key: cord-0883559-u3v2cr1o
authors: Rajwa, Pawel; Przydacz, Mikolaj; Krajewski, Wojciech; Kuffel, Blazej; Zapala, Piotr; Krzywon, Aleksandra; Cortez, Alexander J.; Dybowski, Bartosz; Stamirowski, Remigiusz; Jarzemski, Marcin; Drobot, Rafal B.; Stelmach, Pawel; Mlynarek, Krystyna; Marcinek, Mateusz; Przudzik, Maciej; Krawczyk, Wiktor; Ryszawy, Jakub; Choragwicki, Dominik; Zapala, Lukasz; Lipa, Marcin; Pozniak, Michal; Janczak, Dawid; Słomian, Szymon; Łaszkiewicz, Jan; Nowak, Marcel; Miszczyk, Marcin; Roslan, Marek; Tkocz, Michał; Zdrojowy, Romuald; Potyka, Andrzej; Szydełko, Tomasz; Drewa, Tomasz; Jarzemski, Piotr; Radziszewski, Piotr; Slojewski, Marcin; Antoniewicz, Artur; Paradysz, Andrzej; Chlosta, Piotr L.
title: Changing patterns of urologic emergency visits and admissions during the COVID-19 pandemic: a retrospective, multicenter, nationwide study
date: 2020-08-25
journal: Arch Med Sci
DOI: 10.5114/aoms.2020.98364
sha: 823d132bad68c78b88f93d16215c50d84221ef90
doc_id: 883559
cord_uid: u3v2cr1o

INTRODUCTION: We aimed to examine the change in the number and severity of visits to the emergency departments (EDs) and subsequent admissions for urgent urologic conditions in the early stage of the coronavirus disease 2019 (COVID-19) pandemic in Poland. MATERIAL AND METHODS: We evaluated data from 13 urologic centers in Poland and compared the number of visits to the EDs and subsequent admissions before and after the advent of COVID-19 in 2020, and before and after the escalating national restrictions. Furthermore, data on types of urologic complaints, crucial laboratory parameters, and post-admission procedures were analyzed. RESULTS: In total 1,696 and 2,187 urologic visits (22.45% decrease) and 387 and 439 urologic urgent admissions (11.85% decrease) were reported in given periods in 2020 and 2019, respectively. The year-over-year difference in daily mean visits was clear (36.1 vs. 46.5; p < 0.001). Declines were seen in all complaints but device malfunction. In 2020 daily mean visits and admissions decreased from 40.9 and 9.6 before lockdowns to 30.9 (p < 0.001) and 6.9 (p = 0.001) after severe restrictions, respectively. There was a trend towards more negative laboratory parameter profiles in 2020, with patients who visited the EDs after severe restrictions having twice as high median levels of C-reactive protein (15.39 vs. 7.84, p = 0.03). CONCLUSIONS: The observed declines in ED visits and admissions were apparent with the significant effect of national lockdowns. Our results indicate that some of the patients requiring urgent medical help did not appear at the ED or came later than they would have done before the pandemic, presenting with more severe complaints.

The pandemic of coronavirus disease 2019 (COVID- 19) has had a tremendous impact on healthcare utilization worldwide, including drastically reduced patient care-seeking for medical emergencies unrelated to COVID-19. In China, Italy, the UK, and the US, initial reports suggest a decrease in visits to emergency departments (EDs) and admissions for urgent cardiac and neurological conditions [1] [2] [3] [4] [5] . In Italy and Portugal, there is also evidence of a decrease in ED visits and admissions for urgent urologic conditions but mostly reported in studies of a single center or a short duration [6] [7] [8] [9] [10] .

Poland, a Central European country of 38 million people, had an initial peak of 475 COVID-19 cases on April 5, 2020 and saw its healthcare infrastructure generally less disrupted by the surge of COVID-19 cases than many other countries. However, in the early stage of the pandemic, because healthcare resources must be preserved and nosocomial and community transmission must be limited [11] , the Polish National Health Fund (obligatory public insurance) and other major healthcare organizations recommended postponing routine and elective procedures [12, 13] , and the Polish government introduced an initial national lockdown on March 14, 2020 and additional severe restrictions on March 25, 2020 [14, 15] . In detail, from March 14, 2020 shopping malls, sports centers, bars, cinemas, and libraries were closed. Public gatherings of 50 or more people were banned. The most severe restrictions (e.g., bans on non-essential movements outside the home and gatherings of more than two people) were applied from March 25, 2020. Nevertheless, many urgent urologic conditions, such as gross hematuria, urinary retention, and acute scrotum, require prompt interventions and if untreated can lead to serious morbidity and mortality. Patients with such conditions must seek care even during the COVID-19 era.

In this retrospective, multicenter, nationwide study, we aim to examine the change in the number and severity of visits to the ED and subsequent admissions for urgent urologic conditions in the early stage of the COVID-19 pandemic in Poland. We hypothesize that the number of visits to the ED and subsequent admissions decreased with increased severity of reported conditions.

In this retrospective, multicenter, nationwide study, we analyzed all emergency visits and admissions for urologic complaints at 13 urologic centers in Poland. All of the EDs in the study provided 24-hour urology service. We compared (1) the number of visits to the ED and subsequent admissions and (2) the laboratory patterns of urologic conditions for these visits and admissions before and after the advent of COVID-19 in 2020 and before and after the state of epidemic threat (initial national lockdown) in Poland on March 14, 2020 , and after the most severe restrictions as implemented on March 25, 2020. The specific period of COVID-19 in this study was from February 29, 2020 to April 15, 2020 (2 weeks before to 1 month after the initial national lockdown); a pre-COVID-19 reference period was selected as from February 28, 2019 to April 15, 2019 ( Figure 1 ).

Due to heterogeneity in coding systems across institutions, we categorized urologic conditions into eight major groups by author consensus based on initial patient complaints, brief case descriptions, and reported the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) codes: renal colic, hematuria, urinary retention, urinary tract infection (UTI), device (urinary drainage tube) malfunction (e.g., nephrostomy tube dislocation, urinary catheter obstruction), acute scrotum, trauma, and others. We additionally collected patients' demographic and laboratory data, includ-P. Rajwa Arch Med Sci 5, August / 2021 ing C-reactive protein (CRP), hemoglobin (HGB), serum creatinine, and white blood count (WBC). Of note, because one center was transformed into a dedicated COVID-19 hospital on March 19, 2020, we censored data collected from this center (n = 81) up to March 18, 2019, and March 18, 2020 and did not include this center in analyzing the number of emergency visits and admissions before and after the lockdowns.

Continuous data are shown as median values with interquartile ranges (IQR) and categorical data are presented as absolute and relative frequencies (percentages), unless otherwise stated. Data were analyzed using nonparametric methods. Differences between two groups were determined using the Mann-Whitney U test. Associations between categorical variables were assessed using the c 2 test. Two-sided p-values < 0.05 were considered statistically significant. Analyses were carried out using R software package version 4.0.1.

In 47 days prior to April 15 at 13 urologic centers in Poland, we reported 1,696 ED visits for urological complaints in 2020, a 22.5% decrease from 2,187 in 2019, and 387 subsequent admissions in 2020, an 11.8% decrease from 439 in 2019. These changes corresponded to an increase in the admissions-to-ED-visits ratio from 20.1% in 2019 to 22.8% in 2020 (p = 0.04), as presented in Table I . The daily numbers of ED visits and admissions are depicted in Figure 1 . Mean daily urology emer-gency visits decreased from 46.5 (95% confidence interval (CI): 44.0-49.1) visits in 2019 to 36.1 (95% CI: 33.8-38.4) visits in 2020 (p < 0.001). There was also a non-significant decrease in mean admissions from 9.3 (95% CI: 8.5-10.2) in 2019 to 8.2 (95% CI: 7.4-9.1) in 2020 (p = 0.13). Moreover, in 2020, a higher percentage of patients underwent urgent (within 24 h) surgical intervention after admission (72.89% vs. 81.14%, p = 0.006). In the 1 month after the national lockdown (Table II), we reported 32.8 (95% CI: 30.5-35.1) daily mean ED visits for urological complaints and 7.5 (95% CI: 6.5-8.5) mean subsequent admissions, in comparison to 40.9 (95% CI: 37.6-44.3) and 9.6 (95% CI: 8.2-10.9), respectively, in the 2 weeks before the national lockdown (p < 0.001 and p = 0.014, respectively). The declines were even greater after March 25, 2020 with daily mean visits and admissions decreasing to 30.9 (95% CI: 28.2-33.7) (p < 0.001) and 6.9 (95% CI: 5.7-8.1) (p = 0.007), respectively. Notably, despite a downtrend, no significant differences in visits or admissions were noticed before March 14, 2020 in comparison with the corresponding period (i.e., before March 14, 2019) (Table III) . No significant differences in hospital length of stay were noted with a median of 4 days for all analyzed periods.

Urologic complaints reported at EDs were different between 2019 and 2020 (Table I) . In our study, there was a year-over-year decrease in the absolute number of visits in renal colic (32%), hematuria (25%), urinary retention (10%), acute scrotum (18%), UTI (36%), and trauma (7%), but device malfunction, which increased by 66% (Table I). Also, consulted patients with device malfunction had higher median levels of creatinine: (Table I) .

Finally, patients visiting the EDs after the lockdowns (Table II) had a higher level of CRP: 7.84 (IQR: 1.42-83.98) before, 13.00 (IQR: 2.12-88.30) after the initial lockdown (p = 0.06), and 15.39 (IQR: 2.17-91.70) after the introduction of severe restrictions (p = 0.03). Importantly, patients admitted after the initial lockdown for renal colic had a significantly higher level of CRP -32.60 (IQR: 6.75-97.00) compared to patients admitted before the lockdown -7.77 (IQR: 1.30-83.37) (p = 0.02) ( Table V) . After the initial lockdown patients consulted due to hematuria had due to hematuria had borderline significantly lower median HGB levels -11.60 (IQR: 10.10-13.65) compared to patients visiting before the initial lockdown -12.70 (IQR: 10.90-14.40) (p = 0.05).

In this study, we report a 22.5% year-overyear decrease in the number of visits to the EDs for urgent urologic conditions after the advent of COVID-19 but a 2.7 percentage points (p.p.) yearover-year increase in the number of the admissions-to-ED-visit ratio. Also, in 2020 there were 20% and 24% decreases in the number of visits to the ED and 22% and 28% decreases in the number of subsequent admissions for urgent urologic conditions after the initial lockdown and after further severe restrictions, respectively. Considering laboratory parameters, there was a trend towards more negative laboratory parameter profiles in 2020, and patients who visited the EDs after implementation of the most severe restrictions had almost twice as high median levels of CRP. Furthermore, in 2020 there was an 8 p.p. increase in patients requiring surgical intervention within 24 h after admission.

To our knowledge, we present the largest, multi-center, nationwide study delineating urologic ED visits and urgent admissions during the COVID-19 era, with the subsequent impact of escalating national lockdowns. Furthermore, our study is the first one that has directly aimed to examine the impact of the pandemic on patients complaining about all urologic conditions by analyses of daily mean visits and admissions, crucial laboratory parameters, post-admission procedures, and hospital length of stay. Our analyses revealed lower (22.5%) year-overyear decreases in urologic ED visits, compared to recently published Italian and Portuguese studies, which found over 50% declines during the COVID-19 period [7] [8] [9] [10] . In Poland, the changes were slightly more comparable to more affected countries after the introduction of more severe restrictions on March 25, 2020, with declines up to 34% (Table III) . This has been also seen in another Polish study of Legutko et al., who evaluated pre-COVID-19 and COVID-19 periods (all 2020) in terms of coronary angiography and percutaneous coronary interventions for myocardial infarctions. The authors also found smaller decreases in emergency cases after the lockdown (30%) when compared to the US (38%), Spain (40%), or Austria (39%) [4] . There are several possible explanations for smaller declines in Poland. From the end of February, following massive outbreaks in Italy, France, Spain, and Germany, in Poland the fear and expectance of a COVID-19 outbreak were present. As the first expected COVID-19 case in Poland (March 4, 2020), with subsequent logarithmic case growth, appeared later ( Figure 1 ) when compared to the abovementioned countries, early precautions were taken, leading to a lower, stable COVID-19 incidence ratio, more smoothly manageable for healthcare [16] . Therefore, we speculate that Poland serves as an example of a country where the possible changes in emergency visits and admissions were not due to impaired access to emergency health care but were mainly related to the escalating restrictions (including isolations and limited access to urologic and other specialization outpatient services) followed by fear or patients' perception of hospitals as COVID-19 reservoirs [17, 18] . Further, as fewer doctors in Poland, compared to countries more affected by COVID-19, were directly engaged in managing COVID-19 patients, greater availability and unparalleled popularity of telemedicine consultations could have led to fewer urgent and sometimes unnecessary visits. Finally, cultural differences, media coverage, and population fear level, which varies significantly among nations (e.g. lower COVID-19 fear level in Eastern Europeans), may also have played a role in our lower declines in ED attendance [19] [20] [21] .

In 2020, problems with device malfunctions increased by 66%, while all other groups of urologic problems subsided. The distribution of diseases was significantly different between 2019 and 2020 (p = 0.001), which was also noted in a study of Novara et al. (n = 399) , although in their cohort declines were seen in all disease groups (p = 0.04) [9] . Conversely, in another study from Porto, Portugal (n = 385), a higher proportion of patients visited the ED for administrative and clinical reasons and due to device malfunctions (n = 12 (9.8%) in 2020 and 15 (5.7%) in 2019) [8] . These results can be related to ours, as more patients with device malfunction were noted in EDs, presumably due to limited access to regular outpatient care.

The initial reports from outbreak regions indicate higher general mortality, which cannot be directly linked to COVID-19 deaths [1, 18, 22] . As mortality rates in urologic emergencies are relatively very low, we believe crucial laboratory parameters could substantiate the patients' condition. In our cohort, there were no significant differences between tested laboratory parameters between 2019 and 2020, in either consulted or admitted patients, although a clear more negative tendency was noticed. Requiring particular attention are the higher levels of creatinine, CRP, and WBC in the device malfunction group in 2020, which were either significant or borderline significant for both consulted and admitted patients. In 2020 patients visiting EDs due to UTI had significantly higher levels of CRP. After the lockdowns, compared to the pre-lockdown period, all the visiting patients had approximately twice as high median CRP level and patients consulted due to hematuria had borderline significantly lower HGB levels. All these results may somewhat mirror the delayed care-seeking in 2020 and ED avoidance in milder cases. The only study that evaluated laboratory parameters during the COVID-19 pandemic in urologic emergencies, particularly in renal colic patients (n = 80), was conducted by Flammia et al. [10] . Surprisingly, the patients visiting during the COVID-19 era had non-significantly lower WBC levels (p = 0.052), but significantly higher serum creatinine levels (p = 0.026), which we did not observe in our cohort. Nevertheless, after lockdowns, we found significantly higher median levels of CRP in admitted renal colic patients (Tables V and VI) .

The admissions-to-ED-visit ratio was significantly higher in 2020 compared to 2019, which indicates that presumably in general more "mild" visits were avoided in 2020. On the other hand, in 2020 a higher percentage of admitted patients underwent urgent intervention after admission with general stable absolute numbers of operations between 2019 and 2020, which could indicate a more severe condition of admitted patients. No differences in hospitalization time were noted, which could also be due to a general tendency to shorten patients' hospital length of stay during the COVID-19 pandemic, as also observed in other countries [19] . In a study conducted by the Italian AGILE group, there was an over 50% decline in the ureterorenoscopy (and/ or ureteral stenting), transurethral resection of bladder tumor, and testicular detorsion between a pre-COVID period in 2020 and during the massive outbreak in Italy [6] . In our cohort, the distribution of the interventions was non-significantly different with an 8% decrease in absolute numbers of endoscopic procedures in 2020. At the same time, we noted a higher number of open and percutaneous interventions in 2020 and a higher proportion of percutaneous interventions after the lockdowns. Our results illustrate a distressing tendency that some of the patients who truly needed urgent medical help and/or hospitalization were not seen at urologic EDs or came later than they would have done before the COVID-19 era. In our opinion, the Polish case may arise in other developed countries, after the pandemic stabilizes and in a case of local outbreaks with maintained access to urologic EDs. Lastly, our paper underlines the necessity for adjustment of urology centers during the COVID-19 pandemic. Primarily, despite the unprecedented integration of telemedicine in outpatient clinics, more meticulous patients' qualifications for in-person visits should be implemented. Given the presumable scenario with the COVID-19 pandemic lasting for an unknown period, maintaining regular face-to-face access for needy patients should become a critical aim of health care providers. Additionally, we believe that broader and easily available information provision concerning current epidemiological status should be immediately implemented to both EDs and outpatient service, which could partly mitigate patients' fear and uncertainty.

There are some limitations of our study. Firstly, this is a time-limited, retrospective, single-country study. However, the majority of our 13 study centers have high-volume urology departments, thus providing a robust national sample. Second, there were missing demographic, ICD-10 and laboratory data on ED visits at one center and some missing laboratory data due to a lack of clinical indication. Lastly, we did not control for confounding factors that might have influenced laboratory results in our analyses.

In conclusion, our study compiled several important and exclusive aspects of urology ED visits and admissions during the COVID-19 pandemic, in a country with barely impaired access to emergency medicine. Declines in urologic emergency visits and admissions were apparent, especially after the introduction of restrictions, with alarming trends indicating that some of the patients requiring urgent medical help did not appear at the ED, or came later than they would have done before the pandemic, presenting worse laboratory profiles.

CRP -C-reactive protein, HGB -hemoglobin, LD -lockdown, sCR -serum creatinine, UTI -urinary tract infection, WBC -white blood count. Changing patterns of urologic emergency visits and admissions during the COVID-19 pandemic: a retrospective

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AJC is supported by the European Union through the European Social Fund (POWR.03.02.00-00-I029).

The authors declare no conflict of interest.R e f e r e n c e s