Impact of COVID-19 on emergency department attendance in an Australia hospital: a parallel convergent mixed methods study

Emergency department staff opinion on newly introduced phlebotomy services in the department. A cross-sectional study incorporating thematic analysis

OBJECTIVES

The demand for ED services, both in terms of patient numbers and complexity has risen over the past decades. According to reports, there has been an increase in the ED patient presentation rate from 330 per 1000 to 334 per 1000 between 2018-2019 and 2022-2023. Consequently, new care models have been introduced to address this surge in demand, mitigate associated risks and improve overall safety. Among these models is the concept of 'front loading' clinical care, involving the initiation of interventions at the point of arrival. The present study evaluates the impact of introducing phlebotomists at triage.

METHODS

We conducted a cross-sectional survey using purposive sampling at a single quaternary metropolitan ED with an annual census of greater than 90 000, encompassing all clinical staff in the ED. The survey data were analysed quantitatively and complemented by a thematic analysis.

RESULTS

The response rate for the questionnaire was 61% (n = 207), with good representation from all ED craft groups. Nearly all the staff (99.5%) reported being aware of the presence of phlebotomists in the ED, whereas only 57% of the staff reported working in triage (P = 0.05, 0.00 to 0.04). 'Valuable/vital resource' featured as a common response. Early decision-making, patient safety, staff and patient satisfaction emerged as consistent themes.

CONCLUSIONS

Staff expressed satisfaction that patient care now begins in the waiting room, especially after extended waiting periods prior to cubicle allocation. They assert that this improvement significantly enhances timely treatment and disposition decisions, as well as overall patient satisfaction.

Impact of the COVID-19 pandemic on hospital-based heart failure care in New South Wales, Australia: a linked data cohort study

BACKGROUND

Healthcare policy implemented during the COVID-19 pandemic may have impacted the health of patients with heart failure. Australian data provide a unique opportunity to examine service disruption independent of significant COVID-19 burden. This study aimed to examine heart failure care during the pandemic in New South Wales (NSW).

METHODS

Analysis of hospital utilisation among patients aged ≥ 18 years with a primary diagnosis of heart failure conducted using linked administrative health records from hospital admission, emergency department, non-admitted services, and mortality data collections. Health service utilisation and outcomes were compared "Pre-pandemic" (PP): 16th March 2018 - 28th August 2019 and "During pandemic" (DP): 16th March 2020 - 28th August 2021. Mortality data were available until December 2021.

RESULTS

Heart failure-related ED presentations and hospital admissions were similar between the periods (PP = 15,324 vs DP = 15,023 ED presentations, PP = 24,072 vs DP = 23,145 hospital admissions), though rates of admission from ED were lower DP (PP = 12,783/15,324 (83.4% [95% CI 82.8-84.0]) vs DP = 12,230/15,023 (81.4% [95% CI 80.8-82.0%]). There was no difference according to age, sex, rurality, or socioeconomic status. Outpatient volume reduced DP (PP = 44,447 vs DP = 35,801 occasions of service), but telehealth visits increased nearly threefold (PP = 5,978/44,447 (13.4% [95% CI 13.1-13.8%]) vs DP = 15,901/35,801 (44.4% [95% CI 43.9-44.9%]) with highest uptake among the wealthy and those in major cities. Time to heart failure-related ED presentation, hospitalisation or all-cause mortality following index admission was longer DP (PP = 273 [IQR 259, 290] days, DP = 323 [IQR 300, 342] days, HR 0.91 [95% CI 0.88, 0.95]).

CONCLUSIONS

Policies implemented DP had minimal impact on volumes of inpatient heart failure care in NSW hospitals, but there were fewer admissions from ED and reduced volumes of publicly funded outpatient care. A rapid shift from patient-facing to remotely delivered care enabled compliance with restrictions and was associated with increased time to heart failure-related adverse events, but access was not afforded equally across the socio-demographic spectrum.

Benefits of emergency department routine blood test performance on patients whose allocated triage category is not time critical: a retrospective study

INTRODUCTION

Emergency department clinicians, and particularly nurses in triage, frequently perform routine blood tests on patients whose allocated triage category is not time critical (triage categories 3, 4 and 5 of the Australasian Triage Scale). Some observers have questioned the utility of routine blood testing in these acute healthcare settings given the cost and workload implications.

METHODS

A quantitative method using retrospective observational design was utilised guided by STROBE checklist. Electronic medical records of patient data collected at a quaternary Australian metropolitan hospital emergency department were reviewed.

RESULTS AND DISCUSSION

A total of 74,878 adult patients attended the emergency department between 1st January and 31st December 2021 and a sample of 383 were randomly allocated for this study. Of the 383 patients included, 51% were female, age ranges were 18-99 years (mean 51.6). The majority were Australasian Triage scale (ATS) triage category 3 (55%) and 62% had blood tests performed. Blood test performance was found to be associated with advancing age (p < 0.001) but not with department occupancy as determined by the national emergency department overcrowding scale (p = 0.230).

CONCLUSION

Blood testing in the emergency department in triaged non-time critical patients was found to be frequent thereby affecting nurses' already stretched time resource. Older patients were found to be more likely to have a blood test. There is a positive correlation between blood test performance and length of stay in the emergency department.

Disparities by sex, race, and region in acute myocardial infarction-related outcomes during the early COVID-19 pandemic: the national inpatient sample analysis

BACKGROUND

Disparities in acute myocardial infarction (AMI)-related outcomes have been reported before the COVID-19 pandemic. We studied in-hospital outcomes of AMI across demographic groups in the United States during the early COVID-19 pandemic.

METHODS

The National Inpatient Sample (NIS) database was queried for 2020 to identify AMI-related hospitalizations based on appropriate ICD-10-CM codes categorized by sex, race, and hospital region categories. The primary outcome was in-hospital mortality in females, racial and ethnic minority groups, and Northeast hospital region compared with males, White patients, and Midwest hospital region, respectively. Multivariable regression analysis was used to calculate the adjusted odds ratio and mean difference.

RESULTS

A total of 820,893 AMI-related hospitalizations were identified during the study period. On adjusted analysis, during the early COVID-19 pandemic, females had lower odds of in-hospital mortality [aOR 0.89 (0.85-0.92); P < 0.01] and revascularization [aOR 0.68 (0.66-0.69); P < 0.01] than males. Racial and ethnic based analysis showed that Asian/Pacific Islander patients had higher odds of in-hospital mortality [aOR 1.13 (1.03-1.25); P < 0.01] than White patients. During the early COVID-19 pandemic, Northeast and Western region hospitals had higher odds of in-hospital mortality, lower odds of revascularization, longer length of stay, and higher total hospitalization costs than Midwest region hospitals.

CONCLUSIONS

Our study disclosed disparities in AMI-related mortality and revascularization by sex, race and ethnic, and region during the early COVID-19 pandemic. Special attention should be given to at-risk populations. Whether these disparities continue in the post-vaccination era warrants further study.

The impact of COVID-19 on emergency department presentations for mental health disorders in Queensland, Australia: A time series analysis

BACKGROUND

The COVID-19 pandemic has been associated with detrimental effects on mental health and psychological well-being. Although multiple studies have shown decreases in mental health-related Emergency Department (ED) presentations early in the COVID-19 pandemic, the medium-term effects on mental health-related ED presentations have remained less clear. This study aimed to evaluate the effect of the pandemic on mental health ED presentations by comparing observed presentation numbers to predictions from pre-pandemic data.

METHODS

This retrospective cohort study tallied weekly ED presentations associated with mental health disorders from a state-wide minimum dataset. Three time periods were identified: Pre-Pandemic (January 1, 2018-March 8, 2020), Statewide Lockdown (March 9, 2020-June 28, 2020), and Restrictions Easing (June 29, 2020-June 27, 2021). Time series analysis was used to generate weekly presentation forecasts using pre-pandemic data. Observed presentation numbers were compared to these forecasts.

RESULTS

Weekly presentation numbers were lower than predicted in 11 out of 16 weeks in the Statewide Lockdown period and 52 out of 52 weeks in the Restrictions Easing period. The largest decrease was seen for anxiety disorders (Statewide Lockdown: 76.8% of forecast; Restrictions Easing: 36.4% of forecast), while an increase was seen in presentations for eating disorders (Statewide Lockdown: 139.5% of forecast; Restrictions Easing: 194.4% of forecast).

CONCLUSIONS

Overall weekly mental health-related presentations across Queensland public EDs were lower than expected for the first 16 months of the COVID-19 pandemic. These findings underline the limitations of emergency department provision of mental health care and the importance of alternate care modalities in the pandemic context.

Acute care pathway assessed through performance indicators during the COVID-19 pandemic in OECD countries (2020-2021): a scoping review

BACKGROUND

The COVID-19 pandemic severely impacted care for non-COVID patients. Performance indicators to monitor acute care, timely reported and internationally accepted, lacked during the pandemic in OECD countries. This study aims to summarize the performance indicators available in the literature to monitor changes in the quality of acute care in OECD countries during the first year and a half of the pandemic (2020-July 2021) and to assess their trends.

METHODS

Scoping review. Search in Embase and MEDLINE (07-07-2022). Acute care performance indicators and indicators related to acute general surgery were collected and collated following a care pathway approach. Indicators assessing identical clinical measures were grouped under a common indicator title. The trends from each group of indicators were collated (increase/decrease/stable).

RESULTS

A total of 152 studies were included. 2354 indicators regarding general acute care and 301 indicators related to acute general surgery were included. Indicators focusing on pre-hospital services reported a decreasing trend in the volume of patients: from 225 indicators, 110 (49%) reported a decrease. An increasing trend in pre-hospital treatment times was reported by most of the indicators (n = 41;70%) and a decreasing trend in survival rates of out-of-hospital cardiac arrest (n = 61;75%). Concerning care provided in the emergency department, most of the indicators (n = 752;71%) showed a decreasing trend in admissions across all levels of urgency. Concerning the mortality rate after admission, most of the indicators (n = 23;53%) reported an increasing trend. The subset of indicators assessing acute general surgery showed a decreasing trend in the volume of patients (n = 50;49%), stability in clinical severity at admission (n = 36;53%), and in the volume of surgeries (n = 14;47%). Most of the indicators (n = 28;65%) reported no change in treatment approach and stable mortality rate (n = 11,69%).

CONCLUSION

This review signals relevant disruptions across the acute care pathway. A subset of general surgery performance indicators showed stability in most of the phases of the care pathway. These results highlight the relevance of assessing this care pathway more regularly and systematically across different clinical entities to monitor disruptions and to improve the resilience of emergency services during a crisis.

Using machine learning to mine mental health diagnostic groups from emergency department presentations before and during the COVID-19 pandemic

PURPOSE

The COVID-19 pandemic had a profound negative effect on mental health worldwide. The hospital emergency department plays a pivotal role in responding to mental health crises. Understanding data trends relating to hospital emergency department usage is beneficial for service planning, particularly around preparing for future pandemics. Machine learning has been used to mine large volumes of unstructured data to extract meaningful data in relation to mental health presentations. This study aims to analyse trends in five mental health-related presentations to an emergency department before and during, the COVID-19 pandemic.

METHODS

Data from 690,514 presentations to two Australian, public hospital emergency departments between April 2019 to February 2022 were assessed. A machine learning-based framework, Mining Emergency Department Records, Evolutionary Algorithm Data Search (MEDREADS), was used to identify suicidality, psychosis, mania, eating disorder, and substance use.

RESULTS

While the mental health-related presentations to the emergency department increased during the COVID-19 pandemic compared to pre-pandemic levels, the proportion of mental health presentations relative to the total emergency department presentations decreased. Several troughs in presentation frequency were identified across the pandemic period, which occurred consistently during the public health lockdown and restriction periods.

CONCLUSION

This study implemented novel machine learning techniques to analyse mental health presentations to an emergency department during the COVID-19 pandemic. Results inform understanding of the use of emergency mental health services during the pandemic, and highlight opportunities to further investigate patterns in presentation.

Impact of COVID-19 state-wide lockdown on older adult presentations to Queensland emergency departments

OBJECTIVE

To determine the impact of the COVID-19 state-wide lockdown on ED presentations for older adults in Queensland, Australia.

METHODS

A retrospective cohort study pertaining to adults aged 70+ years who presented to Queensland public hospital EDs across three separate time periods; 11 March to 30 June 2018 and 2019 (pre-pandemic average), 2020 (COVID-19 state-wide lockdown) and 2021 (post-state-wide lockdown). The primary outcome was change in presentation rates to ED. Secondary outcomes included change in triage category rates, length of stay (LOS), diagnosis and disposition.

RESULTS

There was 380 854 older adult presentations. During the COVID-19 state-wide lockdown, ED presentation rates decreased by 12.5% (incidence rate ratio 0.875 [95% confidence interval 0.867-0.883]). All triage category presentation rates decreased, as did ED LOS and reasons for presentation, except sepsis and disorders of the nervous system. In the post-state-wide lockdown period a 22% (incidence rate ratio 1.22 [95% confidence interval 1.21-1.23]) increase in the presentation rate was observed and presentations in all triage categories increased. ED LOS increased to longer than pre-pandemic (P < 0.001). Respiratory presentations increased by 346%. Patients who 'did not wait' increased by 212% and ED mortality rose by 42% compared to during the lockdown.

CONCLUSION

There was a significant decrease in presentation rates to EDs during the COVID-19 state-wide lockdown for the older population, followed by an increase in presentation rates, longer ED LOS, and an increased ED mortality rate, in the post-state-wide lockdown period. It is important to ensure older adults continue to seek appropriate, timely medical care, during a pandemic.

Effective communication of COVID-19 vaccine information to recently-arrived culturally and linguistically diverse communities from the perspective of community engagement and partnership organisations: a qualitative study

BACKGROUND

In many high-income countries, COVID-19 has disproportionately impacted Culturally and Linguistically Diverse (CALD) communities. Barriers to engaging with essential health messaging has contributed to difficulties in following public health advice and exacerbated existing inequity in Australia. Research suggests that recently-arrived CALD populations are particularly vulnerable to misinformation and are more likely to experience vaccine hesitancy. The aim of this study was to explore the barriers and enablers to COVID-19 vaccination among recently-arrived CALD communities in Melbourne's outer north and identify strategies to reduce hesitancy in this population.

METHODS

Semi-structured interviews were conducted with representatives from community organisations working with recently-arrived CALD communities in Melbourne's north. This included a mix of peer (from the community) and health care workers.

RESULTS

Fifteen participants from community organisations participated in interviews. Thematic analysis identified four themes; (1) trusted sources, (2) accurate and culturally sensitive information, (3) supported pathways and (4) enablers to vaccination.

CONCLUSIONS

Participants reported a perceived lack of accurate, culturally sensitive health information and service provision as key barriers to vaccination in recently-arrived CALD communities. Participants identified a range of perceived enablers to increasing vaccination uptake in the communities they work with, including utilising established channels of communication and harnessing the communities' strong sense of collective responsibility. Specific strategies to reduce vaccine hesitancy included identifying and utilising trusted sources (e.g. faith leaders) to disseminate information, tailoring health messages to address cultural differences, providing opportunities to contextualise information, and modifying service delivery to enhance cultural sensitivity. There is an urgent need for increased efforts from health and government agencies to build sustainable, collaborative relationships with CALD communities.

Frequent hospital presenters' use of health information during COVID-19: results of a cross-sectional survey

BACKGROUND

High-frequency hospital users often present with chronic and complex health conditions and are at increased risk of serious morbidity and mortality if they contract COVID-19. Understanding where high-frequency hospital users are sourcing their information, whether they understand what they find, and how they apply the information to prevent the spread of COVID-19 is essential for health authorities to be able to target communication approaches.

METHODS

Cross-sectional survey of 200 frequent hospital users (115 with limited English proficiency) informed by the WHO's "Rapid, simple, flexible behavioral insights on COVID-19". Outcome measures were source of, and trust in information, and knowledge of symptoms, preventive strategies, restrictions, and identification of misinformation.

RESULTS

The most frequently cited source of information was television (n = 144, 72%) followed by the internet (n = 84, 42%). One in four television users sought their information from overseas news outlets from their country of origin, while for those using the internet, 56% relied on Facebook and other forms of social media including YouTube and WeChat. Overall, 41.2% of those surveyed had inadequate knowledge about symptoms, 35.8% had inadequate knowledge about preventative strategies, 30.2% had inadequate knowledge about government-imposed restrictions, and 69% believed in misinformation. Half of the respondents (50%) trusted all information, and only one in five (20%) were uncertain or untrusting. English-speaking participants were almost three times more likely to have adequate knowledge about symptoms (OR 2.69, 95%CI 1.47;4.91) and imposed restrictions (OR 2.10 95%CI 1.06; 4.19), and 11 times more likely to recognize misinformation (OR 11.52 95%CI 5.39; 24.60) than those with limited English.

CONCLUSION

Within this population of high-frequency hospital users with complex and chronic conditions, many were sourcing their information from less trustworthy or locally relevant sources, including social media and overseas news outlets. Despite this, at least half were trusting all the information that they found. Speaking a language other than English was a much greater risk factor for having inadequate knowledge about COVID-19 and believing in misinformation. Health authorities must look for methods to engage diverse communities, and tailor health messaging and education in order to reduce disparities in health outcomes.

Job Satisfaction of Health Practitioners Providing Outreach Health Services during COVID-19 in Rural New South Wales (NSW) and the Australian Capital Territory (ACT), Australia

Background: Outreach health practitioners play a key role in enhancing access to healthcare for remote, rural, regional, and Aboriginal and Torres Strait Islander communities in Australia. Outreach health practitioners are those providing ongoing and integrated health services in communities that would otherwise have limited access. In the context of the COVID-19 pandemic, it is important to understand the job satisfaction of health workers as it correlates with long-term retention of the workforce, as well as effectiveness in the role and clinical outcomes for patients. Method: The study analysed data from 258 outreach health practitioners who responded to two cross-sectional surveys conducted by the NSW Rural Doctors Network during the COVID-19 pandemic in 2020/21 and 2021/22 in NSW and the ACT, Australia. Both bivariate and multivariate analyses were employed to assess the associations between the outcome variable (outreach health practitioners' job satisfaction) and independent variables (sociodemographic factors, motivation, self-confidence, communication, capability). Results: Overall, the study showed that 92.2% of health practitioners were satisfied in their role providing outreach health services during the COVID-19 pandemic. In the multivariable model, factors significantly associated with higher satisfaction included good communication with other local health practitioners, using telehealth along with in-person care, and having high self-rated capability compared to those health practitioners who said they had lower job satisfaction. Conclusions: Outreach health practitioners' job satisfaction is important because poor satisfaction may lead to suboptimal healthcare delivery, poor clinical outcomes, and poor retention of staff in rural settings. These findings should be taken into consideration when developing future strategies to improve job satisfaction among rural outreach health practitioners and to enhance attraction, recruitment and retention and may be applicable to the broader health workforce.

Structured evaluation of a virtual emergency department triage model of care: A study protocol

OBJECTIVE

A new virtual ED service was introduced into a hospital network in the northern suburbs of Melbourne in response to changing needs during the COVID-19 pandemic. The 'virtual ED' utilises a telehealth model as a means of assessment for appropriately selected patients to facilitate either complete care or navigation into streamlined pathways for ongoing care, in some cases bypassing the ED entirely where appropriate. The proposed study aims to evaluate the implementation of the model and identify future improvement opportunities, assess the impact on traditional health service delivery processes and patient experience, and determine the acceptability of the 'virtual ED' model of care.

METHODS

The present study will consist of a pre-post- implementation evaluation using the RE-AIM framework. Routine health service data will be collected for 6 months post-implementation of the virtual ED model and compared to 24 months prior to implementation. Prospective data will be collected using routinely collected and survey data. Interviews and focus groups will be conducted to understand consumer and clinician perspectives on barriers and enablers to implementation and adoption of the virtual ED.

RESULTS

Descriptive statistics will be used to describe the study population and key outcomes, including changes in ED presentations and length of stay. Thematic analysis will be conducted on transcribed interviews and focus group data. This will be triangulated with data collected from patient feedback surveys.

CONCLUSION

This project will support the delivery of care to ED patients by evaluating the 'virtual ED' model of care.

Management of acute appendicitis during the COVID-19 pandemic: a retrospective cohort study

BACKGROUND

The Coronavirus Disease 2019 (COVID-19) pandemic profoundly impacted delivery of health care. South Western Sydney Local Health District (SWSLHD) experienced some of the highest cases, admissions and deaths during the Delta and Omicron waves in New South Wales. This study aims to determine the impact of the pandemic on emergency surgery services for adults presenting with acute appendicitis.

METHODS

A retrospective review of patient records was performed of adults presenting with acute appendicitis between 1st March 2021 and 31st March 2022, which was compared to a pre-COVID control period of the same dates in 2019-2020. Patients managed operatively or conservatively were included.

RESULTS

1556 patients were included in the operative arm; 723 and 833 respectively in the study and control groups, which were comparable at baseline. 1.66% were COVID positive. During the pandemic, patients were significantly more likely to be investigated with computered tomography (CT) scan (p ≤ 0.001), present with complicated appendicitis (p = 0.03), and require caecectomy (p = 0.005). They had higher American Society of Anaesthesiology (ASA) scores (p = 0.001) and significantly lower negative appendectomy rates (p = 0.001). Fifty-two patients were included in the conservative arm; 29 and 23 respectively in the pandemic and control groups. Patients were comparable at baseline. There were two COVID positive patients. During the pandemic, there was a significant reduction in complications (p = 0.033), readmissions (0.044) and interval appendicectomy (p = 0.0044).

CONCLUSION

We identified higher rates of complicated appendicitis, caecectomies and greater reliance on CT imaging preoperatively during the pandemic in SWSLHD.

Staff and patient experience of the implementation and delivery of a virtual health care home monitoring service for COVID-19 in Melbourne, Australia

BACKGROUND

Provision of virtual health care (VHC) home monitoring for patients who are experiencing mild to moderate COVID-19 illness is emerging as a central strategy for reducing pressure on acute health systems. Understanding the enablers and challenges in implementation and delivery of these programs is important for future implementation and re-design. The aim of this study was to explore the perspectives of staff involved with the implementation and delivery, and the experience of patients managed by, a VHC monitoring service in Melbourne, Australia during the COVID-19 pandemic.

METHODS

A descriptive qualitative approach informed by naturalist inquiry was used. Staff interviews were analysed using the Consolidated Framework for Implementation Research (CFIR). Patient experience was captured using a survey and descriptive statistics were used to describe categorical responses while content analysis was used to analyse free text responses as they related to the CFIR. Finally, data from the interviews and patient experience were triangulated to see if patient experience validated data from staff interviews.

RESULTS

All 15 staff were interviewed, and 271 patients were surveyed (42%). A total of four final overarching themes emerged: service implementation enablers, service delivery benefits for patients, fragmentation of care, and workforce strengths. 19 subthemes aligned with 18 CFIR constructs from staff and patient data.

CONCLUSION

Rapid implementation was enabled through shared resources, dividing implementation tasks between senior personnel, engaging furloughed healthcare staff in design and delivery, and having a flexible approach that allowed for ongoing improvements. Benefits for patients included early identification of COVID-19 deterioration, as well as provision of accurate and trustworthy information to isolate safely at home. The main challenges were the multiple agencies involved in patient monitoring, which may be addressed in the future by attributing responsibility for monitoring to a single agency.

Healthcare Avoidance before and during the COVID-19 Pandemic among Australian Youth: A Longitudinal Study

BACKGROUND

Access to healthcare for young people is essential to ensure they can build a foundation for a healthy life. However, during the COVID-19 pandemic, many people avoided seeking healthcare, adversely affecting population health. We investigated the factors associated with the avoidance of healthcare for Australian young people when they reported that they needed healthcare. We were able to compare healthcare avoidance during the COVID-19 pandemic with healthcare avoidance prior to COVID-19.

METHODS

We used two recent data collection waves from the Longitudinal Study of Australian Children (LSAC)-Wave 9C1 during the COVID-19 pandemic in 2020, and Wave 8 data which were collected in 2018. The primary outcome of this study revealed the avoidance of healthcare among those who perceived the need for care. Bivariate analyses and multiple logistic regression models were employed to identify the factors associated with the avoidance of healthcare during the COVID-19 and pre-COVID-19 periods.

RESULTS

In the sample of 1110 young people, 39.6% avoided healthcare during the first year of the COVID-19 pandemic even though they perceived that they had a health problem that required healthcare. This healthcare avoidance was similar to the healthcare avoidance in the pre-COVID-19 pandemic period (41.4%). The factors most strongly associated with healthcare avoidance during the COVID-19 pandemic were female gender, an ongoing medical condition, and moderately high psychological distress. In comparison, prior to the pandemic, the factor associated with healthcare avoidance was only psychological distress. The most common reason for not seeking healthcare was thinking that the problem would spontaneously resolve itself (55.9% during COVID-19 vs. 35.7% pre-COVID-19 pandemic).

CONCLUSIONS

A large proportion of youths avoided healthcare when they felt they needed to seek care, both during and before the COVID-19 pandemic.