sont des éléments fondamentaux qui impactent la pratique de la médecine d’urgence. Il appartient aussi aux professionnels de s’en saisir et de mobiliser avec force les décideurs publics sur ces sujets.

Medical care disruptions during the first six months of the COVID-19 pandemic: the experience of older breast cancer survivors

PURPOSE

Older cancer survivors required medical care during the COVID-19 pandemic, but there are limited data on medical care in this age group.

METHODS

We evaluated care disruptions in a longitudinal cohort of non-metastatic breast cancer survivors aged 60-98 from five US regions (n = 321). Survivors completed a web-based or telephone survey from May 27, 2020 to September 11, 2020. Care disruptions included interruptions in seeing or speaking to doctors, receiving medical treatment or supportive therapies, or filling prescriptions since the pandemic began. Logistic regression models evaluated associations between care disruptions and education, medical, psychosocial, and COVID-19-related factors. Multivariate models included age, county COVID-19 death rates, comorbidity, and post-diagnosis time.

RESULTS

There was a high response rate (n = 262, 81.6%). Survivors were 32.2 months post-diagnosis (SD 17.5, range 4-73). Nearly half (48%) reported a medical disruption. The unadjusted odds of care disruptions were higher with each year of education (OR 1.22, 95% CI 1.08-1.37, p =  < 0.001) and increased depression by CES-D score (OR 1.04, CI 1.003-1.08, p = 0.033) while increased tangible support decreased the odds of disruptions (OR 0.99, 95% CI 0.97-0.99, p = 0.012). There was a trend between disruptions and comorbidities (unadjusted OR 1.13 per comorbidity, 95% CI 0.99-1.29, p = 0.07). Adjusting for covariates, higher education years (OR1.23, 95% CI 1.09-1.39, p = 0.001) and tangible social support (OR 0.98 95% CI 0.97-1.00, p = 0.006) remained significantly associated with having care disruptions.

CONCLUSION

Older breast cancer survivors reported high rates of medical care disruptions during the COVID-19 pandemic and psychosocial factors were associated with care disruptions. CLINICALTRIALS.

GOV IDENTIFIER

NCT03451383.

Impact of a shelter-in-place order during the COVID-19 pandemic on the incidence of opioid overdoses

Introduction

Since the beginning of the novel coronavirus (COVID-19) pandemic in the United States, there have been concerns about the potential impact of the pandemic on persons with opioid use disorder. Shelter-in-place (SIP) orders, which aimed to reduce the spread and scope of the virus, likely also impacted this patient population. This study aims to assess the role of the COVID-19 pandemic on the incidence of opioid overdose before and after a SIP order.

Methods

A retrospective review of the incidence of opioid overdoses in an urban three-hospital system was conducted. Comparisons were made between the first 100 days of a city-wide SIP order during the COVID-19 pandemic and the 100 days during the COVID-19 pandemic preceding the SIP order (Pre-SIP). Differences in observed incidence and expected incidence during the SIP period were evaluated using a Fisher's Exact test.

Results

Total patient visits decreased 22% from 46,078 during the Pre-SIP period to 35,971 during the SIP period. A total of 1551 opioid overdoses were evaluated during the SIP period, compared to 1665 opioid overdoses during the Pre-SIP period, consistent with a 6.8% decline. A Fisher's Exact Test demonstrated a p < 0.0001, with a corresponding Odds Ratio of 1.20 with a 95% confidence interval (1.12;1.29).

Conclusion

The COVID-19 pandemic and the associated SIP order were associated with a statistically and clinically significant increase in the proportion of opioid overdoses in relation to the overall change in total ED visits.