Non-COVID-19 patients in times of pandemic: Emergency department visits, hospitalizations and cause-specific mortality in Northern Italy

Healthcare utilization among Japanese older adults during later stage of prolonged pandemic

This study examines healthcare utilization patterns among Japan's older population (aged 75 and above) during a prolonged public health emergency, focusing on the later phase of the COVID-19 pandemic (November 2021-September 2022). This period was characterized by the Omicron variant, widespread vaccination coverage, and adapted public health measures. Using a comprehensive dataset of 189,841,257 medical claims linked with income tax records, we analyze how healthcare utilization correlates with public health measures, pandemic severity, and income levels. Our findings reveal distinct utilization patterns: moderate decreases in healthcare visits during periods of public health measures, with the association between pandemic severity and healthcare use varying based on whether these measures are in place. Despite fluctuations in visit frequency, healthcare costs remain stable, indicating consistent service intensity. While income-related differences in general healthcare access are modest, dental care shows more pronounced socioeconomic variations. These patterns suggest a transition from initial widespread healthcare avoidance to more stable healthcare engagement, indicating adaptation to prolonged crisis conditions. Our findings provide insights for maintaining healthcare access during extended public health emergencies, particularly in aging societies where balancing healthcare needs with public health measures is crucial.

Impact of physician group practice in the operations, quality of care, and service satisfaction in the non-urgent section of an emergency department in a tertiary hospital in the Philippines: a mixed methods study

BACKGROUND

The Emergency Department (ED) is a primary source of healthcare services for patients with non-urgent conditions in the Philippines. The adaptation of physician group practice (GP) in the ED has gained popularity in the country due to its potential advantage to patient management and physicians compared to independent consultancy (IC). This study aimed to determine the impacts of GP in a non-urgent ED setting in terms of operations, quality of care, and service satisfaction compared to IC.

METHODS

Historical data collection focusing on operations, service costs, patient outcomes, and satisfaction was performed between 2021 and 2022 at a tertiary for-profit private hospital in Metro Manila, Philippines. In addition, patient surveys on demographics, perception, ED accessibility, and descriptive satisfaction ratings were also administered in 2023 (n = 310). These aspects were compared between patients managed by GP and IC quantitatively using univariate descriptive statistics, Mann-Whitney U tests, and ANCOVA to compare operational metrics, financial data, and patient outcomes. Qualitative data from patient surveys were analyzed using a sequential-explanatory approach.

RESULTS

Our analysis of the historical data showed high rates of positive outcomes for non-urgent ED patients in both GP and IC. Total (PhP587,812 vs. PhP379,699; p < 0.001) and per patient (PhP1,801 vs. PhP554; p < 0.001) operational costs were higher for the GPs. However, GPs incurred shorter mean length of stay (165.5 vs. 214.2 min; p < 0.001). There appears to be no difference in service satisfaction and overall patient outcomes between patients managed by GP or IC, although patients of GP physicians assessed the level of care of the ED to be higher (5 vs. 4; p-value = 0.019). In the quantitative and qualitative ratings, most patients provided positive citations on ED service quality, staff, structure, system, physician competency and compassion.

CONCLUSIONS

While GPs were associated with higher operational costs, they improved the ED efficiency and perceived quality of care without compromising patient outcomes. These findings support GP as a viable alternative model for improving ED operations. However, more research is needed to examine its long-term impacts.

The impact of the COVID-19 pandemic on cardiac related emergency department presentations: A scoping review

BACKGROUND

Acute cardiac conditions require timely assessment and management to optimise patient outcomes. It is important to understand whether changes in acute cardiac ED visits occurred in relation to the COVID-19 pandemic.

OBJECTIVE

To provide a comprehensive synthesis of published articles regarding the impact of the pandemic on acute cardiac-related ED presentations in terms of rates, patient demographics, ED clinical characteristics, and outcomes.

METHODS

A scoping review using the Joanna Briggs Institute methodology was undertaken. Four databases (Ovid MEDLINE, CINAHL, Scopus, and the Public Health Database (ProQuest)) were searched for articles published in English between 1 January 2020 and 30 April 2022 that reported on acute cardiac-related ED presentation rates, comparing COVID-19 pandemic and non-pandemic time periods, for adult patients (18 years and over), and demographics, and/or presentation characteristics, and/or outcomes.

RESULTS

Sixteen articles met the inclusion criteria. There was a significant decline in ED presentations for heart failure and myocardial infarction during 2020. Demographic, presentation characteristics and outcomes were inconsistently reported.

CONCLUSION

While there is variation and heterogeneity in the current available evidence, this data is helpful for informing clinicians and policy makers for future pandemics as well as providing a reference point for COVID-19 related research.

Effects of 24/7 palliative care consultation availability on the use of emergency department and emergency medical services resources from non-oncological patients: a before-and-after observational cohort study

OBJECTIVES

The non-oncological population is relatively under-represented among end-of-life (EOL) patients managed by palliative care (PC) services, and the effects of different PC delivery models are understudied in this population.This retrospective observational study on routinely collected data aimed at evaluating the effects of the extension from workday-only to 24/7 mixed hands-on and advisory home PC service on emergency department (ED) access and emergency medical services (EMS) interventions needed by non-oncological patients during their last 90 days of life, and their probability to die in hospital.

METHODS

A before-and-after design was adopted comparing preimplementation and postimplementation periods (2018-2019 and 2021-22).We used a difference-in-differences approach to estimate changes in ED access and EMS intervention rates in the postintervention period through binomial negative regression. The oncological population, always exposed to 24/7 PC, was used as a control. A robust Poisson regression model was adopted to investigate the differences regarding hospital mortality. The analyses were adjusted for age, sex and disease grouping by the system involved. Results were reported as incidence rate ratios (IRRs) and ORs.

RESULTS

A total of 2831 patients were enrolled in the final analysis.After the implementation of 24/7 home PC, both ED admissions (IRR=0.390, p<0.001) and EMS interventions (IRR=0.413, p<0.001) dropped, as well as the probability to die in hospital (OR=0.321, p<0.001).

CONCLUSIONS

The adoption of a 24/7 mixed hands-on and advisory model of home PC could have relevant effects in terms of ED access and EMS use by non-oncological EOL patients under PC.

TRIAL REGISRATION NUMBER

NCT05640076.

Impact of COVID-19 pandemic on the accuracy of telephone triage of callers with shortness of breath and/or chest discomfort in Dutch out-of-hours primary care: A retrospective observational study

BACKGROUND

Anecdotal reports suggest that missed diagnosis in general practice during the first wave of the COVID-19 pandemic contributed to a drop in life-threatening events (LTEs) detected in hospitals.

OBJECTIVES

To investigate the impact of the COVID-19 pandemic on the accuracy of urgency allocation by telephone triage of patients with shortness of breath and/or chest discomfort in out-of-hours primary care (OHS-PC). Accuracy is defined as the correct allocation of high urgency to patients with LTEs and low urgency to those without.

METHODS

Retrospective observational study with data from callers contacting OHS-PC for shortness of breath and/or chest discomfort, between 1 March and 1 June 2019 (pre-pandemic) and 1 March to 1 June 2020 (first wave COVID-19 pandemic). Sensitivity and specificity of telephone urgency allocation were compared during both periods with LTEs, including acute coronary syndrome, and pulmonary embolism, as the reference.

RESULTS

3,064 adults (1,840 COVID-19 pandemic and 1,224 pre-pandemic, p < 0.001) were included in the study. The sensitivity of urgency allocation was similar during and before the COVID-19 pandemic (0.68, 95% CI 0.59 to 0.75 vs. 0.68, 95% CI 0.60 to 0.75, p = 0.944). Specificity was slightly higher during the COVID-19 pandemic (0.52, 95% CI 0.50 to 0.55 vs. 0.45, 95% CI 0.42 to 0.48, p < 0.001).

CONCLUSION

Despite a surge in calls from adults with shortness of breath and/or chest discomfort during the COVID-19 pandemic, the accuracy of telephone triage for LTEs in OHS-PC remained similar to the pre-pandemic era. Improvement of telephone triage seems necessary in both periods.

Use of Telehealth in Autism Spectrum Disorder Assessment in Children: Evaluation of an Online Diagnostic Protocol Including the Brief Observation of Symptoms of Autism

The COVID-19 pandemic revealed the need to develop the field of remote assessment for autism spectrum disorders (ASD). The purpose of the study was to evaluate an online assessment protocol that includes the Brief Observation of Symptoms of Autism (BOSA). The online protocol consisting of BOSA and the Autism Diagnostic Interview-Revised (ADI-R) was administered by experienced examiners to 29 children with suspected ASD. The participants were then evaluated by clinical psychologists in a standard clinical setting using the Autism Diagnostic Observation Schedule-2 (ADOS-2) and other methods, and the ASD diagnosis was confirmed or ruled out. The results show substantial to moderate inter-rater agreement between the online and face-to-face raters with the value of Cohen's Kappa = 0.66 (P < 0.001); this corresponds with 79.8% agreement. The sensitivity of the protocol was approx. 94.7%, the specificity was 70%, the positive predictive value was 85.7%, and the negative predictive value was 87.5%. Further, direct false positive or false negative diagnostic conclusions based on the online protocol were absent when the possible conclusion of "I cannot decide" was included. The items B9 Showing, B10 Spontaneous Initiation of Joint Attention, B1 Unusual Eye Contact, B3 Facial Expressions Directed to Others, and C2 Imagination/Creativity were shown to be well observable in BOSA when related to ADOS-2 scoring. The results indicate that the protocol consisting of BOSA and ADI-R administered by an experienced examiner is a promising combination of tools for remote autism assessment.

Cause-specific excess mortality in Denmark, Finland, Norway, and Sweden during the COVID-19 pandemic 2020-2022: a study using nationwide population data

While there is substantial evidence on excess mortality in the first two years of the COVID-19 pandemic, no study has conducted a cause-specific analysis of excess mortality for the whole period 2020-2022 across multiple countries. We examined cause-specific excess mortality during 2020-2022 in Denmark, Finland, Norway, and Sweden-four countries with similar demographics and welfare provisions, which implemented different pandemic response policies. To this end, we utilized nationwide register-based information on annual cause-specific deaths stratified by age and sex, and applied linear regression models to predict mortality in 2020-2022 based on the reference period 2010-2019. Excess deaths were obtained by contrasting actual and expected deaths. Additional analyses employed standardization to a common population, as well as population adjustments to account for previous deaths. Our results showed that, besides deaths due to COVID-19 (a total of 32,491 during 2020-2022), all countries experienced excess deaths due to cardiovascular diseases (in total 11,610 excess deaths), and under-mortality due to respiratory diseases other than COVID-19 (in total 9878) and dementia (in total 8721). The excess mortality due to cardiovascular diseases was particularly pronounced in Finland and Norway in 2022, and the under-mortality due to dementia was particularly pronounced in Sweden in 2021-2022. In conclusion, while COVID-19 deaths emerge as the most apparent consequence of the pandemic, our findings suggest that mortality has also been influenced by substitutions between different causes of death and over time, as well as indirect consequences of COVID-19 infection and pandemic responses-albeit to different extents in the different countries.

Impacts of Major Changes in China's COVID-19 Prevention and Control Policies on Emergency Department Visits: A Quasi-Experiment

Objective

This study aims to evaluate the impact of COVID-19 prevention and control policies on the frequency of emergency department (ED) visits in a large tertiary hospital in central China, from January 2018 to September 2023.

Methods

We conducted a multi-stage interrupted time series analysis to investigate the impact of various epidemic control policies on weekly ED visits at a tertiary hospital in Hunan Province, China. The study period ranged from January 1, 2018, to September 30, 2023, and was divided into four distinct periods: pre-epidemic, pandemic, normalized control, and end of control. Using a quasi-Poisson regression model, we examined the specific effects of these policies on emergency visits, with a particular focus on stratifying patients based on respiratory versus non-respiratory diseases.

Results

Compared to the pre-pandemic period, the number of ED visits in a tertiary hospital decreased by 38.5% (95% CI: 25.1% to 49.8%) during the COVID-19 pandemic, of which the number of ED visits for respiratory diseases increased by 79.4% (95% CI: 13.2% to 177.2%) and the number of ED visits for non-respiratory diseases decreased by 45.9% (95% CI: -55.7% to -34.2%). After the end of the epidemic control, the total number of ED visits increased by 31.5% (95% CI: 19.1% to 45.0%), with the number of ED visits for respiratory diseases rising by 379.2% (95% CI: 275.9% to 511.8%), but with no significant change in the number of ED visits for non-respiratory emergencies.

Conclusion

Control policies were associated with people avoiding emergency care for non-respiratory related reasons during the pandemic, while the end of control policies was associated with a sharp rise in emergency care for respiratory diseases. This study provides a scientific basis for the different changes in ED visits under the implementation of varying epidemic prevention and control policies.

Efficiency of hospitals in COVID-19 era: a case study of an affected country

BACKGROUND

The COVID-19 pandemic has affected all aspects of human life and society and has damaged the global economy. Health systems and hospitals were not exempted from this situation. The performance of hospitals during the COVID-19 pandemic was affected by policies related to the pandemic and other factors. This study aimed to investigate hospital performance indicators such as admissions and revenue.

METHODS

The medical records of patients with selected orthopedic and general surgical diseases were studied in two government hospitals in the capital city of Urmia in the second quarter of 2019, with the same period in 2020. Data were extracted based on the number of medical records, including length of stay, hospitalization type, sex, age, insurance, number of deaths, and readmissions from the medical records department. Payment amounts were collected from the revenue department and Hospital Information System. Two performance indicators, two result indicators, and two control indicators were used. Mean disease-specific revenue, total revenue, length of stay, and bed occupancy rate were calculated for both periods. Data were analyzed using SPSS (version 16) and the Mann-Whitney statistical test.

RESULTS

2140 cases were studied in the two disease groups. An increase was observed in the number of hospitalizations and average length of stay during the pandemic. The mean disease-specific revenue in the quarter of 2020 was higher than in 2019. However, total revenue decreased, and the difference in the mean of total revenue was significant for the two years (P = 0.00) in teaching center. The number of readmissions remained unchanged throughout in the pandemic. The number of deaths due to general surgery diseases in 2020 compared to the same period in 2019 was associated with a relative increase.

CONCLUSIONS

The COVID-19 pandemic increased the slope of health care costs. The analysis of the studied variables as performance, result, and control indicators showed that hospitalization rate, bed occupancy rate, and total revenue followed a similar and decreasing pattern in the selected hospitals during the COVID-19 pandemic. Hospitals should adopt appropriate strategies so that, in conditions identical to the COVID-19 pandemic, their performance is accompanied by proper management of resources, efficiency, and minimal reduction in revenue.

The impact of SARS-CoV-2 on emergency health care demand: inverse relationship between COVID-like illnesses and ED accesses in Genoa, Italy

Introduction

SARS-CoV-2 has changed the demand for in-person health care. The aim of this study was to retrospectively analyzed data on access to San Martino Hospital Emergency Department (ED), Genoa, Italy, during the COVID-19 pandemic.

Methods

Descriptive statistics for 180,117 records of patients accessing the ED between 2019 and 2021 were reported. A linear regression model was built to evaluate the relationship between the weekly number of COVID-like illness cases and ED attendances.

Results

In comparison to pre-pandemic levels, the median number of ED visits declined by 41.6% in 2020 and by 27.4% in 2021. The period of maximum drop in access (-61.9%) was the 2020 12-16th calendar weeks and coincided with the highest rates of COVID-like illness cases (+360%; 22.8% of total ED attendances). About 20% of the variation of the weekly number of ED attendances was explained by the number of COVID-like illness cases. In 2020 and 2021 non-urgent ED codes decreased (-6.7%; -7.3%) and both urgent and emergency ED codes increased (+4.8% and +3.9% the first; +1.9% and +3.5% the second). However, the absolute number of ED access fell drastically for all codes. In particular, the highest increase was registered in 2020 for acute respiratory infections (ARI), including COVID-19 (+3.28%), while traumas and eye diseases saw the highest decrease (-1.02%; -3.80%).

Conclusions

While the reduction in non-urgent visits suggests avoidable pre-pandemic access levels, the decline in non-COVID-19 urgent accesses potentially points to an increase in delayed and missed care.

The hidden toll of the pandemic on nonrespiratory patients

While many empirical studies have focused on the health consequences of COVID-19 for infected individuals, little attention has been given to its consequences for patients with nonrespiratory medical conditions. In this study, we apply machine learning and regression analysis techniques to complete-coverage administrative records of inpatient hospitalizations in Italy in 2012-2021 to investigate how the outbreak has impacted on the treatment of nonrespiratory patients in one of the countries most acutely affected by the pandemic. A comparison of hospital- and population-level excess deaths suggests that 53.7% of COVID-19 deaths occurred outside of hospitals. We interpret this as evidence of limited hospital resources, and we show that a higher number of hospital beds per capita is associated with a greater proportion of in-hospital deaths. We also document a 22.6% decrease in hospitalizations of nonrespiratory patients, more pronounced for patients in less severe conditions, and a conditional decrease of 0.5 days in the average length of stay for nonrespiratory patients. We attribute these changes to fear of infection and hospital resource limitations, and we show that the drop in admissions is more pronounced in areas that were more impacted by COVID-19 and had fewer hospital beds per capita. Our findings suggested that the pandemic's direct impact on infected individuals is just a fraction of the broader health losses in the population.

Health care utilization and mortality for people with epilepsy during COVID-19: A population study

OBJECTIVE

This study was undertaken to characterize changes in health care utilization and mortality for people with epilepsy (PWE) during the COVID-19 pandemic.

METHODS

We performed a retrospective study using linked, individual-level, population-scale anonymized health data from the Secure Anonymised Information Linkage databank. We identified PWE living in Wales during the study "pandemic period" (January 1, 2020-June 30, 2021) and during a "prepandemic" period (January 1, 2016-December 31, 2019). We compared prepandemic health care utilization, status epilepticus, and mortality rates with corresponding pandemic rates for PWE and people without epilepsy (PWOE). We performed subgroup analyses on children (<18 years old), older people (>65 years old), those with intellectual disability, and those living in the most deprived areas. We used Poisson models to calculate adjusted rate ratios (RRs).

RESULTS

We identified 27 279 PWE who had significantly higher rates of hospital (50.3 visits/1000 patient months), emergency department (55.7), and outpatient attendance (172.4) when compared to PWOE (corresponding figures: 25.7, 25.2, and 87.0) in the prepandemic period. Hospital and epilepsy-related hospital admissions, and emergency department and outpatient attendances all reduced significantly for PWE (and all subgroups) during the pandemic period. RRs [95% confidence intervals (CIs)] for pandemic versus prepandemic periods were .70 [.69-.72], .77 [.73-.81], .78 [.77-.79], and .80 [.79-.81]. The corresponding rates also reduced for PWOE. New epilepsy diagnosis rates decreased during the pandemic compared with the prepandemic period (2.3/100 000/month cf. 3.1/100 000/month, RR = .73, 95% CI = .68-.78). Both all-cause deaths and deaths with epilepsy recorded on the death certificate increased for PWE during the pandemic (RR = 1.07, 95% CI = .997-1.145 and RR = 2.44, 95% CI = 2.12-2.81). When removing COVID deaths, RRs were .88 (95% CI = .81-.95) and 1.29 (95% CI = 1.08-1.53). Status epilepticus rates did not change significantly during the pandemic (RR = .95, 95% CI = .78-1.15).

SIGNIFICANCE

All-cause non-COVID deaths did not increase but non-COVID deaths associated with epilepsy did increase for PWE during the COVID-19 pandemic. The longer term effects of the decrease in new epilepsy diagnoses and health care utilization and increase in deaths associated with epilepsy need further research.

The effect of the SARS-CoV2 pandemic and lockdown on non-Covid ICU admissions: Experience from a South African tertiary hospital

Background

Future pandemic planning involves analysing past experiences. We compared intensive care unit (ICU) admissions during the SARS-CoV-2 pandemic (2020) with the preceding year.

Objectives

To assess the SARS-CoV-2 pandemic's effect on ICU admissions in a tertiary hospital, examining differences in patient characteristics, organ support requirements, reason for admission, mortality rates and length of ICU stay.

Methods

This retrospective cohort study compared ICU patient data at a tertiary hospital during the SARS-CoV-2 pandemic (26 March 2020 to 20 September 2020) with the same period in 2019.

Results

Patient admissions (p=0.39) and severity of illness (p=0.27 adults; p=0.92 paediatrics) showed no differences across the study period. Similarly, no differences were observed for underlying chronic conditions between the two years. Adult trauma admissions significantly declined, specifically those related to road traffic accidents (RR 0.63). Admissions for acute infectious conditions, including respiratory infections, sepsis, urosepsis, septic arthritis and gastroenteritis significantly declined in both adults (RR 0.50) and paediatric admissions (RR 0.25). During the lockdown period, the length of stay (LOS) decreased for adults, but mortality rates remained unchanged across the study period. The paediatric mortality rate decreased during the lockdown period (p=0.004).

Conclusion

There was no reduction in SARS-CoV-2-negative ICU admissions during the 2020 lockdown period compared with the preceding year, likely due to chronic resource limitations. We found a decrease in acute trauma and acute infectious illness admissions, while acute surgical emergency admissions increased. These findings suggest that lockdown orders may have affected admission patterns, aiding in future pandemic planning.

Contribution of the study

The study highlights the chronic shortage of critical care resources in South Africa and aids with future pandemic preparedness and planning in a resource limited setting.

A Systematic Literature Review of the Impact of COVID-19 on the Health of LGBTQIA+ Older Adults: Identification of Risk and Protective Health Factors and Development of a Model of Health and Disease

It is important to understand the differential impact of COVID-19 on the health of older lesbian, gay, bisexual, transgender, queer/questioning, intersex, asexual, and people with other sexual orientations and forms of gender expression (LGBTQIA+). The objective of this study is to systematically review the impact of COVID-19 on LGBTQIA+ older adults' health including risk and protective factors. We reviewed a total of 167 records including LGBTQIA+ older adults published since 2019. Two independent reviewers screened titles and abstracts and extracted information of 21 full-text records meeting inclusion criteria using COVIDENCE software. The results show that the negative health consequences are exacerbated by personal risk (e.g., perceived homo/transphobia and ageism in LGBTQIA+ communities) and environmental factors (e.g., heterosexism within health services). The negative impact seems to be reduced by personal protective (e.g., resilience, spirituality, and hobbies) and environmental factors (e.g., technology use to increase social participation and social rituals). In conclusion, the health of LGBTQIA+ older adults has been disproportionately affected during the pandemic associated to the latest coronavirus (COVID-19). The experiences of LGBTQIA+ older adults during the pandemic are integrated in a Model of Health and Disease for LGBTQIA+ older adults. Specific strategies to promote health and well-being in this community are provided.

Impact of the early phase of the COVID-19 pandemic on emergency department-to-intensive care unit admissions in Korea: an interrupted time-series analysis

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic resulted in significant disruptions to critical care systems globally. However, research on the impact of the COVID-19 pandemic on intensive care unit (ICU) admissions via the emergency department (ED) is limited. Therefore, this study evaluated the changes in the number of ED-to-ICU admissions and clinical outcomes in the periods before and during the pandemic.

METHODS

We identified all adult patients admitted to the ICU through level 1 or 2 EDs in Korea between February 2018 and January 2021. February 2020 was considered the onset point of the COVID-19 pandemic. The monthly changes in the number of ED-to-ICU admissions and the in-hospital mortality rates before and during the COVID-19 pandemic were evaluated using interrupted time-series analysis.

RESULTS

Among the 555,793 adult ED-to-ICU admissions, the number of ED-to-ICU admissions during the pandemic decreased compared to that before the pandemic (step change, 0.916; 95% confidence interval [CI] 0.869-0.966], although the trend did not attain statistical significance (slope change, 0.997; 95% CI 0.991-1.003). The proportion of patients who arrived by emergency medical services, those transferred from other hospitals, and those with injuries declined significantly among the number of ED-to-ICU admissions during the pandemic. The proportion of in-hospital deaths significantly increased during the pandemic (step change, 1.054; 95% CI 1.003-1.108); however, the trend did not attain statistical significance (slope change, 1.001; 95% CI 0.996-1.007). Mortality rates in patients with an ED length of stay of ≥ 6 h until admission to the ICU rose abruptly following the onset of the pandemic (step change, 1.169; 95% CI 1.021-1.339).

CONCLUSIONS

The COVID-19 pandemic significantly affected ED-to-ICU admission and in-hospital mortality rates in Korea. This study's findings have important implications for healthcare providers and policymakers planning the management of future outbreaks of infectious diseases. Strategies are needed to address the challenges posed by pandemics and improve the outcomes in critically ill patients.

Strain on Scarce Intensive Care Beds Drives Reduced Patient Volumes, Patient Selection, and Worse Outcome: A National Cohort Study

OBJECTIVES

Strain on ICUs during the COVID-19 pandemic required stringent triage at the ICU to distribute resources appropriately. This could have resulted in reduced patient volumes, patient selection, and worse outcome of non-COVID-19 patients, especially during the pandemic peaks when the strain on ICUs was extreme. We analyzed this potential impact on the non-COVID-19 patients.

DESIGN

A national cohort study.

SETTING

Data of 71 Dutch ICUs.

PARTICIPANTS

A total of 120,393 patients in the pandemic non-COVID-19 cohort (from March 1, 2020 to February 28, 2022) and 164,737 patients in the prepandemic cohort (from January 1, 2018 to December 31, 2019).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Volume, patient characteristics, and mortality were compared between the pandemic non-COVID-19 cohort and the prepandemic cohort, focusing on the pandemic period and its peaks, with attention to strata of specific admission types, diagnoses, and severity. The number of admitted non-COVID-19 patients during the pandemic period and its peaks were, respectively, 26.9% and 34.2% lower compared with the prepandemic cohort. The pandemic non-COVID-19 cohort consisted of fewer medical patients (48.1% vs. 50.7%), fewer patients with comorbidities (36.5% vs. 40.6%), and more patients on mechanical ventilation (45.3% vs. 42.4%) and vasoactive medication (44.7% vs. 38.4%) compared with the prepandemic cohort. Case-mix adjusted mortality during the pandemic period and its peaks was higher compared with the prepandemic period, odds ratios were, respectively, 1.08 (95% CI, 1.05-1.11) and 1.10 (95% CI, 1.07-1.13).

CONCLUSIONS

In non-COVID-19 patients the strain on healthcare has driven lower patient volume, selection of fewer comorbid patients who required more intensive support, and a modest increase in the case-mix adjusted mortality.

Non-COVID-19 hospitalization and mortality during the COVID-19 pandemic in Iran: a longitudinal assessment of 41 million people in 2019-2022

BACKGROUND

During a COVID-19 pandemic, it is imperative to investigate the outcomes of all non-COVID-19 diseases. This study determines hospital admissions and mortality rates related to non-COVID-19 diseases during the COVID-19 pandemic among 41 million Iranians.

METHOD

This nationwide retrospective study used data from the Iran Health Insurance Organization. From September 23, 2019, to Feb 19, 2022, there were four study periods: pre-pandemic (Sept 23-Feb 19, 2020), first peak (Mar 20-Apr 19, 2020), first year (Feb 20, 2020-Feb 18, 2021), and the second year (Feb 19, 2021-Feb 19, 2022) following the pandemic. Cause-specific hospital admission and in-hospital mortality are the main outcomes analyzed based on age and sex. Negative binomial regression was used to estimate the monthly adjusted Incidence Rate Ratio (IRR) to compare hospital admission rates in aggregated data. A logistic regression was used to estimate the monthly adjusted in-hospital mortality Odds Ratio (OR) for different pandemic periods.

RESULTS

During the study there were 6,522,114 non-COVID-19 hospital admissions and 139,679 deaths. Prior to the COVID-19 outbreak, the standardized hospital admission rate per million person-month was 7115.19, which decreased to 2856.35 during the first peak (IRR 0.40, [0.25-0.64]). In-hospital mortality also increased from 20.20 to 31.99 (OR 2.05, [1.97-2.13]). All age and sex groups had decreased admission rates, except for females at productive ages. Two years after the COVID-19 outbreak, the non-COVID-19 hospital admission rate (IRR 1.25, [1.13-1.40]) and mortality rate (OR 1.05, [1.04-1.07]) increased compared to the rates before the pandemic. The respiratory disease admission rate decreased in the first (IRR 0.23, [0.17-0.31]) and second years (IRR 0.35, [0.26-0.47] compared to the rate before the pandemic. There was a significant reduction in hospitalizations for pneumonia (IRR 0.30, [0.21-0.42]), influenza (IRR 0.04, [0.03-0.06]) and COPD (IRR 0.39, [0.23-0.65]) during the second year. There was a significant and continuous rise in the hematological admission rate during the study, reaching 186.99 per million person-month in the second year, reflecting an IRR of 2.84 [2.42-3.33] compared to the pre-pandemic period. The mortality rates of mental disorders (OR 2.15, [1.65-2.78]) and musculoskeletal (OR 1.48, [1.20-1.82), nervous system (OR 1.42, [1.26-1.60]), metabolic (OR 1.99, [1.80-2.19]) and circulatory diseases (OR 1.35, [1.31-1.39]) increased in the second year compare to pre-pandemic. Myocardial infarction (OR 1.33, [1.19-1.49]), heart failure (OR 1.59, [1.35-1.87]) and stroke (OR 1.35, [1.24-1.47]) showed an increase in mortality rates without changes in hospitalization.

CONCLUSIONS

In the era of COVID-19, the changes seem to have had a long-term effect on non-COVID-19 diseases. Countries should prepare for similar crises in the future to ensure medical services are not suspended.

Changes in emergency department visits and mortality during the COVID-19 pandemic: a retrospective analysis of 956 hospitals

BACKGROUND

During the COVID-19 pandemic, many non-COVID-19 emergency department (ED) visits were indirectly affected. ED visits and mortality were assessed during different pandemic time periods compared with pre-pandemic.

METHODS

The study used data from 41 million Iran Health Insurance Organization members. The outcomes were non-COVID-19 ED visits and associated mortality in 956 hospitals. An analysis of ED visits was conducted both for all-cause and cause-specific conditions: cardiovascular diseases (CVD), mental and substance use disorders, unintentional injuries, and self-harm. In addition, total in-hospital ED mortality was analyzed. A negative binomial regression and a Poisson regression with a log link were used to estimate the incidence rate ratio (IRR) of visits and mortality relative risk (RR).

RESULTS

1,789,831 ED visits and 12,377 deaths were reported during the study. Pre-pandemic (Sep 2019 to Feb 2020), there were 2,767 non-COVID-19 visits rate per million person-month, which decreased to 1,884 during the first COVID-19 wave with a national lockdown from Feb 20 to Apr 19, 2020 (IRR 0.68, [0.56-0.84]). The non-COVID-19 ED mortality risk was 8.17 per 1,000 visit-month during the pre-pandemic period, rising to 12.80 during the first wave of COVID-19 (RR 1.57, [1.49-165]). Non-COVID-19 ED visit rates decreased during the first pandemic year from Sep 2020 to Feb 2021 (IRR 0.73, [0.63-0.86]), but increased after COVID-19 vaccination two years later from Sep 2021 to Feb 2022 (IRR 1.11, [0.96-0.17]). The total ED mortality risk for non-COVID-19 was significantly higher after the COVID-19 outbreak in the first (RR 1.66, [1.59-1.72]) and second years (RR 1.27, [1.22-1.32]) of the pandemic. The visit incidence rate for mental health and substance use disorders declined from 8.18 per million person-month to 4.57 (IRR 0.53, [0.32 to 0.90]) in the first wave. In the second year, unintentional injury visits increased significantly compared with pre-pandemic (IRR 1.63, [1.30-2.03]). As compared to before the pandemic, there was no significant change in CVD and self-harm visit rates during the pandemic. Cardiac arrest was the leading cause of death in Iran hospitals' EDs.

CONCLUSION

In the first year of the COVID-19 pandemic, non-COVID-19 hospital ED visits declined and mortality risk increased. Despite two years since the COVID-19 outbreak, non-COVID-19 ED mortality risk remains high.

Reduction in potentially inappropriate end-of-life hospital care for cancer patients during the COVID-19 pandemic: A retrospective population-based study

BACKGROUND

The COVID-19 pandemic impacted cancer diagnosis and treatment. However, little is known about end-of-life cancer care during the pandemic.

AIM

To investigate potentially inappropriate end-of-life hospital care for cancer patients before and during the COVID-19 pandemic.

DESIGN

Retrospective population-based cohort study using data from the Netherlands Cancer Registry and the Dutch National Hospital Care Registration. Potentially inappropriate care in the last month of life (chemotherapy administration, >1 emergency room contact, >1 hospitalization, hospitalization >14 days, intensive care unit admission or hospital death) was compared between four COVID-19 periods and corresponding periods in 2018/2019.

PARTICIPANTS

A total of 112,919 cancer patients (⩾18 years) who died between January 2018 and May 2021 were included.

RESULTS

Fewer patients received potentially inappropriate end-of-life care during the COVID-19 pandemic compared to previous years, especially during the first COVID-19 peak (22.4% vs 26.0%). Regression analysis showed lower odds of potentially inappropriate end-of-life care during all COVID-19 periods (between OR 0.81; 95% CI 0.74-0.88 and OR 0.92; 95% CI 0.87-0.97) after adjustment for age, sex and cancer type. For the individual indicators, fewer patients experienced multiple or long hospitalizations, intensive care unit admission or hospital death during the pandemic.

CONCLUSIONS

Cancer patients received less potentially inappropriate end-of-life care during the COVID-19 pandemic. Because several factors may have contributed, it is unclear whether this reflects better quality care. However, these findings raise important questions about what pandemic-induced changes in care practices can help provide appropriate end-of-life care for future patients in the context of increasing patient numbers and limited resources.

Pandemic impact on aneurysmal subarachnoid hemorrhage in Peru's high COVID-19 lethality setting: A public institutional experience

Background

The COVID-19 pandemic in 2020 profoundly impacted healthcare worldwide, and Peru was particularly affected, experiencing the highest COVID-19 case fatality rate globally.

Methods

We conducted a retrospective comparative study of patients presenting with aneurysmal subarachnoid hemorrhage (SAH) at a public Peruvian national referral center specializing in cerebrovascular diseases. Two study periods were considered, one during the first wave of the COVID-19 pandemic and a second identical period in 2019. Variables included patient demographics, comorbidities, COVID-19 infection status, clinical presentation, treatment approaches, and hospital outcomes.

Results

We analyzed 114 patients with aneurysmal SAH, 65 (57.0%) treated in 2019 and 49 (43.0%) in 2020. The mean time from emergency admission to the day of definitive treatment during 2019 and 2020 was 2.72 and 1.93 days, respectively. Likewise, the mean time from symptom onset to the date of definitive treatment was 6.71 and 7.70 days, respectively. We identified significant associations between complications such as sepsis, respiratory failure, acute kidney failure, and hospital mortality. The proportion of fatalities was significantly higher in 2020 compared to 2019 (36.7% vs. 15.4%, respectively). Interestingly, there was no statistically significant association between COVID-19 infection status and mortality during the 2020 period.

Conclusion

Patients with aneurysmal SAH treated during the pandemic had a higher proportion of sepsis, respiratory failure, acute kidney failure, and mortality compared to the pre-pandemic period. Reallocating healthcare resources to prioritize COVID-19 patients may have inadvertently neglected or delayed care for patients with other emergency conditions, such as aneurysmal SAH. This highlights the importance of maintaining adequate care for non-infectious emergencies during a pandemic.

Special Issue "Clinical Consequences of COVID-19": Taking a Look at Complexity

The consequences of SARS-CoV-2 infection are far from being fully understood or accounted for [...].

Trends in outpatient and inpatient visits for separate ambulatory-care-sensitive conditions during the first year of the COVID-19 pandemic: a province-based study

Background

The COVID-19 pandemic led to global disruptions in non-urgent health services, affecting health outcomes of individuals with ambulatory-care-sensitive conditions (ACSCs).

Methods

We conducted a province-based study using Ontario health administrative data (Canada) to determine trends in outpatient visits and hospitalization rates (per 100,000 people) in the general adult population for seven ACSCs during the first pandemic year (March 2020-March 2021) compared to previous years (2016-2019), and how disruption in outpatient visits related to acute care use. ACSCs considered were chronic obstructive pulmonary disease (COPD), asthma, angina, congestive heart failure (CHF), hypertension, diabetes, and epilepsy. We used time series auto-regressive integrated moving-average models to compare observed versus projected rates.

Results

Following an initial reduction (March-May 2020) in all types of visits, primary care outpatient visits (combined in-person and virtual) returned to pre-pandemic levels for asthma, angina, hypertension, and diabetes, remained below pre-pandemic levels for COPD, and rose above pre-pandemic levels for CHF (104.8 vs. 96.4, 95% CI: 89.4-104.0) and epilepsy (29.6 vs. 24.7, 95% CI: 22.1-27.5) by the end of the first pandemic year. Specialty visits returned to pre-pandemic levels for COPD, angina, CHF, hypertension, and diabetes, but remained above pre-pandemic levels for asthma (95.4 vs. 79.5, 95% CI: 70.7-89.5) and epilepsy (53.3 vs. 45.6, 95% CI: 41.2-50.5), by the end of the year. Virtual visit rates increased for all ACSCs. Among ACSCs, reductions in hospitalizations were most pronounced for COPD and asthma. CHF-related hospitalizations also decreased, albeit to a lesser extent. For angina, hypertension, diabetes, and epilepsy, hospitalization rates reduced initially, but returned to pre-pandemic levels by the end of the year.

Conclusion

This study demonstrated variation in outpatient visit trends for different ACSCs in the first pandemic year. No outpatient visit trends resulted in increased hospitalizations for any ACSC; however, reductions in rates of asthma, COPD, and CHF hospitalizations persisted.

Mortality and healthcare assessment among patients with chronic disease over 2 years of COVID-19: a population-based study in a large hard-hit Italian region

OBJECTIVES

We aimed to provide a region-wide comprehensive account of the indirect effects of COVID-19 on patients with chronic disease, in terms of non-COVID-19 mortality, and access to both inpatient and outpatient health services over a 2-year pandemic period.

DESIGN

Population-based retrospective study.

SETTING

Adult patients, affected by at least 1 of 32 prevalent chronic conditions, residing in the Emilia-Romagna Region in Italy, during the years 2020 (N=1 791 189, 47.7% of the overall adult regional population) and 2021 (N=1 801 071, 47.8%).

RESULTS

Overall, non-COVID-19 mortality among patients with chronic disease during the pandemic (2.7%) did not differ substantially from the expected mortality (2.5%), based on a 3 years prepandemic period (2017-2019) and adjusting for the demographic and clinical characteristics of the population under study. Indeed, while the first pandemic wave was characterised by a significant non-COVID-19 excess mortality (March: +35%), the subsequent phases did not show such disruptive variations in non-COVID-19 deaths, which remained around or even below the excess mortality threshold. End-of-life care of patients with chronic disease, especially for non-COVID-19 cases, significantly shifted from hospitalisations (-19%), to homecare (ADI: +7%; w/o ADI: +9%). Overall, healthcare of patients without COVID-19 chronic disease decreased, with similar negative trends in hospitalisations (-15.5%), major procedures (-19.6%) and ER accesses (-23.7%). Homecare was the least affected by the pandemic, with an overall reduction of -9.8%. COVID-19 outbreak also impacted on different types of outpatient care. Rehabilitation therapies, specialist visits, diagnostic and lab tests were considerably reduced during the first pandemic wave and consequent lockdown, with access rates of patients without COVID-19 chronic disease below -60%.

CONCLUSIONS

This work thoroughly describes how a large and well-defined population of patients without COVID-19 chronic disease has been affected by the changes and reorganisation in the healthcare system during 2 years of the pandemic, highlighting health priorities and challenges in chronic disease management under conditions of limited resources.

Hospitalization and hospital mortality rates during the first and second waves of the COVID-19 pandemic in Quebec: interrupted time series and decomposition analysis

OBJECTIVES

We investigated hospitalization and hospital mortality rates by cause during the first year of the COVID-19 pandemic in Quebec, Canada.

STUDY DESIGN

Interrupted time series and decomposition analysis.

METHODS

We analyzed hospital mortality during the first (February 25-August 22, 2020) and second waves (August 23, 2020-March 31, 2021), compared with 2019. We identified the cause of death and examined trends using: 1) interrupted time series analysis; 2) log-binomial regression; and 3) decomposition of cause-specific mortality.

RESULTS

Hospitalization rates decreased; however, the proportion of deaths increased from 27.0 per 1000 in 2019 to 35.0 per 1000 in the first wave, for an excess of 8.0 deaths per 1000 admissions. COVID-19 was the cause of a third of excess deaths (2.6 per 1000). Other drivers of excess deaths included respiratory conditions (1.6 deaths per 1000), circulatory disorders (0.6 deaths per 1000), and cancer (0.9 deaths per 1000). COVID-19 was the cause of 58% of excess deaths in the second wave. Interrupted time series regression indicated that the proportion of deaths increased at the outset of the first wave but returned to prepandemic levels before increasing again in the second wave. Compared with 2019, the first wave was associated with 1.31 times (95% confidence interval [CI] 1.28-1.33) and the second wave with 1.17 times (95% CI 1.15-1.19) the risk of death during hospitalization.

CONCLUSIONS

The pandemic was associated with a greater risk of hospital mortality. Excess deaths were driven by COVID-19 but also other causes, including respiratory conditions, circulatory disorders, and cancer.

Disruption Of Non-COVID-19 Health Care In Latin America During The Pandemic: Effects On Health, Lessons For Policy

COVID-19 had severe direct and indirect effects on health and well-being in Latin America. To understand the extent to which disruptions among non-COVID-19-related health services affected population health, we used administrative data from the period 2015-21 to examine public hospital discharges and mortality for conditions amenable to health care in four Latin American countries: Brazil, Ecuador, Mexico, and Peru. Between March 2020 and December 2021, hospitalization rates for these conditions declined by 28 percent and mortality rates increased by 15 percent relative to prepandemic years. Noncommunicable diseases accounted for 89 percent of this rise in mortality. The poorest states in each country experienced relatively larger increases in mortality. Our results, which focus on the health effects of service disruption, suggest that maintaining health care services in this region during the pandemic could have avoided at least 96,000 deaths. Policies should focus on maintaining essential health care services during emergencies, particularly for patients with noncommunicable diseases, and on minimizing negative consequences by ensuring coordinated and continuous care; leveraging alternative modalities of care, such as telemedicine; broadening the role of nonphysician health care workers; and expanding options for medication delivery.

Obstetric and Gynecological Admissions and Hospitalizations in an Italian Tertiary-Care Hospital during COVID-19 Pandemic: A Retrospective Analysis According to Restrictive Measures

BACKGROUND

The national lockdown and the different restrictions applied in 2020 during the COVID-19 pandemic brought several changes to hospitalization procedures. The aim of this study was to evaluate the patterns in access to emergency services and hospitalization in a tertiary-care obstetric and gynecological emergency department (OG-ED) throughout the restrictions applied during 2020.

METHODS

A single-center retrospective comparative study on data from January to December 2020 was carried out on the following timeframes: January to February 2020 (before COVID-19 pandemic), March to June 2020 (nationwide lockdown period), July to September 2020 (removal of restrictive measures), October to December 2020 (regional lockdown) and compared to the same periods of 2019. All obstetric and gynecological patients with complete medical data admitted to the OG-ED were included.

RESULTS

Overall, 4233 accesses for 2019 and 3652 for 2020 were reported, with a decreasing trend of -13.7%. Between March and June 2020 (nationwide lockdown) and 2019, the overall number of patients attending the OG-ED decreased compared to July-September and October-December differences (Δ -23.5% vs. -3.1% and -5.9%; p = 0.001 respectively) for 2020-2019, but this reduction was not statistically significant when compared to January-February (Δ -23.5% vs. -18.5%; p = 0.356). No significant differences for obstetric patients (Δ -1.8% vs. -1.0% vs. -2.3% and +1.9% respectively; p = 0.883) were noted. Hospitalizations showed a stable trend with an increase between October-December 2019 and 2020 (Δ +4.6%; p = 0.001 vs. January-February (+2.4%) and March-June (+2.6%) 2019-2020), mainly related to regional lockdowns.

CONCLUSIONS

In contrast to available national studies, in our institution, the overall rate of OG-ED admissions was slightly reduced with a similar trend of decrease even before COVID-19, with an increase in admissions for serious issues, despite expectations that the suspension of elective admissions and outpatient services would have led to an increase in non-urgent hospitalizations during the COVID-19 lockdown period.

Initial response to SARS-CoV-2 (COVID-19) outbreak in Sri Lanka; views of public health specialists through an International Health Regulations lens

The COVID-19 pandemic affected Sri Lanka despite having developed an International Health Regulations (IHR) steering committee in 2016 and a national action plan for health security following the Joint External Evaluation in 2018. Many steps were taken to improve the disaster management skills of healthcare workers even before the COVID-19 outbreak. We interviewed seven public health specialists to obtain their views on the country's response to the pandemic. A thematic analysis was conducted, leading to the emergence of three major themes and seven subthemes. The major themes included health security preparedness; COVID-19 management; and effects of COVID-19. The subthemes were; preparedness prior to pandemic and gaps in the preparedness (under health security preparedness); dual burden for the curative sector, strategies to reduce transmission and barriers to managing COVID-19 (under COVID-19 management) and negative and positive effects of COVID-19 (under effects of COVID-19). When COVID-19 reached Sri Lanka, healthcare workers, border control authorities and those involved with infectious disease control were overwhelmed by the magnitude of the pandemic. Healthcare workers' hesitation to work amidst the pandemic due to fear of infection and possible transmission of infection to their families was a major issue; the demand for personal protective equipment by health workers when stocks were low was also a contributory factor. Lockdowns with curfew and quarantine at government regulated centers were implemented as necessary. Perceptions of the public including permitting healthcare workers to perform field public health services, logistical barriers and lack of human resources were a few of the barriers that were expressed. Some persons did not declare their symptoms, fearing that they would have to be quarantined. The pandemic severely affected the economy and Sri Lanka relied on donations and loans to overcome the situation. Pandemic also brought about innovative methods to maintain and upgrade health service provision. Individuals with non-communicable diseases received their regular medications through the post which reduced their risk of being infected by visiting hospitals. Improvement of laboratory services and quarantine services, a reduction of acute respiratory infections and diarrhoeal diseases, improved intersectoral coordination and public philanthropic response were other positive effects.

Skin and soft tissue infection incidence before and during the COVID-19 pandemic

Skin and Soft Tissue Infections (SSTIs) are common bacterial infections. We hypothesized that due to the COVID-19 pandemic, SSTI rates would significantly decrease due to directives to avoid unneeded care and attenuated SSTIs risk behaviours. We retrospectively examined all patients with an ICD-10 diagnosis code in the Los Angeles County Department of Health Services, the second largest U.S. safety net healthcare system between 16 March 2017 and 15 March 2022. We then compared pre-pandemic with intra-pandemic SSTI rates using an interrupted time series analysis. We found 72,118 SSTIs, 46,206 during the pre-pandemic period and 25,912 during the intra-pandemic period. Pre-pandemic SSTI rate was significantly higher than the intra-pandemic rate (3.27 vs. 2.31 cases per 1,000 empanelled patient-months, P < 0.0001). The monthly SSTI cases decreased by 1.19 SSTIs/1,000 empanelled patient-months between the pre- and intra-pandemic periods (P = 0.0003). SSTI subgroups (inpatient, observation unit, emergency department, and outpatient clinics), all had significant SSTI decreases between the two time periods (P < 0.05) except for observation unit (P = 0.50). Compared to the pre-COVID-19 pandemic period, medically attended SSTI rates in our large U.S. safety net healthcare system significantly decreased by nearly 30%. Whether findings reflect true SSTI decreases or decreased health system utilization for SSTIs requires further examination.

Use of tranexamic acid-soaked NasoPore® in the emergency department, to reduce epistaxis admissions

OBJECTIVES

The aim of this study was to assess the efficacy of a new emergency department (ED) intervention for the management of non-traumatic, anterior epistaxis in adult patients, aiming to reduce epistaxis admissions.

DESIGN

A new epistaxis pathway was introduced for use by ED practitioners. This was disseminated in ED through an educational campaign by the ear, nose and throat team. A tranexamic acid (500 mg/5 mL)-soaked NasoPore® packing step was introduced for epistaxis which did not terminate following 10 min of simple first aid. The pathway was utilised for adult patients presenting with non-traumatic, anterior epistaxis. Pre- and post-implementation periods were defined, and all adults attending ED with non-traumatic, anterior epistaxis were included. Pre- and post-implementation epistaxis treatment interventions, admission rates and re-attendance rates were recorded by retrospective audit and compared.

RESULTS

In the post-implementation group, epistaxis admissions were 51.7% (p < .05) lower than in the pre-implementation group, as a proportion of the total number attending ED with epistaxis during these periods.

CONCLUSIONS

The significant reduction in epistaxis admissions demonstrates that this ED intervention is beneficial for patient outcomes.

Forecasting emergency department arrivals using INGARCH models

BACKGROUND

Forecasting patient arrivals to hospital emergency departments is critical to dealing with surges and to efficient planning, management and functioning of hospital emerency departments.

OBJECTIVE

We explore whether past mean values and past observations are useful to forecast daily patient arrivals in an Emergency Department.

MATERIAL AND METHODS

We examine whether an integer-valued generalized autoregressive conditional heteroscedastic (INGARCH) model can yield a better conditional distribution fit and forecast of patient arrivals by using past arrival information and taking into account the dynamics of the volatility of arrivals.

RESULTS

We document that INGARCH models improve both in-sample and out-of-sample forecasts, particularly in the lower and upper quantiles of the distribution of arrivals.

CONCLUSION

Our results suggest that INGARCH modelling is a useful model for short-term and tactical emergency department planning, e.g., to assign rotas or locate staff for unexpected surges in patient arrivals.

A proposal for formal fairness requirements in triage emergency departments: publicity, accessibility, relevance, standardisability and accountability

This paper puts forward a wish list of requirements for formal fairness in the specific context of triage in emergency departments (EDs) and maps the empirical and conceptual research questions that need to be addressed in this context in the near future. The pandemic has brought to the fore the necessity for public debate about how to allocate resources fairly in a situation of great shortage. However, issues of fairness arise also outside of pandemics: decisions about how to allocate resources are structurally unavoidable in healthcare systems, as value judgements underlie every allocative decision, although they are not always easily identifiable. In this paper, we set out to bridge this gap in the context of EDs. In the first part, we propose five formal requirements specifically applied for ED triage to be considered fair and legitimate: publicity, accessibility, relevance, standardisability and accountability. In the second part of the paper, we map the conceptual and empirical ethics questions that will need to be investigated to assess whether healthcare systems guarantee a formally just ED triage. In conclusion, we argue that there is a vast research landscape in need of an in-depth conceptual and empirical investigation in the context of ED triage in ordinary times. Addressing both types of questions in this context is vital for promoting a fair and legitimate ED triage and for fostering reflection on formal fairness allocative issues beyond triage.

Big data evidence of the impact of COVID-19 hospitalizations on mortality rates of non-COVID-19 critically ill patients

The COVID-19 virus caused a global pandemic leading to a swift policy response. While this response was designed to prevent the spread of the virus and support those with COVID-19, there is growing evidence regarding measurable impacts on non-COVID-19 patients. The paper uses a large dataset from administrative records of the Brazilian public health system (SUS) to estimate pandemic spillover effects in critically ill health care delivery, i.e. the additional mortality risk that COVID-19 ICU hospitalizations generate on non-COVID-19 patients receiving intensive care. The data contain the universe of ICU hospitalizations in SUS from February 26, 2020 to December 31, 2021. Spillover estimates are obtained from high-dimensional fixed effects regression models that control for a number of unobservable confounders. Our findings indicate that, on average, the pandemic increased the mortality risk of non-COVID-19 ICU patients by 1.296 percentage points, 95% CI 1.145-1.448. The spillover mortality risk is larger for non-COVID patients receiving intensive care due to diseases of the respiratory system, diseases of the skin and subcutaneous tissue, and infectious and parasitic diseases. As of July 2023, the WHO reports more than 6.9 million global deaths due to COVID-19 infection. However, our estimates of spillover effects suggest that the pandemic's total death toll is much higher.

The Rates of Postmastectomy Immediate Breast Reconstruction during the Initial Months of the COVID-19 Pandemic

Background

Coronavirus disease 2019 (COVID-19) pandemic-related changes may have led to changes in immediate breast reconstruction (IBR) rates. We aimed to evaluate these changes before, during, and after the initial wave of COVID-19.

Methods

We retrospectively reviewed women who underwent mastectomy with or without IBR from January 1 to September 30, 2019 and from January 1 to September 30, 2020, and compared demographic, clinical, and surgical variables between defined time periods.

Results

A total of 202 mastectomies were included. Fewer patients underwent IBR during the initial surge of COVID-19 (surge period) compared with the months before (presurge period; 38.46% versus 70.97%, P = 0.0433). When comparing the postsurge period with a year before (postsurge control), fewer patients underwent reconstruction even after the initial surge had passed (53.13% versus 81.25%, P = 0.0007). Those who underwent IBR were older than the year before (59.34 versus 53.06, P = 0.0181). The median number of postoperative visits in the postsurge period was 8.50 (interquartile range: 6-12) compared with 14 (interquartile range: 8-20.50) in the year before (P = 0.0017). The overall incidences of complications and unanticipated resource utilization were also significantly lower in the postsurge period compared with the year before [5.88% versus 30.77% (P = 0.0055), and 14.71% versus 28.85% (P = 0.0103), respectively].

Conclusions

IBR rates were lower even after the initial surge than at the year before. Furthermore, during the pandemic, IBR patients were older, had fewer follow-up visits, and fewer reported complications.

Evaluating the Patient Boarding during Omicron Surge in Hong Kong: Time Series Analysis

The fifth wave of COVID-19 outbreaks in Hong Kong (HK) from January to March 2022 has the highest confirmed cases and deaths compared with previous waves. Severe hospital boarding (to inpatient wards) was noted in various Emergency Departments (EDs). Our objective is to identify factors associated with hospital boarding during Omicron surge in HK. We conducted a retrospective cohort study including all ED visits and inpatient (IP) ward admissions from January 1st to March 31st, 2022. Vector Autoregression model evaluated the effects of a single variable on the targeted hospital boarding variables. Admissions from elderly homes with 6 lag days held the highest positive value of statistical significance (t-stat = 2.827, P < .05) caused prolonged admission waiting time, while medical patients with 4 lag days had the highest statistical significance (t-stat = 2.530, P < .05) caused an increased number of boarding patients. Within one week after impulses, medical occupancy's influence on the waiting time varied from 0.289 on the 1st day to -0.315 on the 7th day. While occupancy of medical wards always positively affected blocked number of patients, and its response was maximized at 0.309 on the 2nd day. Number of confirmed COVID-19 cases was not the sole significant contributor, while occupancy of medical wards was still a critical factor associated with patient boarding. Increasing ward capacity and controlling occupancy were suggested during the outbreak. Moreover, streamlining elderly patients in ED could be an approach to relieve pressure on the healthcare system.

Evaluating the Impact of COVID-19 on Hospital Profit Compensation Activities: A Difference-in-Differences Event Study Analysis in China

The impact of the 2019 coronavirus disease (COVID-19) pandemic is still being revealed, and little is known about the effect of COVID-19-induced outpatient and inpatient losses on hospital operations in many counties. Hence, we aimed to explore whether hospitals adopted profit compensation activities after the 2020 first-wave outbreak of COVID-19 in China. A total of 2,616,589 hospitalization records from 2018, 2019, and 2020 were extracted from 36 tertiary hospitals in a western province in China; we applied a difference-in-differences event study design to estimate the dynamic effect of COVID-19 on hospitalized patients' total expenses before and after the last confirmed case. We found that average total expenses for each patient increased by 8.7% to 16.7% in the first 25 weeks after the city reopened and hospital admissions returned to normal. Our findings emphasize that the increase in total inpatient expenses was mainly covered by claiming expenses from health insurance and was largely driven by an increase in the expenses for laboratory tests and medical consumables. Our study documents that there were profit compensation activities in hospitals after the 2020 first-wave outbreak of COVID-19 in China, which was driven by the loss of hospitalization admissions during this wave outbreak.

No Excess of Mortality from Lung Cancer during the COVID-19 Pandemic in an Area at Environmental Risk: Results of an Explorative Analysis

BACKGROUND

The COVID-19 pandemic and the restrictive measures associated with it placed enormous pressure on health facilities and may have caused delays in the treatment of other diseases, leading to increases in mortality compared to the expected rates. Areas with high levels of air pollution already have a high risk of death from cancer, so we aimed to evaluate the possible indirect effects of the pandemic on mortality from lung cancer compared to the pre-pandemic period in the province of Taranto, a polluted site of national interest for environmental risk in the south of Italy.

METHODS

We carried out a retrospective observational study on lung cancer data (ICD-10: C34) from the Registry of Mortality (ReMo) for municipalities in Taranto Province over the period of 1 January 2011 to 31 December 2021. Seasonal exponential smoothing, Holt-Winters additive, Holt-Winters multiplicative, and auto-regressive integrated moving average (ARIMA) models were used to forecast the number of deaths during the pandemic period. Data were standardized by sex and age via an indirect method and shown as monthly mortality rates (MRs), standardized mortality ratios (SMRs), and adjusted mortality rates (AMRs).

RESULTS

In Taranto Province, 3108 deaths from lung cancer were recorded between 2011 and 2021. In the province of Taranto, almost all of the adjusted monthly mortality rates during the pandemic were within the confidence interval of the predicted rates, with the exception of significant excesses in March (+1.82, 95% CI 0.11-3.08) and August 2020 (+2.09, 95% CI 0.20-3.44). In the municipality of Taranto, the only significant excess rate was in August 2020 (+3.51, 95% CI 0.33-6.69). However, in total, in 2020 and 2021, the excess deaths from lung cancer were not significant both for the province of Taranto (+30 (95% CI -77; +106) for 2020 and +28 (95% CI -130; +133) for 2021) and for the municipality of Taranto alone (+14 (95% CI -47; +74) for 2020 and -2 (95% CI -86; +76) for 2021).

CONCLUSIONS

This study shows that there was no excess mortality from lung cancer as a result of the COVID-19 pandemic in the province of Taranto. The strategies applied by the local oncological services during the pandemic were probably effective in minimizing the possible interruption of cancer treatment. Strategies for accessing care in future health emergencies should take into account the results of continuous monitoring of disease trends.

The positive impact of COVID-19 on critical care: from unprecedented challenges to transformative changes, from the perspective of young intensivists

Over the past 2 years, SARS-CoV-2 infection has resulted in numerous hospitalizations and deaths worldwide. As young intensivists, we have been at the forefront of the fight against the COVID-19 pandemic and it has been an intense learning experience affecting all aspects of our specialty. Critical care was put forward as a priority and managed to adapt to the influx of patients and the growing demand for beds, financial and material resources, thereby highlighting its flexibility and central role in the healthcare system. Intensivists assumed an essential and unprecedented role in public life, which was important when claiming for indispensable material and human investments. Physicians and researchers around the world worked hand-in-hand to advance research and better manage this disease by integrating a rapidly growing body of evidence into guidelines. Our daily ethical practices and communication with families were challenged by the massive influx of patients and restricted visitation policies, forcing us to improve our collaboration with other specialties and innovate with new communication channels. However, the picture was not all bright, and some of these achievements are already fading over time despite the ongoing pandemic and hospital crisis. In addition, the pandemic has demonstrated the need to improve the working conditions and well-being of critical care workers to cope with the current shortage of human resources. Despite the gloomy atmosphere, we remain optimistic. In this ten-key points review, we outline our vision on how to capitalize on the lasting impact of the pandemic to face future challenges and foster transformative changes of critical care for the better.

The Impact of the COVID-19 Pandemic and Socioeconomic Deprivation on Admissions to the Emergency Department for Psychiatric Illness: An Observational Study in a Province of Southern Italy

The restriction measures adopted to limit population movement in order to contain the COVID-19 pandemic contributed to a global public health system crisis. This retrospective study aimed at identifying changes in psychiatric admissions to Accident and Emergency Departments (A&Es) in a province in southern Italy during the first two years of the pandemic and was characterized by two different restriction levels (phases 2 and 3) compared to the pre-pandemic period (phase 1). We also investigated the role of socioeconomic deprivation (DI) on psychiatric admissions. The total number of patients admitted to the A&Es was 291,310. The incidence of admission for a psychiatric disorder (IPd) was 4.9 per 1000 admissions, with a significant younger median age of 42 [IQR 33–56] compared to non-psychiatric patients (54 [35–73]). The type of admission and type of discharge were factors related to the psychiatric admission to A&E, and their relationship was modified by the pandemic. In the first year of the pandemic, patients with psychomotor agitation increased compared to the pre-pandemic period (72.5% vs. 62.3%). In the period preceding the spread of SARS-CoV-2, the IPd was equal to 3.33 ± 0.19; after the pandemic started, there was an increase in the IPd: 4.74 ± 0.32 for phase 2 and 3.68 ± 0.25 for phase 3. The IPd was higher for psychiatric admissions from areas with a very low DI compared to areas with a low DI; however, during phase 2, this difference was reduced. In conclusion, an increase in admissions for psychiatric disease was observed during the initial spread of SARS-CoV-2. Patients who lived in the most deprived municipalities generally came to the A&Es less than others, probably because the patients and their families had less awareness of their mental health. Therefore, public health policies to address these issues are needed to reduce the pandemic’s impact on these conditions.

Is COVID-19 All That Glitters?

Over the last three years, the Coronavirus-19 disease has been a global health emergency, playing a primary role in the international scientific community. Clinical activity and scientific research have concentrated their efforts on facing the pandemic, allowing the description of novel pathologies correlated to Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), such as the Multisystemic Inflammatory Syndrome in Children and Adults (MIS-C, MIS-A). Conversely, this shift of attention to COVID-19 disease and its complications could, in some cases, have delayed and underestimated the diagnosis of diseases not associated with SARS-CoV-2, including rare diseases. Here we describe the diagnostic process that led to the definition of a rare vasculitis in a young woman with a recent clinical history of SARS-CoV-2.

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.

COVID-19 impact on an oncologic emergency department visits: observational study

OBJECTIVE

This study aimed at evaluating the impact of COVID-19 on emergency department (ED) visits in a tertiary cancer centre and providing information on the features of the unplanned events during the first wave of COVID-19 pandemic.

METHODS

This retrospective observational study based on data from ED reports was divided into three periods of 2 months each around the first lockdown announcement of 17 March 2020: pre-lockdown, lockdown and post-lockdown.

RESULTS

A total of 903 ED visits were included in the analyses. The mean (±SD) daily number of ED visits did not change during the lockdown period (14.6±5.5) when compared with the periods before (13.6±4.5) and after lockdown (13.7±4.4) (p=0.78). The proportion of ED visits for fever and respiratory disorders increased significantly to 29.5% and 28.5%, respectively (p<0.01) during lockdown. Pain, the third most frequent motive, remained stable with 18.2% (p=0.83) throughout the three periods. Symptom severity also showed no significant differences in the three periods (p=0.31).

CONCLUSION

Our study shows that ED visits during the first wave of the COVID-19 pandemic remained stable for our patients regardless of the symptom's severity. The fear of an in-hospital viral contamination appears weaker than the need for pain management or for the treatment of cancer-related complications. This study highlights the positive impact of cancer ED in the first-line treatment and supportive care of patients with cancer.

Impact of COVID-19 Pandemic on Adherence to Chronic Therapies: A Systematic Review

The spread of the coronavirus disease 2019 (COVID-19) pandemic caused a sudden and significant disruption in healthcare services, especially for patients suffering from chronic diseases. We aimed at evaluating the impact of the pandemic on adherence to chronic therapies through a systematic review of available studies. PubMed, EMBASE, and Web of Science were searched since inception to June 2022. Inclusion criteria were: (1) observational studies or surveys; (2) studies on patients with chronic diseases; (3) reporting the effects of COVID-19 pandemic on adherence to chronic pharmacological treatment, as a comparison of adherence during the pandemic period vs. pre-pandemic period (primary outcome) or as rate of treatment discontinuation/delay specifically due to factors linked to COVID-19 (secondary outcome). Findings from 12 (primary outcome) and 24 (secondary outcome) studies showed that many chronic treatments were interrupted or affected by a reduced adherence in the pandemic period, and that fear of infection, difficulty in reaching physicians or healthcare facilities, and unavailability of medication were often reported as reasons for discontinuation or modification of chronic therapies. For other therapies where the patient was not required to attend the clinic, continuity of treatment was sometimes ensured through the use of telemedicine, and the adherence was guaranteed with drug stockpiling. While the effects of the possible worsening of chronic disease management need to be monitored over time, positive strategies should be acknowledged, such as the implementation of e-health tools and the expanded role of community pharmacists, and may play an important role in preserving continuity of care for people with chronic diseases.

Emergency department presentations during the COVID-19 pandemic in Queensland (to June 2021): interrupted time series analysis

OBJECTIVES

To assess emergency department (ED) presentation numbers in Queensland during the coronavirus disease 2019 (COVID-19) pandemic to mid-2021, a period of relatively low COVID-19 case numbers.

DESIGN

Interrupted time series analysis.

SETTING

All 105 Queensland public hospital EDs.

MAIN OUTCOME MEASURES

Numbers of ED presentations during the COVID-19 lockdown period (11 March 2020 - 30 June 2020) and the period of easing restrictions (1 July 2020 - 30 June 2021), compared with pre-pandemic period (1 January 2018 - 10 March 2020), overall (daily numbers) and by Australasian Triage Scale (ATS; daily numbers) and selected diagnostic categories (cardiac, respiratory, mental health, injury-related conditions) and conditions (stroke, sepsis) (weekly numbers).

RESULTS

During the lockdown period, the mean number of ED presentations was 19.4% lower (95% confidence interval, -20.9% to -17.9%) than during the pre-pandemic period (predicted mean number: 5935; actual number: 4786 presentations). The magnitudes of the decline and the time to return to predicted levels varied by ATS category and diagnostic group; changes in presentation numbers were least marked for ATS 1 and 2 (most urgent) presentations, and for presentations with cardiac conditions or stroke. Numbers remained below predicted levels during the 12-month post-lockdown period for ATS 5 (least urgent) presentations and presentations with mental health problems, respiratory conditions, or sepsis.

CONCLUSIONS

The COVID-19 pandemic and related public restrictions were associated with profound changes in health care use. Pandemic plans should include advice about continuing to seek care for serious health conditions and health emergencies, and support alternative sources of care for less urgent health care needs.

Challenges in Care for Non-COVID-19 Patients with Severe Chronic Illnesses during COVID-19 Pandemic: A Qualitative Study of Healthcare Providers Working around Acute Care Hospitals in South Korea

BACKGROUND

The COVID-19 epidemic has afflicted patients with severe chronic illnesses who need continuous care between home and hospitals. This qualitative study examines the experiences and challenges of healthcare providers around acute care hospitals who have cared for patients with severe chronic illness in non-COVID-19 situations during the pandemic.

METHODS

Eight healthcare providers, who work in various healthcare settings around acute care hospitals and frequently care for non-COVID-19 patients with severe chronic illnesses, were recruited using purposive sampling from September to October 2021 in South Korea. The interviews were subjected to thematic analysis.

RESULTS

Four overarching themes were identified: (1) deterioration in the quality of care at various settings; (2) new emerging systemic problems; (3) healthcare providers holding on but reaching their limit; and (4) a decline in the quality of life of patients at the end of their lives, and their caregivers.

CONCLUSION

Healthcare providers of non-COVID-19 patients with severe chronic illnesses reported that the quality of care was declining due to the structural problems of the healthcare system and policies centered solely on the prevention and control of COVID-19. Systematic solutions are needed for appropriate and seamless care for non-infected patients with severe chronic illness in the pandemic.

Influence of epidemics and pandemics on paediatric ED use: a systematic review

OBJECTIVE

To assess the impact of epidemics and pandemics on the utilisation of paediatric emergency care services to provide health policy advice.

SETTING

Systematic review.

DESIGN

Searches were conducted of Medline, EMBASE, CINAHL, Scopus, Web of Science and the Cochrane Library for studies that reported on changes in paediatric emergency care utilisation during epidemics (as defined by the WHO).

PATIENTS

Children under 18 years.

INTERVENTIONS

National Institutes of Health quality assessment tool for observational cohort and cross-sectional studies was used.

MAIN OUTCOME MEASURES

Changes in paediatric emergency care utilisation.

RESULTS

131 articles were included within this review, 80% of which assessed the impact of COVID-19. Studies analysing COVID-19, SARS, Middle East respiratory syndrome (MERS) and Ebola found a reduction in paediatric emergency department (PED) visits, whereas studies reporting on H1N1, chikungunya virus and Escherichia coli outbreaks found an increase in PED visits. For COVID-19, there was a reduction of 63.86% (95% CI 60.40% to 67.31%) with a range of -16.5% to -89.4%. Synthesis of results suggests that the fear of the epidemic disease, from either contracting it or its potential adverse clinical outcomes, resulted in reductions and increases in PED utilisation, respectively.

CONCLUSIONS

The scale and direction of effect of PED use depend on both the epidemic disease, the public health measures enforced and how these influence decision-making. Policy makers must be aware how fear of virus among the general public may influence their response to public health advice. There is large inequity in reporting of epidemic impact on PED use which needs to be addressed.

TRIAL REGISTRATION NUMBER

CRD42021242808.

Effect of the COVID-19 pandemic on the frequency of emergency department visits in Portugal: An interrupted time series analysis until July 2021

Objectives

This study aims to evaluate the effect of the COVID-19 pandemic on the frequency of emergency department (ED) visits in Portugal between March 2020 and July 2021.

Methods

We used data on the monthly number of visits for all public hospitals' EDs from mainland Portugal between January 2017 and July 2021. We studied the impact of the pandemic overall, by type of ED (general, pediatric, and obstetric) and by Manchester Triage System color (red, orange, yellow, green, and blue) using an interrupted time series analysis. The prepandemic period corresponded to the months from January 2017 to February 2020 and the pandemic period to the months from March 2020 to July 2021.

Results

We observed over 26 million ED visits, the majority in general EDs (74.0%) and triaged yellow (48.4%) or green (38.4%). During the pandemic period, ED visits decreased 45.7% (95% confidence interval [CI]: -39.8% to -51.2%) and pediatric ED visits decreased by 72.4% (95% CI: -64.6% to -78.6%). A decrease was observed for all colors but tended to be progressively smaller as the priority increased. There was an increase in ED visits during the pandemic period (2.3%; 95% CI: 1.4% to 3.2%), eventually returning to prepandemic values.

Conclusion

Our data indicate a considerable and long-lasting effect of the COVID-19 pandemic affecting mainly pediatric and milder cases, which were returning toward prepandemic values as the pandemic progressed. In a country with frequent use of EDs, the health system may need to be prepared to respond to prepandemic baseline ED demand, together with additional demand because of long-term sequels of COVID-19 cases and delayed care for chronic and acute conditions.

Observational Study on Antibody Response to COVID-19 Vaccines in PAtients with Gastro-Entero-PanCreatic Cancers and NeuroendocrIne NeoplAsms on Systemic TreatmEnts (VACCINATE)

The coronavirus disease-19 (COVID-19) pandemic dramatically impacted oncological patients' care. Since the introduction of vaccines and the demonstration of their benefit on frail patients, COVID-19 vaccinations were indicated to also be beneficial to oncological population. However, data about the impact of anticancer-treatments and the timing between vaccinations and systemic therapy delivery were not available. We aimed to evaluate potential factors influencing the outcome of the COVID-19 vaccination in cancer patients. We prospectively collected data of patients undergoing the COVID-19 vaccination with gastro-entero-pancreatic and neuroendocrine neoplasms, treated at our institute, between 03/2021 and 12/2021. We enrolled 46 patients, 63.1% males; at the time of data collection, 86.9% had received two-doses of Pfizer-BioNTech and the rest had received the Moderna vaccine. All patients obtained a subsequent immune-response. Chemotherapy seems to determinate a significantly lower antibody response after vaccination compared to the other anti-cancer agents (p = 0.004). No significant effect on immune-response was reported for both vaccinations performed ≤7 vs. >7 days from the last systemic treatment (p = 0.77) and lymphocytes count (p = 0.11). The findings suggest that the optimal timing for COVID-19 vaccination and lymphocytes count are not the issue, but rather that the quality of the subset of lymphocytes before the vaccination determine the efficacy level of immune-response in this population.

The Collateral Benefit of COVID Pandemic: Improved Pharmacological Venous Thromboembolism Prophylaxis Practices in Non-COVID Patients

Background

COVID-19 creates a hypercoagulable state with a wide spectrum of clinical manifestations. Of those, venous thromboembolism (VTE) is prevalent, and numerous studies have highlighted the importance of VTE prophylaxis. Pre-pandemic VTE prophylaxis practices have already been poor, despite guidelines. We hypothesized that the gap between guidelines and practices might have been closed due to increased awareness.

Materials and Methods

Non-COVID-19 patients hospitalized in the internal medicine ward of a university hospital between January 1st, 2021, and June 30th, 2021, were assessed. VTE risk and thromboprophylaxis requirements were assessed using the Padua Prediction Score (PPS). The results were compared with the findings of the study conducted in the same setting before the pandemic.

Results

A total of 267 patients were included, and 81 patients (30.3%) received prophylaxis. A total of 128 patients' (47.9%) PPS was ≥ 4, and 69 patients (53.9%) received prophylaxis; 12 low-risk patients (8.6%) received prophylaxis although it was not indicated. Compared to the pre-pandemic figures, both appropriate prophylaxis use and overuse rates have risen. While the increment rate of appropriate prophylaxis was statistically significant, the increment rate of overuse did not reach statistical significance. Patients hospitalized for infectious diseases and respiratory failure were more likely to receive appropriate prophylaxis.

Conclusion

We have demonstrated a significant increase in appropriate pharmacologic prophylaxis rates among high-risk patients. Besides all the collateral damage the pandemic has created, it might also have brought collateral benefits with regards to VTE prophylaxis.