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Cardiovascular
Original Article
8 (
1
); 18-24
doi:
10.25259/IJCDW_17_2023

Outpatient Attendance in COVID Pandemic Lockdown: An Observational Study

Department of Cardiology, Dayanand Medical College and Hospital, Unit Hero DMC Heart Institute, Ludhiana, Punjab, India
Research and Developement Centre, Dayanand Medical College and Hospital, Punjab, India
Corresponding author: Shibba Takkar Chhabra, Department of Cardiology, Dayanand Medical College and Hospital, Unit Hero DMC Heart Institute, Ludhiana, Punjab, India. shibbachhabra@yahoo.com
Licence
This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

How to cite this article: Chhabra SK, Kaur G, Aggarwal R, Bansal N, Kishore H, Goyal M, et al. Outpatient attendance in COVID pandemic lockdown: An observational study. Indian J Cardiovasc Dis Women 2023;8:18-24.

Abstract

Objectives:

The objectives of this study were to analyze the profile of outpatient department (OPD) attendance of a tertiary care hospital during pre- and post-pandemic lockdown period.

Materials and Methods:

All consecutive patients presenting to OPD from August 1, 2019 to November 23, 2020 were included in the study. The sample was divided into Zone R (Regular domain) and Zone L (Lockdown domain). Zone L was divided into three groups A, B, and C; representing attendance to be <30%, 30–60%, and >60% of previous (i.e., Zone R), respectively. The patient gender, intradepartmental, and inter departmental OPD attendance data were collected and analyzed.

Results:

n = 428,322 patients attended the OPD in the study period. 301,586 patients presented in Zone R and 126,736 presented in Zone L (P = 0.000). Zone L recorded an OPD attendance drop to 42% of Zone R. The least attended an OPD (Group A) was ophthalmology, ENT, dermatology, surgery, and orthopedics versus highest attendance (Group C) was noticed in emergency OPD and oncology with a moderate decline in the rest (P = −0.00, 0.00, and 0.00, respectively). Both male and female attendance in the OPD showed a decline; however, the gender divide was apparent with significantly low women attendance in all the departments (P = 0.00).

Conclusion:

OPD attendance showed a significant reduction in COVID lockdown era hitting the non-emergent medical branches the most. The gender divide significantly widened with less female attendance recorded in most OPDs in pandemic lockdown. Apt administrative measures could prove fruitful by an improved OPD attendance and its psychosocial implications to a society with less disease burden.

Keywords

COVID 19
Outpatients
Lock down

ABSTRACT IMAGE

INTRODUCTION

SARS-CoV-2 has brought unprecedented catastrophe to mankind. Besides physical illness, psychological pressures, the economic brunt is being faced by major sections of society. As the society curtails on its basic expenditure, several health-related issues are also nipped off. Baring major emergencies, the patient population avoids any routine visits, semi-elective or elective procedures.

To curb the disease transmission, many countries have adopted the policy of lockdown, an action for mass quarantine. The government of India ordered a nationwide lockdown for 3 weeks on March 24, 2020, which was subsequently extended and still remains in effect with some relaxations at the time of writing.

The COVID-19 pandemic has dramatically changed how outpatient care is delivered in health care practices. Several previous reports reveal a lower footfall to their outpatient departments (OPD). In the present review, we attempt to analyzed data on changes in visit volume of OPD attendance in our hospital during the pandemic lockdown and pre-pandemic era.

MATERIALS AND METHODS

Study design and study population

The outpatient attendance data were collected from a tertiary care hospital of North India, a non-profit organization with a high footfall and volume. The research was performed with patient or public involvement. All consecutive patients presenting to OPD from August 1, 2019, to November 23, 2020, were included in the study. The attendance of all the departments of the hospital was considered and the percentage of patients presenting in each was calculated. The lockdown in India in the first wave of COVID-19 was initiated on March 24, 2020.[1] The sample was divided into two time domains, a pre-lockdown domain labeled as Zone R (Regular Domain) from August 1, 2019, to March 23, 2020, and a lockdown domain labeled as Zone L (Lockdown Domain) from March 23, 2020, to November 23, 2020. The number and percentage of patients presenting overall in all departments together and then individually in each were compared in the two domains. The attendance in Zone L was further segregated into three groups: A, B, and C; representing attendance to be <30%, 30–60%, and >60% of the previous (i.e., Zone R). The male and female attendance was recorded and noticed for each of the departments.

The study was conducted under real-life conditions of daily clinical practice and in accordance with the Declaration of Helsinki. Study protocol was approved by the Institutional Ethics Committee and it conformed to ethical guidelines of the 1975 Declaration of Helsinki (DMCH/R&D/2020/145).

Statistical analysis

Data were described in terms of frequencies (number of cases) and relative frequencies (percentages) as appropriate. For comparing categorical data, Chi-square (χ2) test was performed. A probability value (P value) <0.05 was considered statistically significant. All statistical calculations were done using (Statistical Package for the Social Science) SPSS 21version (SPSS Inc., Chicago, IL, USA) statistical program for Microsoft Windows.

RESULTS

A total sample size of 428,322 patients attended the OPD in the study period. Of these, 301,586 patients presented in Zone R (Regular period) versus 126,736patients in Zone L (Lockdown period) (P = 0.000). Besides overall reduction in OPD volume in Zone L, the individual attendance of each department in Zone L was also significantly reduced [Table 1 and Figure 1]. Collectively, only 42% of Zone R’s attendance was seen in Zone L [Table 2].

Table 1: OPD attendance in various departments in Zone L and Zone R.
Department Zone R (regular zone) Zone l (lockdown zone) P-value
Anesthesiology 54 0.02% 13 0.01% 0.080
Cardiac thoracic surgery 3899 1.29% 2316 1.83% 0.000
Cardiology 31222 10.35% 16661 13.15% 0.000
Dental 3471 1.15% 899 0.71% 0.000
Dermatology 23825 7.90% 6679 5.27% 0.000
ENT 13741 4.56% 3689 2.91% 0.000
Emergency 24279 8.05% 16722 13.19% 0.000
Endocrinology 7531 2.50% 2714 2.14% 0.000
Eye 14454 4.79% 3420 2.70% 0.000
G. I. Surgery 1242 0.41% 603 0.48% 0.003
Gastroenterology 26524 8.79% 14305 11.29% 0.000
Hypertension (HDHI) 913 0.30% 191 0.15% 0.000
Liver transplant/hepathobiliary 54 0.02% 20 0.02% 0.700
Medicine 30172 10.00% 14199 11.20% 0.000
Nephrology 3838 1.27% 2008 1.58% 0.000
Neurosurgery 4144 1.37% 1030 0.81% 0.000
Neurology 14669 4.86% 6400 5.05% 0.010
Obst&gyne 12350 4.10% 4415 3.48% 0.000
Oncowing medical oncology 3748 1.24% 2951 2.33% 0.000
Oncowing radiation oncology 1766 0.59% 1152 0.91% 0.000
Oncowing surgical oncology 961 0.32% 901 0.71% 0.000
Oncology 190 0.06% 364 0.29% 0.000
Orthopedics 14889 4.94% 4358 3.44% 0.000
Pediatric surgery 696 0.23% 221 0.17% 0.000
Pediatrics 13404 4.44% 4741 3.74% 0.000
Plastic surgery 1800 0.60% 591 0.47% 0.000
Psychiatry 9865 3.27% 4494 3.55% 0.000
Pulmonary medicine 6289 2.09% 2219 1.75% 0.000
Radiology 268 0.09% 275 0.22% 0.000
Rheumatology and immunology 1598 0.53% 671 0.53% 1.000
Spine center 1024 0.34% 46 0.04% 0.000
Surgery 15095 5.01% 2073 1.64% 0.000
Urban health center 9040 3.00% 3741 2.95% 0.420
Surgical oncology 347 0.12% 169 0.13% 0.120
Urology 4224 1.40% 1485 1.17% 0.000
Total 301,586 100.00% 126,736 100.00% 0.000

OPD: Outpatient department

Table 2: Percentage reduction in OPD attendance of Zone L.
Department Zone R (regular zone) Zone l (lockdown zone) Percentage of previous
Anesthesiology 54 13 24.07
Cardiac thoracic surgery 3899 2316 59.40
Cardiology 31222 16661 53.36
Dental 3471 899 25.90
Dermatology 23825 6679 28.03
ENT 13741 3689 26.85
Emergency 24279 16722 68.87
Endocrinology 7531 2714 36.04
Eye 14454 3420 23.66
G. I. Surgery 1242 603 48.55
Gastroenterology 26524 14305 53.93
Hypertension (HDHI) 913 191 20.92
Liver transplant/hepathobiliary 54 20 37.04
Medicine 30172 14199 47.06
Nephrology 3838 2008 52.32
Neurosurgery 4144 1030 24.86
Neurology 14669 6400 43.63
Obst&Gyne 12350 4415 35.75
Oncowing medical oncology 3748 2951 78.74
Oncowing radiation oncology 1766 1152 65.23
Oncowing surgical oncology 961 901 93.76
Oncology 190 364 191.58
Orthopedics 14889 4358 29.27
Pediatric surgery 696 221 31.75
Pediatrics 13404 4741 35.37
Plastic surgery 1800 591 32.83
Psychiatry 9865 4494 45.55
Pulmonary medicine 6289 2219 35.28
Radiology 268 275 102.61
Rheumatology and immunology 1598 671 41.99
Spine center 1024 46 4.49
Surgery 15095 2073 13.73
Urban health center 9040 3741 41.38
Surgical oncology 347 169 48.70
Urology 4224 1485 35.16
Total 301586 126736 42.02

OPD: Outpatient department

Comparison of attendance in various departments in Zone L and Zone R.
Figure 1:
Comparison of attendance in various departments in Zone L and Zone R.

In Zone L, Group A (<30% of previous) consisted of the least attended OPDs, Group B (30–60% of previous) consisted of moderately attended OPDs, and Group C (>60% of previous) were the OPDs with maximum attendance during the lockdown phase. The least attended OPDs include ophthalmology, ENT, dermatology, orthopedics, neurosurgery, anesthesia, and general surgery. Moderate attendance was noted in pediatric surgery, plastic surgery, urology, pulmonary medicine, pediatrics, obstetrics and gynecology, endocrinology, urban health center, rheumatology, neurology, psychiatry, medicine, nephrology, cardiology, and cardiothoracic surgery. Maximum attendance was observed in oncology with its medical, surgical and radiation wings, and in emergency OPD. Furthermore, a statistically significant rise in attendance in Zone L as compared to Zone R was noticed in oncology and radiology (P = 0.003, 0.600 respectively) [Table 3]. The gender description of our subject population was noticed and separated into male and female subsets. A significant decline in OPD attendance was apparent among both the sexes in Zone L versus Zone R. However, the gender divide was significantly higher with relatively a smaller number of females presenting in the lockdown era. A statistically significant reduction in number of women presenting in Zone L versus Zone R was noticed in cardiology, emergency, endocrinology, ophthalmology, medicine, neurosurgery, neurology, oncology, orthopedics, psychiatry, pulmonary medicine, surgery, and urology departments [Table 4 and Figure 2].

Table 3: Group stratification of OPD attendance of Zone L.
OPD attendance as compared to previous Percentage Departments P-value
Group A
<30% 4.49 Spine center
13.73 Surgery
20.92 Hypertension
23.66 Eye
24.07 Anesthesiology
24.86 Neuro surgery
25.90 Dental
26.85 ENT
28.03 Dermatology
29.27 Orthopedics 0.00
Group B
30–60% 31.75 Pediatric surgery
32.83 Plastic Surgery
35.16 Urology
35.28 Pulmonary
medicine
35.37 Pediatrics
35.75 Obst&Gyne
36.04 Endocrinology
37.04 Liver transplant/Hepathobiliary
41.38 Urban health
center
41.99 Rheumatology and immunology
43.63 Neurology
45.55 Psychiatry
47.06 Medicine
48.55 G. I. Surgery
48.70 Surgical oncology
52.32 Nephrology
53.36 Cardiology
53.93 Gastroenterology
59.40 Cardiac thoracic surgery 0.00
Group C
>60% 68.87 Emergency
78.74 Medical oncology
65.23 Radiation oncology
93.76 Surgical oncology
191.58 Oncology
102.61 Radiology 0.00

OPD: Outpatient department

Table 4: Gender discrepancy of OPD attendance in Zone L versus Zone R.
Department ZONE R ZONE L P-value ZONE R ZONE L
Male Female Male Female Female% Female%
Anesthesiology 36 18 9 4 1.000 33.33 30.77
Cardiac thoracic surgery 2783 1116 1662 654 0.740 28.62 28.24
Cardiology 19138 12084 10362 6299 0.050 38.70 37.81
Dental 1798 1673 467 432 0.940 48.20 48.05
Dermatology 12470 11355 3549 3130 0.240 47.66 46.86
ENT 7688 6053 2084 1605 0.880 44.05 43.51
Emergency 14948 9331 10501 6221 0.011 38.43 37.20
Endocrinology 3326 4205 1294 1420 0.001 55.84 52.32
Eye 7511 6943 1890 1530 0.001 48.04 44.74
G. I. Surgery 695 547 343 260 0.720 44.04 43.12
Gastroenterology 16381 10143 9015 5290 0.012 38.24 36.98
Hypertension 617 296 132 59 0.730 32.42 30.89
Liver transplant/hepathobiliary 37 17 17 3 0.230 31.48 15.00
Medicine 15074 15098 8294 5905 0.000 50.04 41.59
Nephrology 2437 1401 1275 733 1.000 36.50 36.50
Neurosurgery 2488 1656 679 351 0.000 39.96 34.08
Neurology 7433 7236 3381 3019 0.004 49.33 47.17
Obst&gyne 203 12147 68 4347 0.670 98.36 98.46
Oncowing medical oncology 1728 2020 1307 1644 0.144 53.90 55.71
Oncowing radiation oncology 774 992 482 670 0.300 56.17 58.16
Oncowing surgical oncology 375 586 371 530 0.340 60.98 58.82
Oncology 91 99 222 142 0.003 52.11 39.01
Orthopedics 7110 7779 2278 2080 0.000 52.25 47.73
Pediatric surgery 505 191 163 58 0.790 27.44 26.24
Pediatrics 8137 5267 2907 1834 0.460 39.29 38.68
Plastic surgery 1164 636 406 185 0.800 35.33 31.30
Psychiatry 5673 4192 2688 1806 0.009 42.49 40.19
Pulmonary medicine 3528 2761 1337 882 0.006 43.90 39.75
Radiology 151 117 162 113 0.600 43.66 41.09
Rheumatology and immunology 448 1150 165 506 0.090 71.96 75.41
Spine center 537 487 25 21 0.880 47.56 45.65
Surgery 8449 6646 1274 799 0.000 44.03 38.54
Surgical oncology 139 208 45 124 0.003 59.94 73.37
Urban health center 3639 5401 1431 2310 0.030 59.75 61.75
Urology 3219 1005 1197 288 0.004 23.79 19.39
Total 160,730 140,856 71,482 55,254 0.000 46.71 43.60

OPD: Outpatient department

Comparison of female attendance in outpatient department in Zone L versus Zone R.
Figure 2:
Comparison of female attendance in outpatient department in Zone L versus Zone R.

DISCUSSION

The year 2020–2021 has brought the mankind and medical profession at the crossroads with a calamity never before seen. A hospital is nurtured primarily through it is outpatient visits besides the visits to the emergency department. The attendance to the outpatient department is reflective of the care provided by the hospital and also the care sought by the public at large. The data from several institutes documented reduction in the out-patient department during the pandemic and lockdown phase.[2-4]

As expected, in the present study, the visit to out-patient departments were significantly reduced during the lockdown phase. This reduction can be attributed to the overall decrease in elective or preventive visits such as annual health check-ups, fear of transmission of infection among health workers, and public and travel restrictions implemented by the government at large.[3] While maximum reduction was seen in Ophthalmology, ENT, Dermatology, Dental, Anesthesia, Neurosurgery, and Orthopedics OPD, the least reduction in patient attendance was seen the emergency wing and oncology (inclusive of medical, radiation, and surgical oncology). Rest all the OPDs documented a moderate (30–60% attendance of previous) reduction in OPD attendance and these reductions were statistically significant. These OPD trends are consistent with several previous reports documenting a fall in OPDs with a smaller number of emergent or critical procedures and issues. However, a rebound increase in these OPDs with patients presenting with chronic ailments could be expected in times to come.[3] It was interesting to note that besides emergency visits the number of patient reduction in the OPD department of oncology was the least, which is very encouraging since any withdrawal of chemotherapy or radiotherapy in carcinomatous patients could mean a worsening stage of carcinogenesis and rapid deterioration and loss of human life. It could also be reflective of inability of primary care centers and primary care physicians to render medical services to sick oncological patients with active disease.[5-7]

Another interesting finding in our study was the disparity in female attendance to the various OPDs. Gender bias in seeking health care by women has been reported even in the preCOVID era.[1,8-11] This study documents a further reduction in health-care seeking behavior in women presenting to the out-patient department of the hospital during the pandemic which is of statistical significance. Although, the trend for reduced female attendance was seen in all the OPDs, the statistically significant reduction was seen in cardiology, emergency, endocrinology, ophthalmology, gastroenterology, medicine, neurosurgery, neurology, oncology, orthopedics, and psychiatry departments (P = 0.050, 0.011, 0.001, 0.001, 0.012, 0.000, 0.000, 0.004, 0.003, 0.000, 0.009, 0.006, 0.000, and 0.004, respectively).

As the mankind boggles in hands of nature and COVID pandemic peaks, waxes and wanes, the provision of healthcare to the needy is of utmost importance. Notwithstanding the fall in OPD attendance, serious attempts should be made to deliver healthcare to the recipient at their doorstep. Telemedicine can be of respite[2,3,7] and it can be supported by an organized schemata from hospital administration bodies organizing smooth, hassle free, and less time-consuming visits to the hospitals.[5,6] An improved OPD attendance could make not only the point of care health delivery to recipients but shall also foresee a major reduction in chronic ailments and psychological issues which could prove to be detrimental if permitted to accumulate.

CONCLUSION

OPD attendance has shown a significant reduction in COVID pandemic era especially in the non-emergent fields. Pre-existent gender divide in OPD presentation has increased all the more in the COVID pandemic era. It is imperative that measures such as telemedicine and organized protocols ensuring smooth, hassle free, and rapid OPD visits are encouraged. This could foresee a relatively healthy society with less chronic ailments and psychosocial issues.

Authors’ contributions

Shibba Takkar Chhabra, Gurleen Kaur, Namita Bansal, Harsh Kishore, Vivek Gupta, Gurbhej Singh, Bhupinder Singh, Abhishek Goyal, Rohit Tandon, Mamta Bansal, Naved Aslam, Bishav Mohan, Gurpreet Singh Wander – contributed in planning, conduct, and reporting of the work described in the article and being responsible for the overall content as guarantor(s).

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent.

Conflicts of interest

There are no conflicts of interest.

Audio summary available at

https://doi.org/10.25259/IJCDW_17_2023

Financial support and sponsorship

Nil.

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