The first case of coronavirus disease (COVID‐19) caused by severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) in humans occurred in December 2019 in China. COVID‐19 has subsequently spread all over the world. 1 To prevent further spread of this disease, a state of emergency was declared in Hokkaido, February 28th, 2020. This declaration means that the people must work together to avoid infection to themselves and others by implementing basic infection prevention measures, refraining from going out unnecessarily. The legal restrictions were not limited to hospital appointments. To determine the effect of these restrictions on pediatric health care, we investigated changes in pediatric health‐care visits.
This was a retrospective review of the activity in pediatric outpatient departments in Hokkaido, Japan. We invited possible cooperating institutions in Hokkaido; 17 institutions participated. No clinics were included. We included patients who presented for unscheduled pediatric outpatient visits from January 2020 to July 2020. A comparison of the number of unscheduled visits during this period was performed from January to July for each year from 2016 to 2019. The number of unscheduled outpatient visits in 2020 was corrected by weekday. The mean number of unscheduled outpatient visits from January to July from 2016 to 2019 and the standard deviation (SD) were calculated.
A total of 17 institutions participated. Two institutions were excluded due to insufficient data, resulting in 15 institutions contributing data to the final results. There were no reports of complications or serious illness due to refraining from seeing a doctor. We investigated the number of beds, population of the area (including percentage of children), and the number of pediatric physicians to reveal a relevance to the degree of decrease (Table S1). It is difficult to generalize and compare the rate of decline because the scale of institutions, their specialties, and the characteristics of each area are different and the activity of pediatric practice is defined in a complex way. In 2020, the number of unscheduled outpatient visits decreased from March to July compared with the corresponding periods in the previous 4 years (Fig. S1). From March to July, 2020, all units experienced a decrease in unscheduled appointments below lower −2SD from 2016 to 2019, except Rumoi in the northern area in June (Table 1).
Table 1.
The number of unscheduled pediatric outpatient visits in 2020 corrected by weekday
| Area name | The number of unscheduled pediatric outpatient corrected by weekday (Mean of 2016 through 2019, SD † ) | ||||||
|---|---|---|---|---|---|---|---|
| January | February | March | April | May | June | July | |
| Central area | |||||||
| Iwamizawa | 17.2 ‡ (23.8, 2.4) | 37.2 (31.6, 2.9) | 17.9 ‡ (29.5, 1.7) | 12.1 ‡ (28.5, 2.5) | 11.6 ‡ (33.6, 1.8) | 11.5 ‡ (29.0, 1.4) | 9.1 ‡ (26.5, 2.9) |
| Muroran | 14.8 ‡ (21.0, 0.7) | 18.4 (20.8, 3.5) | 12.3 ‡ (20.4, 3.9) | 11.2 ‡ (20.4, 2.3) | 9.1 ‡ (24.6, 2.2) | 9.5 ‡ (23.1, 1.7) | 9.5 ‡ (21.9, 1.9) |
| Sapporo (Hokkaido Medical Center) | 5.8 (6.7, 1.6) | 8.6 (8.4, 2.0) | 3.8 ‡ (8.0, 1.3) | 2.6 ‡ (7.6, 0.5) | 1.3 ‡ (10.0, 0.6) | 4.0 ‡ (9.2, 0.5) | 2.9 ‡ (10.0, 0.6) |
| Sapporo (Sapporo Hokushin Hospital) | 10.9 ‡ (14.6, 1.8) | 9.8 (13.5, 2.9) | 6.9 ‡ (14.6, 3.8) | 5.2 ‡ (12.3, 2.5) | 3.2 ‡ (13.6, 3.5) | 6.0 ‡ (13.4, 1.3) | 6.2 ‡ (13.8, 1.2) |
| Sapporo (Sapporo Medical Center NTT) | 20.5 ‡ (26.3, 2.4) | 23.8 (28.5, 3.0) | 13.9 ‡ (28.9, 2.4) | 12.1 ‡ (29.7, 1.2) | 10.3 ‡ (31.3, 1.9) | 12.1 ‡ (30.7, 2.9) | 14.6 ‡ (28.1, 2.3) |
| Sunagawa | 48.9 (44.2, 2.6) | 63.6 (48.4, 4.6) | 28.1 ‡ (46.4, 5.1) | 30.8 ‡ (51.5, 2.8) | 28.8 ‡ (57.2, 5.9) | 28.8 ‡ (51.4, 5.0) | 31.5 ‡ (49.0, 7.0) |
| Takikawa | 44.9 (52.4, 8.3) | 64.1 (62.6, 10.1) | 29.8 ‡ (59.5, 3.8) | 28.0 ‡ (55.9, 6.3) | 21.3 ‡ (56.5, 3.9) | 21.8 ‡ (52.3, 5.8) | 21.4 ‡ (48.6, 4.2) |
| Urakawa | 24.7 ‡ (1.2, 1.5) | 30.6 (42.2, 7.0) | 10.2 ‡ (35.2, 3.5) | 8.3 ‡ (30.6, 3.2) | 8.3 ‡ (33.7, 5.7) | 15.5 ‡ (33.5, 3.0) | 17.2 ‡ (33.7, 5.0) |
| Southern area | |||||||
| Esashi | 29.3 (26.5, 2.6) | 25.4 (30.7, 2.7) | 9.2 ‡ (26.8, 2.4) | 8.3 ‡ (24.4, 2.4) | 12.1 ‡ (31.4, 3.3) | 14.1 ‡ (25.8, 2.7) | 13.6 ‡ (24.4, 2.1) |
| Hakodate (Hakodate Kyouaikai Hospital) | 20.7 (24.3, 3.0) | 25.8 (31.8, 4.1) | 11.0 ‡ (24.8, 2.9) | 9.7 ‡ (23.5, 0.4) | 8.6 ‡ (24.6, 1.0) | 10.4 ‡ (24.5, 1.6) | 12.1 ‡ (20.8, 0.9) |
| Hakodate (Hakodate Municipal Hospital) | 13.4 ‡ (17.9, 1.4) | 13.6 ‡ (24.5, 3.9) | 4.6 ‡ (19.7, 3.2) | 5.8 ‡ (19.4, 1.9) | 4.5 ‡ (23.9, 1.8) | 6.8 ‡ (24.6, 2.1) | 7.8 ‡ (20.9, 1.5) |
| Yakumo | 34.1 (32.3, 5.8) | 22.4 ‡ (30.9, 3.7) | 10.0 ‡ (26.4, 3.2) | 13.7 ‡ (29.6, 1.2) | 11.4 ‡ (31.1, 2.3) | 14.1 ‡ (25.3, 1.2) | 14.5 ‡ (22.7, 1.2) |
| Northern area | |||||||
| Rumoi | 12.9 ‡ (15.6, 1.0) | 13.2 (17.2, 3.1) | 6.7 ‡ (16.6, 3.2) | 5.1 ‡ (16.0, 4.1) | 6.9 ‡ (19.6, 1.6) | 9.6 (17.8, 4.2) | 7.6 ‡ (15.6, 2.9) |
| Eastern area | |||||||
| Kushiro | 53.1 (58.9, 6.3) | 56.6 (59.9, 4.4) | 32.0 ‡ (59.4, 2.1) | 28,9 ‡ (54.5, 1.1) | 27.6 ‡ (62.7, 1.0) | 35.9 ‡ (63.3, 1.2) | 36.7 ‡ (58.3, 1.8) |
| Nemuro | 24.6 ‡ (30.5, 2.2) | 37.2 (40.7, 3.1) | 17.9 ‡ (40.5, 4.7) | 16.9 ‡ (42.0, 3.7) | 20.8 ‡ (46.5, 4.7) | 24.2 ‡ (48.8, 7.2) | 19.6 ‡ (42.1, 4.4) |
| Total | 375.9 ‡ (426.2, 25.1) | 450.3 (491.7, 46.9) | 214.0 ‡ (456.8, 25.5) | 198.7 ‡ (445.7, 18.9) | 185.6 ‡ (500.4, 17.1) | 224.4 ‡ (472.5, 14.9) | 224.3 ‡ (436.5, 12.3) |
SD, standard deviation.
The number of unscheduled pediatric outpatient visits fallen below −2SD.
This significant decrease in visits could have an effect on healthcare policy to support pediatric practices. We suggest that there were two reasons for the reduction in outpatient visits. First, people refrained from visiting hospitals. They were not able to assess which hospitals accepted SARS‐CoV‐2 patients, and might have avoided any hospital as a potentially risky place for exposure to the disease. The fear from COVID‐19 pandemic resulted in delayed diagnosis and higher complication rates in common pediatric medical conditions. 2 Second, the occurrence of other infectious diseases was reduced as the restrictions on normal daily activities curbed their spread. Preventive measures instituted for SARS‐CoV‐2 such as hand washing, wearing a mask, and avoiding close contact curbed the spread of any infectious disease; social distancing also reduced the spread of influenza and respiratory syncytial virus. 3 , 4 The decrease in outpatient visits in January and February varied by regions. We believe that SARS‐CoV‐2‐related decrease in outpatient visits occurred since March because the state of emergency was declared on February 28, 2020; almost all regions showed a marked decrease from March. The results of this study may have an effect medical staffs and health policy‐makers. An investigation of medical billing by the Ministry of Health, Labor, and Welfare found a 50% decrease in medical charges of pediatric departments from February 1 to May 31, 2020 compared with the corresponding periods in the previous 2 years. 5 A decrease in the number of pediatric medical staff may result in scaling back the activities of the pediatric department or even closure of the pediatric clinic. Methods must be found to change the medical care system before collapse occurs. Health policy‐makers need to take countermeasures and economically support pediatric practices to avoid a collapse in the pediatric community health system.
We have not analyzed any potential confounding variables such as a decrease in child population and outpatient visits. Residual confounding by unmeasured factors is also likely to exist. Our study did not specifically study the reasons for people decreasing hospital visits and whether the spread of other infectious diseases was suppressed.
In conclusion, we confirmed that the number of unscheduled pediatric outpatient visits decreased in Hokkaido during the spread of SARS‐CoV‐2. There is concern about the impact of this decrease in visits on the pediatric medical system due to a decrease in financial income. Future research on these topics would be helpful to understand the public’s behavior during a pandemic.
Disclosure
The authors declare no conflict of interest.
Author contributions
T.W., Y.S, and Y.S contributed to the conception and design of this study. T.W., Y.S, and Y.S performed the statistical analysis and drafted the manuscript. H.S. supervised statistical aspects of this manuscript. Y.K. critically reviewed the manuscript and supervised the whole study process. All authors read and approved the final manuscript.
Ethical consideration
This study was approved by the ethical board of Hakodate Municipal Hospital, Hokkaido, Japan (August 11, 2020, No. 2020‐55).
Supporting information
Fig. S1. Monthly number of unscheduled outpatient visits in 2020 compared with the mean of 2016–2019 and the mean −2SD.
Table S1. The comparison of the scale of the hospital, the characteristics of the area, and the specialty of the institution
Acknowledgments
We gratefully acknowledge the support provided by Toshiya Sato (Department of Pediatrics, Iwamizawa City General Hospital, Iwamizawa, Japan), Masatoshi Tatsumi (Department of Pediatrics, Otaru Association, Otaru, Japan), Makoto Saito (Department of Pediatrics, Steel Memorial Muroran Hospital, Muroran, Japan), Masayoshi Nagao (Department of Pediatrics, Hokkaido Medical Center, Sapporo, Japan), Yoshihito Higashidate (Department of Pediatrics, Sapporo Hokushin Hospital, Sapporo, Japan), Toshihiko Mori (Department of Pediatrics, Sapporo Medical Center NTT, Sapporo, Japan), Masayoshi Kikuchi (Department of Pediatrics, Sunagawa City Hospital, Sunagawa, Japan), Kazushige Nagai (Department of Pediatrics, Takikawa City Hospital, Takikawa, Japan), Minako Kihara (Department of Pediatrics, Tomakomai City Hospital, Tomakomai, Japan), Keisuke Oyatani (Department of Pediatrics, Urakawa Red Cross Hospital, Urakawa, Japan), Yasuhumi Asakura (Department of Pediatrics, Hokkaido Esashi Hospital, Esashi, Japan), Hideatsu Yoshimura (Department of Pediatrics, Hakodate Kyoaikai Hospital, Hakodate, Japan), Masaki Yoshida (Department of Pediatrics, Yakumo General Hospital, Yakumo, Japan), Hidehumi Sueoka (Department of Pediatrics, Rumoi City Hospital, Rumoi, Japan), Noriaki Adachi (Department of Pediatrics, Kushiro City General Hospital, Kushiro, Japan), Ryo Takeuchi (Department of Pediatrics, Municipal Nemuro Hospital, Nemuro, Japan), and for their assistance in obtaining clinical data.
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Associated Data
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Supplementary Materials
Fig. S1. Monthly number of unscheduled outpatient visits in 2020 compared with the mean of 2016–2019 and the mean −2SD.
Table S1. The comparison of the scale of the hospital, the characteristics of the area, and the specialty of the institution