The impact of the COVID-19 pandemic on health services utilization in China: Time-series analyses for 2016-2020

Background: The aim of this study is to quantify the effects of the SARS-CoV-2 pandemic on health services utilization in China using over four years of routine health information system data. Methods: We conducted a retrospective observational cohort study of health services utilization from health facilities at all levels in all provinces of mainland China. We analyzed monthly all-cause health facility visits and inpatient volume in health facilities before and during the SARS-CoV-2 outbreak using nationwide routine health information system data from January 2016 to June 2020. We used interrupted time series analyses and segmented negative binomial regression to examine changes in health-care utilization attributable to the pandemic. Stratified analyses by facility type and by provincial Human Development Index (HDI) - an area-level measure of socioeconomic status - were conducted to assess potential heterogeneity in effects. Findings: In the months before the SARS-CoV-2 outbreak, a positive secular trend in patterns of health-care utilization was observed. After the SARS-CoV-2 outbreak, we noted statistically significant decreases in all indicators, with all indicators achieving their nadir in February 2020. The magnitude of decline in February ranged from 63% (95% CI 61-65%; p<0.0001) in all-cause visits at hospitals in regions with high HDI and 71% (95% CI 70-72%; p<0.0001) in all-cause visits at primary care clinics to 33% (95% CI 24-42%; p<0.0001) in inpatient volume and 10% (95% CI 3-17%; p = 0.0076) in all-cause visits at township health centers (THC) in regions with low HDI. The reduction in health facility visits was greater than that in the number of outpatients discharged (51% versus 48%; p<0.0079). The reductions in both health facility visits and inpatient volume were greater in hospitals than in primary health care facilities (p<0.0001) and greater in developed regions than in underdeveloped regions (p<0.0001). Following the nadir of health services utilization in February 2020, all indicators showed statistically significant increases. However, even by June 2020, nearly all indicators except outpatient and inpatient volume in regions with low HDI and inpatient volume in private hospitals had not achieved their pre-SARS-COV-2 forecasted levels. In total, we estimated cumulative losses of 1020.5 (95% CI 951.2- 1089.4; P<0.0001) million or 23.9% (95% CI 22.5-25.2%; P<0.0001) health facility visits, and 28.9 (95% CI 26.1-31.6; P<0.0001) million or 21.6% (95% CI 19.7-23.4%; P<0.0001) inpatients as of June 2020. Interpretation: Inpatient and outpatient health services utilization in China declined significantly after the SARS-CoV-2 outbreak, likely due to changes in patient and provider behaviors, suspension of health facilities or their non-emergency services, massive mobility restrictions, and the potential reduction in the risk of non-SARS-COV-2 diseases. All indicators rebounded beginning in March but most had not recovered to their pre-SARS-COV-2 levels as of June 2020. (C) 2021 The Author(s). Published by Elsevier Ltd.