ABSTRACT
ObjectivesTo determine the extent and nature of changes in utilisation of healthcare services during COVID-19 pandemic. DesignSystematic review EligibilityEligible studies compared utilisation of services during COVID-19 pandemic to at least one comparable period in prior years. Services included visits, admissions, diagnostics, and therapeutics. Studies were excluded if from single-centres or studied only COVID-19 patients. Data sourcesPubMed, Embase, Cochrane COVID-19 Study Register, and pre-prints were searched, without language restrictions, until August 10, using detailed searches with key concepts including COVID-19, health services and impact. Data analysisRisk of bias was assessed by adapting ROBINS-I and Cochrane Effective Practice and Organization of Care tool. Results were analysed using descriptive statistics, graphical figures, and narrative synthesis. Outcome measuresPrimary outcome was change in service utilisation between pre-pandemic and pandemic periods. Secondary outcome was the change in proportions of users of healthcare services with milder or more severe illness (e.g. triage scores). Results3097 unique references were identified, and 81 studies across 20 countries included, reporting on >11 million services pre-pandemic and 6.9 million during pandemic. For the primary outcome, there were 143 estimates of changes, with a median 37% reduction in services overall (interquartile range -51% to -20%), comprising median reductions for visits of 42%(-53% to -32%), admissions, 28%(-40% to -17%), diagnostics, 31%(-53% to -24%), and for therapeutics, 30%(-57% to -19%). Among 35 studies reporting secondary outcomes, there were 60 estimates, with 27(45%) reporting larger reductions in utilisation among people with a milder spectrum of illness, and 33 (55%) reporting no change. ConclusionsHealthcare utilisation decreased by about a third during the pandemic, with considerable variation, and with greater reductions among people with less severe illness. While addressing unmet need remains a priority, studies of health impacts of reductions may help health-systems prioritise higher-value care in the post-pandemic recovery. Funding, Study registrationNo funding was required. PROSPERO: CRD42020203729 Strengths and limitations of this study- The review is the first broad synthesis of global studies of pandemic related changes in utilisation across all categories of healthcare services. - The review provides novel findings informing design of future studies of pandemic-related changes in utilisation and its impacts. - Limitations include the possibility of publication bias and the potential of our eligibility criteria to exclude important data sources such as studies in single-centres and unpublished datasets from health systems. - Heterogenous designs and settings precluding meta-analysis.
ABSTRACT
ObjectiveTo compare the effectiveness of hand hygiene using alcohol-based hand sanitiser to soap and water for preventing the transmission of acute respiratory infections (ARIs), and assess the relationship between the dose of hand hygiene and the number of ARI, influenza-like illness (ILI), or influenza events. MethodsSystematic review of randomised trials that compared a community-based hand hygiene intervention (soap and water, or sanitiser) with a control, or trials that compared sanitiser with soap and water, and measured outcomes of ARI, ILI, or laboratory-confirmed influenza or related consequences. Searches were conducted in CENTRAL, PubMed, Embase, CINAHL and trial registries (April 2020) and data extraction completed by independent pairs of reviewers. ResultsEighteen trials were included. When meta-analysed, three trials of soap and water versus control found a non-significant increase in ARI events (Risk Ratio (RR) 1.23, 95%CI 0.78-1.93); six trials of sanitiser versus control found a significant reduction in ARI events (RR 0.80, 95%CI 0.71-0.89). When hand hygiene dose was plotted against ARI relative risk, no clear dose-response relationship was observable. Four trials were head-to-head comparisons of sanitiser and soap and water but too heterogeneous to pool: two found a significantly greater reduction in the sanitiser group compared to the soap group; two found no significant difference between the intervention arms. ConclusionAdequately performed hand hygiene, with either soap or sanitiser, reduces the risk of ARI virus transmission, however direct and indirect evidence suggest sanitiser might be more effective in practice.
