The COVID-19 Pandemic and Outpatient Prescribing Patterns: A Longitudinal Study of Corticosteroid Use, Drug Costs, and Physician Workload in Iran

Background The COVID-19 pandemic disrupted global healthcare delivery, notably altering prescribing practices. While systemic corticosteroids like dexamethasone became a cornerstone for hospitalized COVID-19 patients, the longitudinal impact of these guideline changes on outpatient prescription patterns, healthcare economics, and clinician workload remains underexplored, particularly in real-world, operational primary care settings. Methods We conducted a four-year retrospective, descriptive-analytical study using electronic prescription data from a high-volume, 24-hour outpatient clinic affiliated with Iran's Social Security Organization. A total of 572,849 prescriptions from March 2018 to March 2024 were analyzed across four periods: pre-pandemic, first and second pandemic years, and post-pandemic. Key outcomes included prescription volume, average cost per prescription, the proportion of prescriptions containing injectable medications, and the prescribing frequency of specific systemic corticosteroids (dexamethasone, hydrocortisone, betamethasone). Trends were compared using Chi-square tests and ANOVA. Results Total prescription volume increased by 47.1% from the pre-pandemic to the post-pandemic period. The average cost per prescription escalated sharply by 123%, more than doubling the financial burden per script. Dexamethasone prescribing surged 9.7-fold at its peak during the pandemic and remained 3.8 times higher than the pre-pandemic baseline afterward. Despite a stable number of General Practitioners (range: 18-21), the average prescription load per clinician increased by 33%. The use of injectable medications followed an inverted "U" shape, rising to 32% in the first pandemic year before declining to 21% in the post-pandemic period. Conclusions The COVID-19 pandemic triggered a profound and lasting transformation in outpatient prescribing, characterized by a guideline-driven explosion in systemic corticosteroid use, particularly dexamethasone. These shifts were directly associated with a substantial increase in pharmaceutical expenditures and an intensification of clinical workload in primary care, without corresponding workforce expansion. Our findings underscore the necessity for proactive, adaptable drug formularies, robust cost-monitoring mechanisms, and explicit support structures for primary care providers to ensure the resilience and sustainability of outpatient services during public health crises.