Keywords COVID-19 - children - public health - health care utilization - Turkey
Introduction
The international public health emergency created by coronavirus disease 2019 (COVID-19),
which is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has
generated an enormous burden for health care systems worldwide.[1 ] The World Health Organization declared this epidemic a “Public Health Emergency
of International Concern” on January 30, 2020 and a pandemic on March 11, 2020.[2 ] Turkey reported its first official case of COVID-19 on March 11, 2020, after which
the number of cases progressed rapidly. Since then, many stay-at-home orders have
been enacted to slow down the spread of SARS-CoV-2. Additionally, the Turkish Ministry
of Health recommended prioritizing urgent hospital visits and delaying elective cases
to decrease the number of patients in the Turkish health care system. The Turkish
government recommended a voluntary quarantine for all citizens and announced a curfew
for those over the age of 65 years on March 21, 2020. Another curfew was later enacted
for people younger than the age of 20 years. Schools and sports activities were closed,
and numerous preventive precautions were implemented.[3 ] Consequently, there was a decrease in patient visits to emergency departments (EDs)
and outpatient clinics. Although the precise cause of the decline is unknown, improvements
in behavioral measures, environmental cleaning, and hand hygiene, plus the use of
face masks and social distancing, may have reduced the spread of non-COVID-19 diseases.
Additionally, fear of SARS-CoV-2 infection has been linked to a reluctance to visit
hospitals.[4 ]
[5 ]
In this study, we aimed to assess how the COVID-19 pandemic affected the utilization
patterns in emergency and outpatient service visits among children and to describe
the changes in the number of patient applications in our medical center. We collected
the service volume of outpatient and EDs in a public training and research hospital
that functions as the maternity and children's diseases center in Istanbul, Turkey,
for the first 3 months of the COVİD-19 pandemic in 2020 and the same period of the
preceding year. To the best of our knowledge, no similar study on Turkish pediatric
hospitals has been undertaken previously.
We conducted this study as a starting point for present and future research on COVID-19's
long-term effects on health care.
Materials and Methods
We conducted this interrupted time-series study retrospectively by analyzing the numbers
and diagnoses of patients who visited the ED and outpatient clinics at the pediatric
department of the University of Health Sciences and the tertiary Zeynep Kamil Maternity
and Children's Hospital in Istanbul, Turkey. Our 160-year-old training and research
hospital offers free services to 0 to 18-year-old patients from various socioeconomic
levels; both local citizens and patients from other cities are accepted. The ED is
open to patients 24/7, and outpatient clinics are available for 8 hours during the
day, Monday through Friday.
The defined study period was March 11, 2020 to June 11, 2020—the 3 months immediately
following the first confirmed case of COVID-19 in Turkey. We determined the changes
in the volume of patients and rates of various diagnoses after the COVID-19 pandemic
began and compared the same 3-month period to the year before the onset of the pandemic.
We collected the outpatient and emergency service volumes for both years. The general
outpatient clinic was included in the study, but subspecialties and healthy child
follow-up clinics were not. Thus, most of those patients appear to be “newcomers.”
The total number of patients, between 0 and 18 years, seen before the COVID-19 outbreak
(March 11 to June 11, 2019) was 65,456; after the COVID-19 outbreak (March 11 to June
11, 2020), only 24,151 patients visited the hospital. Medical and demographic data
were extracted from the hospital database. Every application was documented using
electronic records, including the patients' age, sex, date, patient complaints, and
diagnoses. The diagnoses were coded according to the International Classification
of Diseases, Tenth Revision, and Clinical Modification (ICD-10-CM) and then categorized.
The ICD R50–R69 codes classify general signs and symptoms such as headache, tiredness,
unknown fever, pain not classified elsewhere, and edema not classified elsewhere.
Using the numbers obtained from the data released by the Ministry of Health in Turkey,
we examined the relationship between the volume of patients who had requested a daily
visit to the pediatric department and the increasing number of COVID-19 cases. We
also analyzed the patient rates for the most common diseases requiring emergency or
outpatient clinic visits before and during the pandemic study period.
This study was approved by the Ministry of Health of Turkey and the Ethics Committee
of Zeynep Kamil Maternity and Children's Diseases Training and Research Hospital (approval
number: 148; approval date: July 08, 2020).
Continuous variables are presented as mean ± standard deviation. Categorical variables
were presented as n (%), and χ was used to compare the qualitative variables. They were analyzed using
SPSS 21.0 program (SPSS Inc. Chicago, IL, United States); p < 0.05 was considered statistically significant. Additionally, Pearson's correlation
was used for data normally distributed in continuous measurement variables.
Results
In the first 3 months of the COVID-19 outbreak (March 11 to June 11, 2020), the total
number of patients who visited our pediatric department was 24,151 ( 12,774 to the ED; 11,377 to the outpatient clinic's four examination rooms), which
was 36.89% of the 65,456 patient visits during the corresponding time frame in the
preceding year (35,340 patients to the ED; 30,116 to the outpatient clinic). [Fig. 1 ] compares the visits to the ED in the period in 2020 with the corresponding period
in 2019. [Fig. 2 ] similarly compares the visits to the outpatient clinic during both periods.
Fig. 1 Visits to pediatric emergency departments from March 11 through June 11, 2020, compared
with the same period in 2019.
Fig. 2 Visits to pediatric outpatient clinics from March 11 through June 11, 2020, compared
with the same period in 2019.
The mean daily number of patients who visited the hospital's pediatric department's
outpatient and emergency clinics started to decrease following the report of the country's
first case of COVID-19. The decrease in attendance accelerated following Turkey's
lockdown announcement on April 1, 2020. The most rapid decline in visits occurred
in April, as COVID-19 cases increased (p < 0.01). Although COVID-19 cases increased daily, patient visits started to rise
again at the end of May and into June, when lockdown measurements were reduced. The
correlation between the numbers of COVID-19 cases and number of patients admitted
in March, April, May, and June was r = − 0.87389, p = 0.022854, r = − 0.95669, p = 0.010749, r = 0.99955, p = 0.010749, and r = 0.93108, p = 0.0221494, respectively ([Fig. 3 ]).
Fig. 3 Changes in the number of request for pediatric clinic visits as the number of COVID-19
cases in the country (Turkey) increased. COVID-19, coronavirus disease 2019.
A total of 89,607 patients (42,648 females and 46,959 males) were included in the
present study. A comparison of the demographics showed that the age of the patients
who visited the outpatient service was significantly less during the COVID-19 period
(mean age = 2.75 ± 4.438 years) than at the same time the previous year (mean age = 4.43 ± 4.717
years) (p < 0.01). There was no statistical difference regarding gender (p > 0.05).
During the COVID-19 outbreak, respiratory system diseases (49.1%), gastrointestinal
diseases (19%), and neonatal problems (9.9%) were the most common diseases seen in
the pediatric ED. Statistically significant differences (p < 0.01) were found between the 2 years for patient diagnoses in EDs.
In addition to the general impacts of COVID-19 on the total volume of ED visits, there
were significant variations in the distribution of children's diagnoses compared to
the prior year. Specifically, we found statistically significant decreases (p < 0.001) in cases of respiratory and gastrointestinal system diseases caused by transmissible
infections and in allergic, immunological, and ophthalmological diseases. In contrast,
we observed relatively significant increases (p < 0.001) in percentages of neonatal, urogenital, neurological, cardiovascular, hematological,
and dermatological diseases ([Table 1 ]).
Table 1
The distribution of diseases in pediatric emergency department before and during the
COVID-19
Before COVID-19 n = 35,043 (%)
During COVİD-19 n = 12,774 (%)
p -Value
Respiratory system diseases
18,908 (53.1)
6,276 (49.1)
<0.001
Gastrointestinal system diseases
8,292 (23.3)
2,432 (19)
<0.001
Neonatal problems
1,429 (4)
1,169 (9.9)
<0.001
Otorhinolaryngological diseases
1,175 (3.3)
515 (3.2)
0.7
Allergic and immunological diseases
Urogenital diseases
1,169 (3.3)
1,028 (2.9)
268 (2.1)
570 (4.5)
<0.001
<0.001
Neurological diseases
484 (1.4)
339 (2.7)
<0.001
Cardiovascular diseases
456 (1.3)
307 (2.4)
<0.001
Ophthalmological diseases
428 (1.2)
84 (0.7)
<0.001
Dermatological diseases
424 (1.2)
387 (3)
<0.001
Exanthematous diseases
373 (1)
29 (0.2)
<0.001
Musculoskeletal disorders
364 (1)
95 (0.7)
0.005
Intoxication and trauma
197 (0.6)
64 (0.5)
0.4
Endocrinological diseases
112 (0.3)
38 (0.3)
0.7
Hematological diseases
71 (0.2)
67 (0.5)
<0.001
Rheumatological disorders
66 (0.2)
10 (0.1)
0.009
Nutrition and metabolism disorders
26 (0.1)
4 (0)
0.1
Child psychiatric disorders
18 (0.1)
9 (0.1)
0.4
Surgical diseases
12 (0)
9 (0.1)
0.08
General sign and symptoms
7 (0)
2 (0)
1
Genetic disorders
4 (0)
1 (0)
1
COVID-19
0 (0)
99 (0.8)
<0.001
Abbreviation: COVID-19, coronavirus disease 2019.
Neonatal problems (42.4%), respiratory system diseases (13.1%), and general symptoms
(10.8%) were observed in the outpatient clinics during the COVID-19 period, and there
were statistically significant differences (p < 0.01) between the 2 years in terms of the diagnoses of the patients who visited
the outpatient clinics. According to the distribution of the diseases, only neonatal
problems and general signs and symptoms increased (p < 0.01) ([Table 2 ]).
Table 2
The distribution of diseases in pediatric outpatient clinics before and during the
COVID-19
Before COVID-19 n = 30,413
During COVİD-19 n = 11,377
p -Value
Respiratory system diseases
6,854 (22.5)
1,486 (13.1)
<0.001
Neonatal problems
4,992 (16.4)
4,821 (42.4)
<0.001
Endocrinological diseases
3,851 (12.7)
870 (7.6)
<0.001
Hematological diseases
3,265 (10.7)
812 (7.1)
<0.001
General sign and symptoms
2,836 (9.3)
1,227 (10.8)
<0.001
Gastrointestinal system diseases
2,280 (7.5)
577 (5.1)
<0.001
Urogenital diseases
1,643 (5.4)
440 (3.9)
<0.001
Allergic and immunological diseases
1,117 (3.7)
203 (1.8)
<0.001
Dermatological diseases
818 (2.7)
211 (1.9)
<0.001
Neurological diseases
661 (2.2)
208 (1.8)
0.02
Otorhinolaryngological diseases
489 (1.6)
82 (0.7)
<0.001
Cardiovascular diseases
389 (1.3)
98 (0.9)
<0.001
Child psychiatric disorders
228 (0.7)
27 (0.2)
<0.001
Ophthalmological diseases
221 (0.7)
50 (0.4)
0.001
Nutrition and metabolism disorders
204 (0.7)
38 (0.3)
<0.001
Musculoskeletal disorders
155 (0.5)
53 (0.5)
0.5
Genetic disorders
129 (0.4)
26 (0.2)
0.003
Rheumatological disorders
93 (0.3)
16 (0.1)
0.003
Surgical diseases
85 (0.3)
41 (0.4)
0.1
Exanthematous diseases
84 (0.3)
12 (0.1)
0.001
Intoxication and trauma
19 (0.1)
9 (0.1)
0.5
COVID-19
0 (0)
70 (0.6)
<0.001
Abbreviation: COVID-19, coronavirus disease 2019.
When considering hospitalization in both periods, 619 patients were hospitalized in
total: 376 (60.74%) of the hospitalizations occurred before the pandemic and 243 (39.26%)
occurred within the COVID-19 pandemic period. The total hospitalization rate dropped
by 35.37%, but the maximum decrease was seen in the second month of the lockdown when
it dropped by 53.12% compared with the same period of 2019. Analysis showed that the
top three reasons for hospitalization in the study period before COVID-19 were respiratory
system diseases (60%), gastrointestinal system diseases (9.57%), and urogenital system
diseases (3.72%). Those diseases comprised 44.85, 10.28, and 9.46%, respectively,
of all analyzed hospitalizations during the pandemic. However, among both study periods,
the second month of the pandemic had the fewest recorded hospitalized patients, but
urogenital diseases were the most common cause (25.42% of all hospitalizations).
The percentage of pediatric intensive care unit patients dropped by 15.38% during
the pandemic compared with the same time last year. Although respiratory system diseases
were the most common reason for intensive care hospitalization (79.48%), they dropped
by 64.51% during the pandemic, and neurological diseases increased to 30.30%.
In the first trimester of the pandemic, COVID-19 patients comprised 0.8% of the ED
admissions. Our COVID-19 patients had a milder clinic course, and 11.1% were asymptomatic.
The most common clinical findings were acute upper respiratory tract infections (59.2%)
and pneumonia (29.6%). The hospitalization rate of COVID-19 patients was 6.06%; the
length of stay ranged from 4 to 13 days (median 5). Finally, there were no cases of
death between the study periods.
Discussion
At the time of the writing of this paper, the COVID-19 pandemic has impacted the health
sector globally. Our study data indicate a significant reduction in the total number
of visits to the pediatric department of the university hospital during the first
3 months of the pandemic in Turkey. Pediatric patient visits to EDs drastically reduced
during the lockdown period compared to the preceding year, dropping by 63.85% in 2020
to 36.15% of the total for 2019; the decrease has been attributed to the curfew for
children in Turkey. Similarly, other studies have also shown a significant reduction
in emergency visits during the initial weeks of the pandemic.[6 ]
[7 ] Talarico et al observed a reduction of approximately 70% in both visits to Italian
pediatric EDs and the number of hospitalizations.[8 ] Erlichman et al reported a decrease in pediatric ED visits.[9 ] This decrease in the number of visits to the pediatric department contrasts with
the increased number of patient visits during the influenza epidemic[10 ]
[11 ] and could be attributed to the well-characterized cause and knowledge of the symptoms
of influenza, which, unlike COVID-19, emerged as a new infection caused by a virus
that was not well understood. Turkey saw exponential growth in COVID-19 cases in March
2020, and the Turkish government imposed a stay-at-home policy.
The results suggest that the restrictive policy and preventive measures, including
restricting international travel and public transportation, implementing distance
education, and improving hand hygiene in the community, may be responsible for reducing
some patient visits.[12 ] The Ministry of Health in Turkey designated some public hospitals to admit COVID-19
patients. This regulation has a positive effect on controlling the pandemic and reminds
society of the necessity of preventive medicine. On March 12, 2020, the Turkish government
declared the closure of all schools.[3 ] Schools are significant vectors for infectious disease transmission; therefore,
the closing of schools has reduced non-COVID-19 respiratory and gastrointestinal tract
infections and accidental traumas among children.[13 ] Improved social hygiene in society may also have had similar effects. However, as
children may become sick from occasional infections and chronic conditions, this factor
cannot explain the sharp decline in-patient visits. It is, therefore, surmised that
COVID-19 created an environment of fear in society. Mantica et al emphasize that national
lockdowns created an environment of strong emotions within communities—especially
fear. The survey conducted by Kadambari et al showed that 37% of parents delayed seeking
any medical attention as they avoided visiting their family doctor. Additionally,
10% delayed attending hospital because of COVID-19 fears. This delay may have been
exacerbated by the rapid local and international spread affecting vast numbers of
people and hospital staff,[14 ]
[15 ] some of whom eventually required intensive care. Ahorsu et al suggest fear of COVID-19
is positively associated with hospital anxiety.[16 ] Additionally, continuous exposure to news of worldwide infection rates of the pandemic
and deaths may have escalated people's fear, as distress about the risk of getting
infected increases fear among the population.[17 ] In that case, a reduction in noninfectious diagnosis would be conceivable.
Additionally, considering the other causes of fewer admissions during the COVID-19
pandemic, patients from remote cities may have failed to reach our hospital because
of public transport restrictions. As our hospital did not offer telemedicine services,
those patients may have sought care at other medical centers or online. Additionally,
EDs are often described as overwhelmed by a high volume of nonurgent admissions in
nonpandemic times[18 ]; thus, parents may have felt less stressed about nonurgent issues. Also, as most
of the parents were working from home, parents may have received less feedback from
teachers, grandparents, and caregiver workers; the reduced feedback may have contributed
to decreased ED visits.[19 ]
Although respiratory system diseases were the most common disease in both periods
considered in this study, there was a significant decrease in ED visits for such ailments
during the COVID-19 period. Personal protective equipment usage, increased hygiene
measures, and the stay-at-home policy[20 ]
[21 ] are likely causal factors for the decline. Although the total number of patients
decreased when the fear of COVID-19 grew following its rapid spread, the number of
patients admitted for neonatal problems and percentages of those with cardiological
and hematological diseases were relatively higher than before the pandemic period,
possibly suggesting that parents used the ED for situations they considered “severe.”
One limitation of our study was that it was a single-center study conducted during
a limited period. Also, the center where the study was conducted was not a pandemic
hospital. Furthermore, although we thought that parents avoided seeking medical services
because they feared contracting the COVID-19, we did not explore this assumption as
a part of this study. Additionally, the retrospective design of this study did not
allow for the comparison of the levels of disease severity.
The COVID-19 pandemic has had severe effects on many aspects of health care, including
the numbers of, and reasons for, hospital visits. This study is the first in Turkey
to investigate the frequency and nature of ED and outpatient pediatric visits during
this pandemic. International attention has primarily concentrated on COVID-19's direct
impacts on adults; however, it is essential not to overlook the severe pediatric health
consequences resulting from people's fear of COVID-19. The data herein raise the question,
“Where are these patients? Have some patients not received the necessary treatment
during the COVID-19 pandemic?” Therefore, the long-term effects of fewer pediatric
hospital visits must be further explored to prevent future problems. Moreover, the
public must be educated about the safety of hospital environments and measures to
decrease the risks of contracting COVID-19.
