Impact of COVID-19 pandemic on utilisation of healthcare services: a systematic review

Abstract

To determine the extent and nature of changes in utilisation of healthcare services during COVID-19 pandemic.

Design

Systematic review.

Eligibility

Eligible studies compared utilisation of services during COVID-19 pandemic to at least one comparable period in prior years. Services included visits, admissions, diagnostics and therapeutics. Studies were excluded if from single centres or studied only patients with COVID-19.

Data sources

PubMed, Embase, Cochrane COVID-19 Study Register and preprints were searched, without language restrictions, until 10 August, using detailed searches with key concepts including COVID-19, health services and impact.

Data analysis

Risk of bias was assessed by adapting the Risk of Bias in Non-randomised Studies of Interventions tool, and a Cochrane Effective Practice and Organization of Care tool. Results were analysed using descriptive statistics, graphical figures and narrative synthesis.

Outcome measures

Primary outcome was change in service utilisation between prepandemic and pandemic periods. Secondary outcome was the change in proportions of users of healthcare services with milder or more severe illness (eg, triage scores).

Results

3097 unique references were identified, and 81 studies across 20 countries included, reporting on >11 million services prepandemic and 6.9 million during pandemic. For the primary outcome, there were 143 estimates of changes, with a median 37% reduction in services overall (IQR −51% to −20%), comprising median reductions for visits of 42% (−53% to −32%), admissions 28% (−40% to −17%), diagnostics 31% (−53% to −24%) and for therapeutics 30% (−57% to −19%). Among 35 studies reporting secondary outcomes, there were 60 estimates, with 27 (45%) reporting larger reductions in utilisation among people with a milder spectrum of illness, and 33 (55%) reporting no difference.

Conclusions

Healthcare utilisation decreased by about a third during the pandemic, with considerable variation, and with greater reductions among people with less severe illness. While addressing unmet need remains a priority, studies of health impacts of reductions may help health systems reduce unnecessary care in the postpandemic recovery.

PROSPERO registration number

CRD42020203729.

SciScore for 10.1101/2020.10.26.20219352: (What is this?)

Please note, not all rigor criteria are appropriate for all manuscripts.

Table 1: Rigor

Institutional Review Board Statement	not detected.
Randomization	not detected.
Blinding	not detected.
Power Analysis	not detected.
Sex as a biological variable	not detected.

Table 2: Resources

No key resources detected.

Results from OddPub: Thank you for sharing your data.

Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:

Study limitations include the inability to undertake a meta-analysis because of considerable heterogeneity, the possibility of publication bias, the potential of our eligibility criteria to exclude important data sources such as studies in single-centres and unpublished datasets from health systems, subjectivity in our assessments of the secondary outcomes, and the use of an adapted but unvalidated risk of bias tool. The massive global reduction in healthcare utilisation summarised in this review makes a compelling case for prioritising efforts that address the unmet needs of those with non-COVID 19 illness. Consistent messages from the primary studies include calls for monitoring the long-term impacts of this missed care, public campaigns to urge people to seek medical care when they need it, and better preparedness for reducing the extent of missed care in future waves of the pandemic. Evidence of excess population mortality, in addition to deaths from COVID-19, and related phenomena such as increases in out-of-hospital cardiac arrests and contacts with emergency phone-lines 33,34 make these calls to action even more urgent. Conversely, the review’s finding that reductions often tended to be greater for milder or less severe forms of illness, combined with existing evidence about too much medicine, 11-17 suggest that for some people, missing care may not have caused harm. This unprecedented pandemic-induced natural experiment in reduced healthcare utilisation provides a gen...

Results from TrialIdentifier: No clinical trial numbers were referenced.

Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

Results from JetFighter: We did not find any issues relating to colormaps.

Results from rtransparent:

Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
Thank you for including a protocol registration statement.

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