key: cord-0749383-rmrp8st3
authors: Daniel, Pinggera; Johannes, Kerschbaumer; Lukas, Grassner; Matthias, Demetz; Sebastian, Hartmann; Claudius, Thomé
title: Effect of the COVID-19 pandemic on patient presentation and perception to a neurosurgical outpatient clinic
date: 2021-02-18
journal: World Neurosurg
DOI: 10.1016/j.wneu.2021.02.037
sha: ab87d38c9764540ca2f84149b7ca41018f7c5c1e
doc_id: 749383
cord_uid: rmrp8st3

Background The world currently faces the novel COVID-19 pandemic with cutbacks in patient care. Little is known about the effects of a pandemic on the presentation and admission to an outpatient clinic. Our aim was to gain a better understanding of the effects of reduced neurosurgical care access from the patient perspective, especially in terms of anxiety and urgency of treatment, and to improve outpatient management in case of a potential second wave and potential restrictions on health care. Methods: A questionnaire study over a period of four weeks following the COVID-19 lock down at our academical neurosurgical department was performed. A 15-items questionnaire was distributed to the patients with 3 additional questions to be answered by the treating neurosurgeon. Results: A total of 437 questionnaires was analyzed. Overall anxiety to visit a general practitioner or the outpatient facility within the hospital was very low among patients. A quarter of all appointments had to be postponed due to COVID-19, in 0.6 % of which postponement was perceived as incorrect by the treating neurosurgeon. 43% did not get an appointment due to the restrictions, 20 % did not want to bother the medical system and only 4 % were afraid to get infected in the hospital. Conclusion: Despite COVID-19, patients in need of neurosurgical service were hardly afraid to visit doctors and/or hospitals. Nonetheless, due to legal requirements, access has been restricted causing potential collateral damages in a small subset of neurosurgical patients.

Introduction 32 33 COVID-19 represents a great global health challenge. The severe acute respiratory syndrome 34 coronavirus 2 (SARS-CoV-2) emerged at the end of 2019 in the Chinese city of Wuhan and 35 rapidly progressed to a global pandemic 1, 2 . The healthcare, economic and social challenges 36 posed by this novel disease are immense 3 . The potentially serious course of this disease, 37 especially in elderly or immunocompromised individuals, has been widely reported 4-7 . 38 Due to the rapid global spread of the virus and the quickly increasing number of infections in 39 combination with a missing vaccination/causative treatment, a lock down for the state of 40

Tyrol, Austria was imposed mid-March 2020. The lock down was characterized by a strict 41 curfew and the shutdown of all non-essential infrastructure. Furthermore, governmental 42 and hospital task forces determined that all elective surgeries had to be postponed and only 43 emergencies should be addressed in order to maintain ICU capacities for COVID-19 patients. 44

These drastic measures also influenced the neurosurgical workflow and led to a massive 45 change in our outpatient clinic, as all non-urgent appointments and control visits have been 46 significantly curtailed. All elective procedures of the Department of Neurosurgery were 47 rescheduled and only urgent or emergency operations were performed. The classification 48 was based on the recommendation of executive committees of the German Society of 49 Neurosurgery (DGNC) and the Professional Association of German Neurosurgeons (BDNC) 8 . 50

Whereas the impact of COVID-19 on neurosurgical emergencies is already well researched, 51 data on outpatient services and elective case management is rare 9-15 . 52 53 Mid-April, strict regulations were stepwise withdrawn, resulting in rising numbers in our 54 institutional outpatient clinic. The rescheduling of operations and outpatient appointments 55 posed an unforeseen challenge for all employees. The clinical and psychological effects on 56 individuals presenting as outpatients during an ongoing pandemic were unclear. 57

In order to evaluate the effect of the COVID-19 pandemic regulations on patients presenting 59 to our outpatient clinic, a questionnaire study was undertaken. Our aim was to gain a better 60 understanding on the effects of reduced neurosurgical care access from the perspective of 61 J o u r n a l P r e -p r o o f patients with focus on patient´s anxiety and urgency of treatment. Also, we tried to assess 62 potential collateral damage in times of restricted access to the health care system. 63

We conducted a questionnaire over a 4-week period following the lock down at our 66 academic neurosurgical department, namely in the period from April 20th 2020 till May 15th 67 2020. Strict restrictions in the federal state of Tyrol lasted from March 16th until April 6th, 68 2020 with gradual easings afterwards. Some places in the districts of Landeck and Imst, 69

including the famous skiing areas of Ischgl and Sölden, were under quarantine even until 70

April 24th 2020. As our department is the only public neurosurgical unit in the state of Tyrol, 71 patients with neurosurgical diseases are referred exclusively to our hospital, either after 72 arranging a scheduled appointment or acutely in case of emergencies. In normal times about 73 60 to 70 patients per day present at our outpatient clinic, resulting in at least 1.200 patients 74 per 4-week period. 75

All patients frequenting our outpatient clinic, either scheduled or as emergencies, were 77 asked to participate in the study. The outpatient clinic is located inside the hospital and 78 reached via a public square and elevators. A questionnaire with 15 items was distributed 79 among the patients as seen in Figure 1 . Additionally, one part of the questionnaire with 3 80 items had to be filled out by the treating neurosurgeon (Figure 2 ). All patients gave informed 81 consent to participate in the study. The study was approved by the local ethics committee of 82 the Medical University Innsbruck (Protocol number: AN 2020-1125). 83

Descriptive statistics were used to characterize the overall responses from the study cohort 84 using IBM SPSS Statistics 21 (IBM Corporation, Armonk, NY, USA). Graphs were created using 85

GraphPad Prism (version 6.0, GraphPad Software Inc.). 86 87

In this 4-week period 605 patients visited our outpatient clinic. 437 questionnaires (72%) 89

were completed and analyzed. The mean age was 57 years (range 14 -93 years) with an 90 almost equal gender distribution (55% female versus 45 % male patients). Thirty percent 91 visited the neurosurgical outpatient clinic for the first time, in contrast to 70 % presenting 92 for a repeat or follow-up visit. 93

Half of the patients were either from the district of Innsbruck or its surrounding areas. 8.3 % 94 of the patients were from the COVID-19 hotspot districts of Landeck and Imst. Further 95 distribution was in accordance with distribution of the population in Tyrol. 96

The majority of patients presented with long-lasting symptoms. The waiting time for an 97 appointment exceeded 3 months in almost half the cases (43 %). Fifty-three percent visited 98 their general practitioner or outside specialist more than one month ago, whereas 26 % did 99 not visit any doctor before at all (details are shown in Figure 3) . 100

In 23 % of all cases the appointment was postponed due to COVID-19. In about 6 % the 102 patients did not believe that the delay was to be justified or only with limitations. 103

The main reason for postponement was impossibility to get an appointment (43.8 %). 104

Twenty percent did not want to put burden on the public health system and 4 % were afraid 105 to get infected. Further reasons are displayed in Figure 4 . 106

Mean level of fear to visit the general practitioner was low, even the visit in the clinic was 108 not associated with a higher fear of getting in contact with COVID 19 (Figure 5) . 109

The most frequent neurosurgical diagnoses leading to a visit at the outpatient clinic were 111 degenerative spine cases and spinal infections with 50 %. Second most common diagnoses 112 were intrinsic or extrinsic tumors ( Table 1) The COVID-19 pandemic continues to have a significant impact on healthcare systems 129 worldwide. This is caused not only by COVID-19 itself, but also due to collateral 130 consequences by delaying treatment for people with non-COVID-related diseases [16] [17] [18] [19] [20] [21] [22] . Our 131 study provides first insights on the impact of the "COVID-19"-lockdown on a neurosurgical 132 outpatient clinic in terms of fear of visiting it and urgency of treatment. Since our institution 133 is the only public neurosurgical unit in the state of Tyrol, we are able to analyze 134 comprehensive data surveying patients` responses to reduced access to neurosurgical care. 135

To the best of our knowledge, this is the first prospective study investigating the direct 136 influence of the COVID-19 pandemic on outpatient clinic access in a neurosurgical 137 department from the patient's perspective. with serious conditions were scheduled for outpatient visits or presented acutely without 146 appointment 8, 27, 28 . Most of the cases in our series could be planned, only in less than 1 % 147 the COVID-19 pandemic led to a potentially deleterious postponement. Despite a potential 148 personal bias, this also demonstrates that strategic schemes to overcome endangering 149 situation seem useful, same as acclaimed telemedicine during COVID-19 21, 24, 29-31 . However, 150 it has to be taken into account that our health care system was never overwhelmed by 151 COVID-19, which has less likely minimized malmanagement. Initial drastic decline in the 152 number of in-person neurosurgery clinic visits with a subsequent ramping up of the 153 outpatient services was seen in other neurosurgical departments as well 14, 32 . . This could not be confirmed in our patients, reporting a very low level of anxiety to 158 visit the hospital and/or general practitioner. Despite the fact, that the data was collected 159 after the local peak of COVID-19 infections in Tyrol, we believe it to be reliable as people 160

were still under strong influence of media and the global information tide about the 161 pandemic. This statement is further supported by the low number of postponements caused 162 by patients´ fear of getting sick and bad treatment and the long-lasting symptoms described 163 in our cohort. 164

Nevertheless, there obviously is selection bias, as the questioned population has presented 165 to the outpatient clinic. Those severely afraid may have never approached the hospital in the 166 first place even after the ease of restriction. With the overall low level of anxiety and the fact 167 that there were hardly any patients with delayed presentation in the weeks following the 168 study it may be hypothesized that anxiety levels remain low, as long as the health care Three quarter of all patients described symptoms to last more than one month, underlying 173 the elective nature of an outpatient clinic. Nearly half of all postponements were caused by 174 not getting an appointment due to strict legal regulations, as elective cases had to be 175 postponed. A quarter of all patients didn´t want to put further burden on the medical 176 system. This reluctance was also seen in different other medical fields and requires further 177 attention 16, 20, 22, 33, 34 . Media campaigns may be helpful for future crisis to ensure timely 178 patient presentation. Our data, however, demonstrate that neurologic symptoms and severe 179 pain appear to be a sufficient trigger for early urgent medical care and fear of COVID-19 180 seems to be less deterrent as spread by media or authorities. 181

In 3.2 % of all cases (0.9% emergent and 2.3% acute, Figure 6 ) presenting to the outpatient 182 clinic and in 6 % of all initial visits, surgical treatment had to be performed within 24 hours. 183 This is below other reported data, but comparison is cumbersome as emergencies and 184 urgent cases (subarachnoid hemorrhage, traumatic brain injury) are often managed via an 185 emergency room and are thus not analyzed in our study 24 . Yet, these cases are not regularly 186 treated in an outpatient clinic. 187 J o u r n a l P r e -p r o o f Some further limitations need to be acknowledged in our study. First the questionnaire was 188 performed after the peak of COVID-19 in Tyrol, potentially underestimating some surveyed 189 data. Second, judgment about postponement and its urgency was at the discretion of the 190 treating neurosurgeon. 191

Despite COVID-19, patients in need of neurosurgical service were hardly afraid to visit 193 doctors and/or hospitals. Nonetheless, due to legal requirements, access has been restricted 194 leading to potential collateral damages in a small subset of neurosurgical patients. These 

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