Abstract
Background
In this brief report, we investigated the impact of COVID‐19 on outpatient stroke clinics and inpatient services and their recovery process.
Methods
We sent a survey to physicians worldwide through the network of the World Stroke Organization to investigate the impact of COVID‐19 on stroke clinics. To farther along in recovering from the outbreak, we reviewed stroke and other neurology outpatient clinic visits (approximately 50% were stroke related) and the number of inpatient services from December 2019 to July 2020 in a large neurology department in Shanghai, China, where there was no official city lockdown.
Results
We received 112 valid survey responses from 46 countries, representing all continents except for Antarctica. Only seven of the survey responders (7/112, 6.3%) reported that they have kept their outpatient clinics open as usual, but they did exercise increased precautions for COVID‐19 by following recent guidelines regarding use of personal protective equipment and isolation techniques. The remainder of the respondents have either reduced outpatient clinic services or suspended outpatient clinics completely. Telephone consultation or telemedicine with video capability was used for new patients or follow‐ups, with limited in‐person evaluations when necessary. Outpatient clinic visits and inpatient services from a large tertiary hospital in China decreased dramatically during the peak period of the outbreak, but then rebounded back quickly following the partial or full recovery from the outbreak. Compared with the recovery process of inpatient services, outpatient clinic visits decreased faster and recovered much slower. This is consistent with our global survey data which indicates that some outpatient clinics have rescheduled their outpatient visits for 3 to 6 months.
Conclusions
The COVID‐19 pandemic caused a significant drop of in‐person outpatient visits and inpatient services. Clinic visits recovered slower than inpatient services in stroke and other neurological diseases after the pandemic.
Keywords: clinic, COVID‐19, global impact, hospitalization, stroke, stroke care
The changes in outpatient visits and inpatient services from the neurology department in a tertiary hospital in Shanghai, China, where there was no official city lockdown during the pandemic. A. It indicates the clinic visits from January 2019 to July 2020. Clinic visits dropped by 36.6% in February 2020 as compared to that in February in 2019, with a partial rebound as the effects of the pandemic waned; B. It indicates the inpatient services in stroke and all neurological diseases from January 2019 to July 2020. Inpatient services in stroke and all neurological diseases dropped by 27.4% and 23.8%, respectively, in February 2020 as compared to that in February in 2019 and then rose rapidly to a nearly normal status
1. INTRODUCTION
We and others have reported recently that a significant drop of stroke admissions, evaluations, and related stroke care delivery occurred during the peak period of the novel coronavirus disease (COVID‐19) outbreak. 1 , 2 , 3 , 4 , 5 As we continue monitoring the situation, we observed that many outpatient clinics have reduced or completely stopped in‐person outpatient visits, and there is possible significant difference in recovery process for clinic visits and inpatient services which may have a profound impact on disease management and prevention. In this brief report, we compared the impact of COVID‐19 pandemic on outpatient stroke clinics and inpatient services and their potential difference in recovery process.
2. MATERIALS AND METHODS
There is no patient or individual information involved in this study; therefore, no Internal Review Board approval was needed. We sent a survey, during the last two weeks of April 2020, through the network of the World Stroke Organization to ask two simple questions: “(a) Which country are you in? and (b) How are you handling outpatient stroke‐related visits now?”. Since China is the place where COVID‐19 was initially reported, and is therefore farther along in recovering from the outbreak, we reviewed stroke and other neurology outpatient clinic visits (of which approximately 50% were stroke related) and inpatient services from January 2019 to July 2020 from one large neurology department in Shanghai, China, where there had been no city lockdown.
2.1. Statistical analysis
This was a survey‐based study. All statistical analyses are descriptive, or reported as the actual numbers of observations. The graph is generated using Prism GraphPad (Version 8.2.1 for Windows 10, GraphPad Software, San Diego, CA). The recovery rate is calculated as follows: recovery rate = (number in the same month in 2020/number in the same month in 2019) × 100. A full recovery is defined as 100% as compared to the same period in 2019. Multiple comparisons for the differences among the recovery rates were performed using a chi‐square test. SPSS software (version 20.0, IBM Corporation, NY) was used for data analyses. Values of P < .05 are considered statistically significant.
3. RESULTS
We received 112 valid survey responses from 46 countries representing all continents except for Antarctica. The list of countries and the number of responses, and the summary of the responses are presented in Table 1. Only seven of the survey responders (7/112, 6.3%) reported that they have kept their outpatient clinics open as usual, but with increased precautions for COVID‐19 and following recent guidelines regarding personal protective equipment and isolation techniques. The remainder of the respondents reduced outpatient clinic services or suspended outpatient clinics completely. Telephone consultation or telemedicine with video capability was used for new patients or follow‐ups with limited in‐person evaluations when necessary. Two respondents reported that they have rescheduled their outpatient visits for 3 to 6 months. One reported from Australia that they are changing to telemedicine or phone follow‐up for approximately 80% of their patients. Transient ischemic attack patients are triaged and reviewed by a consultant, and telemedicine or phone visits are arranged with appropriate investigations. Inpatient stroke patients who are discharged are provided with detailed summaries for their family doctors to follow, to reduce postadmission reviews. New medical home visits are provided by some centers in the UK. One survey response from South Korea indicated that telemedicine was allowed during the pandemic, despite not being allowed prior to the pandemic.
TABLE 1.
The impact on outpatient clinics from COVID‐19 pandemic and the usage of telemedicine
| Where do you come from? | Number of answers | Impact on clinics | Telemedicine | |
|---|---|---|---|---|
| Africa | Nigeria | 2 | Reduced/closed | No mention |
| Asia | China | 1 | Reduced | Telephone |
| India | 4 | Reduced/closed | Telephone | |
| Japan | 2 | Open as usual with PPE | No mention | |
| Kyrgyzstan | 1 | Closed | No mention | |
| Malaysia | 5 | Reschedule 3‐6 mo | Virtual clinic/telephone | |
| Myanmar | 1 | Reduced/closed | No mention | |
| Nepal | 1 | Closed | No mention | |
| Oman | 1 | Closed | No mention | |
| Pakistan | 1 | Reduced | No mention | |
| Philippines | 3 | Reduced/closed | Email/SeriousMD App | |
| Saudi Arabia | 1 | Reduced | Video visit | |
| Singapore | 1 | Reduced | No mention | |
| South Korea | 1 | Mostly as usual | Newly allowed tele‐visit | |
| Sri Lanka | 1 | Reduced | Mainly teleconsults | |
| Thailand | 1 | Reduced or rescheduled | No mention | |
| Vietnam | 1 | Reduced/closed | Telemedicine | |
| Europe | Belgium | 4 | Reduced/closed | Telephone |
| Cornwall | 1 | Reduced/closed | Telephone/video call | |
| Croatia | 1 | Reduced/closed | Telephone | |
| France | 2 | Reduced | Telephone/telemedicine | |
| Germany | 4 | Normal/rescheduled | No mention | |
| Greece | 4 | Closed | Telephone/email | |
| Ireland | 2 | Reduced/closed | Phone/virtual clinic | |
| Italy | 5 | Normal/only for emergency | Telephone | |
| Lithuania | 1 | Closed | No mention | |
| North Macedonia | 1 | Open only for emergency | No mention | |
| Norway | 1 | Reduced | Telephone/video | |
| Portugal | 2 | Closed | No mention | |
| Russia | 1 | Closed | No mention | |
| Scotland | 1 | Closed | Telephone | |
| Slovakia | 1 | Closed | No mention | |
| Spain | 5 | Closed | Telephone | |
| Sweden | 4 | Reduced | Telephone/video | |
| United Kingdom | 9 | Limited visit/closed | Telephone/video | |
| Ukraine | 3 | Closed | Teleconsultations | |
| North America | Canada | 8 | Closed | Telemedicine platform |
| Costa Rica | 1 | Closed | Telephone | |
| United States | 8 | Limited visit/closed | Telehealth/video visits | |
| South America | Argentina | 1 | Closed | Telemedicine |
| Australia | 3 | Normal/reduced | Telemedicine | |
| Austria | 2 | Closed | Telephone | |
| Brazil | 4 | Reduced/closed | Telemedicine | |
| Chile | 1 | Closed | Telemedicine | |
| Colombia | 3 | Closed | Telemedicine | |
| Venezuela | 1 | Private emergency unit | No mention | |
COVID‐19, novel coronavirus disease; App, Application; Teleconsults, telephone consult.
As indicated in Figure 1A, outpatient clinic visits to a large tertiary hospital in China decreased dramatically by 36.6% during the peak period of the outbreak in February but then returned to 60.5%, 78.3%, 77.6%, 89.0%, and 78.8% in March, April, May, June, and July, respectively, as compared to the same month in 2019 (Table 2). This is consistent with our global survey data, which indicated that some of the outpatient clinics have rescheduled their outpatient visits for 3 to 6 months. As shown in Figure 1B, due to the fluctuation of outpatient clinic services, inpatient services in all neurological diseases dropped rapidly by 23.8% in February and in the following four months they returned to 65.8%, 82.2%, 64.7%, 78.5%, and 89.1%, respectively. Inpatient stroke admissions dropped rapidly by 27.4% in February and then rebounded quickly recovering to 103.9%, 92.2%, 66.1%, 90.0%, and 100% in March, April, May, June, and July, respectively, as compared to its pre‐COVID‐19 period. Other neurological disease leading to admission included vertebrobasilar insufficiency, epilepsy, Parkinson's disease, intracranial infection, headache, dementia, sleep disturbance, motor neuron disease, and spinal cord disease. Inpatient services experienced a decline in May 2020 similar to that in the peak period of COVID‐19 epidemic in the recovery process, which was related to the overly strict nucleic acid test mandate for inpatients and family members which was removed later on. The number and recovery rate of clinic visits and inpatient services in a large tertiary hospital in China were shown in Table 2. Compared with the recovery process of clinic visits, inpatient services recovered faster, and the number of visits did not fully recover at the end of this investigation.
FIGURE 1.
The changes in outpatient visits and inpatient services from the neurology department in a tertiary hospital in Shanghai, China, where there was no official city lockdown during the pandemic. A. It indicates the clinic visits from January 2019 to July 2020. Clinic visits dropped by 36.6% in February 2020 as compared to that in February in 2019, with a partial rebound as the effects of the pandemic waned; B. It indicates the inpatient services in stroke and all neurological diseases from January 2019 to July 2020. Inpatient services in stroke and all neurological diseases dropped by 27.4% and 23.8%, respectively, in February 2020 as compared to that in February in 2019 and then rose rapidly to a nearly normal status
TABLE 2.
The number and recovery rate of clinic visits and inpatient services in a large tertiary hospital in Shanghai
| Time (Mo, Y) | Clinic Visits | Inpatients (neurological diseases) | Stroke inpatients | |||
|---|---|---|---|---|---|---|
| Number of visits | Comparison with the same month last year | Number of patients | Comparison with the same month last year | Number of patients | Comparison with the same month last year | |
| Jan 2019 | 9316.5 | — | 226 | — | 143 | — |
| Feb 2019 | 6438 | — | 164 | — | 117 | — |
| Mar 2019 | 9761.5 | — | 269 | — | 103 | — |
| Apr 2019 | 9659.5 | — | 253 | — | 129 | — |
| May 2019 | 9827 | — | 249 | — | 127 | — |
| Jun 2019 | 9307 | — | 242 | — | 145 | — |
| Jul 2019 | 9923 | — | 221 | — | 140 | — |
| Aug 2019 | 9570.5 | — | 218 | — | 134 | — |
| Sep 2019 | 7322 | — | 228 | — | 124 | — |
| Oct 2019 | 7106 | — | 219 | — | 127 | — |
| Nov 2019 | 9532 | — | 219 | — | 127 | — |
| Dec 2019 | 9705 | — | 228 | — | 127 | — |
| Jan 2020 | 7108.5 | — | 209 | — | 122 | — |
| Feb 2020 | 4083.5 | 63.4% | 125 | 76.2%* | 85 | 72.6% |
| Mar 2020 | 5909.5 | 60.5% | 177 | 65.8% | 107 | 103.9%* |
| Apr 2020 | 7565 | 78.3% | 208 | 82.2% | 119 | 92.2%* |
| May 2020 | 7629.5 | 77.6% | 161 | 64.7%* | 84 | 66.1%* |
| Jun 2020 | 8286.5 | 89.0% | 190 | 78.5%* | 129 | 90.0%# |
| Jul 2020 | 7822.5 | 78.8% | 197 | 89.1%* | 140 | 100%* |
P < .05, compared with the changes in the clinic visits.
P < .05, compared with the changes of inpatients for all neurological diseases.
4. DISCUSSION
Outpatient clinic visits play a critical role in patient education and stroke (and other neurological disease) prevention, and documenting patient characteristics related to stroke outcome. 6 Secondary stroke prevention, including blood pressure, diabetes, and anticoagulation management, can reduce the incidence and severity of recurring stroke. 7 The reduced service, or the total shutdown, of outpatient clinics for stroke patients can potentially lead to an increased incidence of stroke in the future. Fortunately, due to technology development, the availability of telemedicine was able to offset some of the negative impact from the pandemic related shutdown of outpatient clinics. Based on current clinical experience (personal experience), the adherence of patients to their scheduled telemedicine visits was actually improved compared to prior in‐person visits, with less patients missing their scheduled telemedicine appointments. Compared with the impact on inpatient services from the COVID‐19 epidemic, outpatient clinic visits decreased faster and recovered slower. Telemedicine could potentially play a significant role in the slower recovery of the outpatient clinic visit. It is possible that the negative psychological impact of COVID‐19 could potentially play a role in the slower recovery in the in‐person outpatient clinic visits. This is consistent with the observation that number of hospitalization dropped to a similar extent when a viral test is mandated despite there is no increase of COVID‐19 new cases.
The stroke‐related hospitalization recovered quite quickly since hospitalization for stroke therapy is necessary. This also reflects successful efforts from stroke neurologist in managing stroke patients in the era of COVID‐19 pandemic.
As hospitals and clinics are preparing to reopen to a full “routine” schedule, patients and accompanying person(s) will likely be required to wear masks to avoid hospital acquired COVID‐19, as we proposed recently as a “new normal.” 8 Some hospitals and clinics have already implemented such a universal mask policy, for now and for as long as we still see COVID‐19 patients in the hospital or clinic settings.
The major limitation of this study is that we included only one center to indicate the trend of clinic visit and inpatient services recovery. We did not investigate the key factors that will drive the recovery and mechanisms of future clinic visits and inpatient services, so further studies are needed to investigate these issues. Another limitation is that the survey responses consist of those from only one center in some of the countries, which may not reflect the whole picture of the impact COVID‐19 has had on stroke clinics in these countries.
In conclusion, the COVID‐19 pandemic caused a significant drop of in‐person outpatient visits and inpatient services. The recovery process of clinic visits and inpatient services was different, and clinic visits recovered slower than inpatient services in stroke and other neurological diseases after the pandemic.
CONFLICT OF INTEREST
None of the authors have any conflicts to report.
ACKNOWLEDGMENTS
The authors appreciate the editing assistance from Dr John R. Grothusen at the University of Pennsylvania.
Zhao J, Wang Y, Fisher M, Liu R. Slower recovery of outpatient clinics than inpatient services for stroke and other neurological diseases after COVID‐19 Pandemic. CNS Neurosci Ther. 2020;26:1322–1326. 10.1111/cns.13459
Funding information
Dr. Zhao appreciate the following funding support from the National Natural Science Foundation of China (81973157, PI: JZ); Shanghai Natural Science Foundation (17dz2308400, PI: JZ). Dr. Liu Appreciate the China Research Engagement Funding from the University of Pennsylvania (CREF‐030, PI: RL).
DATA AVAILABILITY STATEMENT
The original data are available for reasonable request to Dr Zhao (zhaojingssmu@163.com) and Dr Liu (RenYu.Liu@pennmedicine.upenn.edu).
REFERENCES
- 1. Kansagra AP, Goyal MS, Hamilton S, Albers GW. Collateral effect of Covid‐19 on stroke evaluation in the United States. N Engl J Med. 2020;383:400‐401. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2. Katsanos AH, de Sa BD, Ahmed Al‐Qami M, et al. In‐hospital delays for acute stroke treatment delivery during the COVID‐19 pandemic. Can J Neurol Sci. 2020;1–17. 10.1017/cjn.2020.170 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3. Liu R, Zhao J, Fisher M. The global impact of COVID‐19 on acute stroke care. CNS Neurosci Ther. 2020;26:1103‐1105 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4. Zhao J, Li H, Kung D, Fisher M, Shen Y, Liu R. Impact of the COVID‐19 Epidemic on stroke care and potential solutions. Stroke. 2020;51:1996‐2001. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5. Zhao J, Rudd A, Liu R. Challenges and potential solutions of stroke care during the coronavirus disease 2019 (COVID‐19) outbreak. Stroke. 2020;51:1356‐1357. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6. Webster F, Saposnik G, Kapral MK, Fang J, O'Callaghan C, Hachinski V. Organized outpatient care: stroke prevention clinic referrals are associated with reduced mortality after transient ischemic attack and ischemic stroke. Stroke. 2011;42:3176‐3182. [DOI] [PubMed] [Google Scholar]
- 7. Deng YX, Wang YL, Gao BQ, et al. Age differences in clinical characteristics, health care, and outcomes after ischemic stroke in China. CNS Neurosci Ther. 2012;18:819‐826. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8. Liu R, Fleisher LA. Getting to a new normal: mandating that patients wear masks as hospitals fully reopen during the coronavirus pandemic. Anesthesiology. 2020;133:479‐481. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The original data are available for reasonable request to Dr Zhao (zhaojingssmu@163.com) and Dr Liu (RenYu.Liu@pennmedicine.upenn.edu).