Impact of the COVID-19 Pandemic on Outpatient Service in Primary Healthcare Institutions: An Inspiration From Yinchuan of China

Document Type : Original Article


1 Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing, China

2 Research Center of Clinical Epidemiology, Peking University Third Hospital, Beijing, China

3 Maternal and Child Health Care Hospital of Ningxia Hui Autonomous Region, Yinchuan, China

4 Peking University Health Information Technology Co. Ltd, Beijing, China

5 Center for Intelligent Public Health, Institute for Artificial Intelligence, Peking University, Beijing, China

6 Department of Paediatrics, Peking University First Hospital, Beijing, China


The coronavirus disease 2019 (COVID-19) pandemic has posed a great challenge to the healthcare system. This study evaluated the impact of the pandemic on the utilization of primary healthcare (PHC).
The outpatient data from 158 PHC institutions in Yinchuan from May 1, 2017 to April 30, 2020 were used. The difference in difference (DID) model was used to analyze the difference in the number of outpatient visits per day, total outpatient expenditure per day, and outpatient expenditure per visit between December 2019 and February 2020 compared with the same periods in two previous years. The autoregressive integrated moving average (ARIMA) modelling was used to investigate the association between the outpatient volume and the number of the last week’s new COVID-19 cases in Yinchuan, Ningxia, and China.
From December 2019 to February 2020, the decline in the number of outpatient visits per day (DID: -367.21 times, P = .004) was larger than that in two previous years, and a similar trend can be seen in the outpatient expenditure per day. However, the rise in the outpatient expenditure per visit (DID: 19.06 thousand yuan, P = .003) was larger than that in two previous years. In 2020, the outpatient visits for most types of diseases decreased from week 3 and rebounded after week 5. The decline and rebound of outpatient visits in the population aged 45 years and older were steeper than in those younger. The outpatient volume was negatively associated with the number of the last week’s new COVID-19 cases.
This study indicated a significant impact of the pandemic on PHC service utilization. Since PHC service is the foundation of the healthcare system in most developing countries, measures should be taken to make PHC help cope with the crisis and relieve the burden of hospital care.


Main Subjects

  1. Zhu N, Zhang D, Wang W, et al. A novel coronavirus from patients with pneumonia in China, 2019. N Engl J Med. 2020;382(8):727-733. doi:1056/NEJMoa2001017
  2. WHO announces COVID-19 outbreak a pandemic. World Health Organization website. Accessed January 21, 2021. Updated March 1, 2020.
  3. Chang HJ, Huang N, Lee CH, Hsu YJ, Hsieh CJ, Chou YJ. The impact of the SARS epidemic on the utilization of medical services: SARS and the fear of SARS. Am J Public Health. 2004;94(4):562-564. doi:2105/ajph.94.4.562
  4. Bolkan HA, Bash-Taqi DA, Samai M, Gerdin M, von Schreeb J. Ebola and indirect effects on health service function in sierra leone. PLoS Curr. 2014;6. doi:1371/currents.outbreaks.0307d588df619f9c9447f8ead5b72b2d
  5. Lee H, Park JH. Changes in health care utilization during the MERS epidemic. Int J Infect Dis. 2018;73 Suppl:187. doi:1016/j.ijid.2018.04.3838
  6. Whaley CM, Pera MF, Cantor J, et al. Changes in health services use among commercially insured US populations during the COVID-19 pandemic. JAMA Netw Open. 2020;3(11):e2024984. doi:1001/jamanetworkopen.2020.24984
  7. Nourazari S, Davis SR, Granovsky R, et al. Decreased hospital admissions through emergency departments during the COVID-19 pandemic. Am J Emerg Med. 2021;42:203-210. doi:1016/j.ajem.2020.11.029
  8. Hung KK, Walline JH, Chan EYY, et al. Health service utilization in Hong Kong during the COVID-19 pandemic - a cross-sectional public survey. Int J Health Policy Manag. 2020. doi:34172/ijhpm.2020.183
  9. Stöhr E, Aksoy A, Campbell M, et al. Hospital admissions during COVID-19 lock-down in Germany: differences in discretionary and unavoidable cardiovascular events. PLoS One. 2020;15(11):e0242653. doi:1371/journal.pone.0242653
  10. Birkmeyer JD, Barnato A, Birkmeyer N, Bessler R, Skinner J. The impact of the COVID-19 pandemic on hospital admissions in the United States. Health Aff (Millwood). 2020;39(11):2010-2017. doi:1377/hlthaff.2020.00980
  11. Chou YC, Yen YF, Feng RC, et al. Impact of the COVID-19 pandemic on the utilization of hospice care services: a cohort study in Taiwan. J Pain Symptom Manage. 2020;60(3):e1-e6. doi:1016/j.jpainsymman.2020.07.005
  12. Zhang YN, Chen Y, Wang Y, et al. Reduction in healthcare services during the COVID-19 pandemic in China. BMJ Glob Health. 2020;5(11):e003421. doi:1136/bmjgh-2020-003421
  13. Jeffery MM, D'Onofrio G, Paek H, et al. Trends in emergency department visits and hospital admissions in health care systems in 5 states in the first months of the COVID-19 pandemic in the US. JAMA Intern Med. 2020;180(10):1328-1333. doi:1001/jamainternmed.2020.3288
  14. Okpokoro E. Primary health care: a necessity in developing countries? J Public Health Afr. 2013;4(2):e17. doi:4081/jphia.2013.e17
  15. Langlois EV, McKenzie A, Schneider H, Mecaskey JW. Measures to strengthen primary health-care systems in low- and middle-income countries. Bull World Health Organ. 2020;98(11):781-791. doi:2471/blt.20.252742
  16. Li X, Krumholz HM, Yip W, et al. Quality of primary health care in China: challenges and recommendations. Lancet. 2020;395(10239):1802-1812. doi:1016/s0140-6736(20)30122-7
  17. Tu J, Wang C, Wu S. The internet hospital: an emerging innovation in China. Lancet Glob Health. 2015;3(8):e445-e446. doi:1016/s2214-109x(15)00042-x
  18. Giannouchos TV, Biskupiak J, Moss MJ, Brixner D, Andreyeva E, Ukert B. Trends in outpatient emergency department visits during the COVID-19 pandemic at a large, urban, academic hospital system. Am J Emerg Med. 2021;40:20-26. doi:1016/j.ajem.2020.12.009
  19. Chen Q, Li M, Wang Y, Zhang L, Tan X. Changes in anxiety, depression, and stress in 1 week and 1 month later after the Wuhan shutdown against the COVID-19 epidemic. Disaster Med Public Health Prep. 2021:1-8. doi:1017/dmp.2021.20
  20. Reale SC, Fields KG, Lumbreras-Marquez MI, et al. Association between number of in-person health care visits and SARS-CoV-2 infection in obstetrical patients. JAMA. 2020;324(12):1210-1212. doi:1001/jama.2020.15242
  21. Williams TC, MacRae C, Swann OV, et al. Indirect effects of the COVID-19 pandemic on paediatric healthcare use and severe disease: a retrospective national cohort study. Arch Dis Child. 2021;106(9):911-917. doi:1136/archdischild-2020-321008
  22. Lauer SA, Grantz KH, Bi Q, et al. The incubation period of coronavirus disease 2019 (COVID-19) from publicly reported confirmed cases: estimation and application. Ann Intern Med. 2020;172(9):577-582. doi:7326/m20-0504
  23. Tan JY, Conceicao EP, Sim XYJ, Wee LEI, Aung MK, Venkatachalam I. Public health measures during COVID-19 pandemic reduced hospital admissions for community respiratory viral infections. J Hosp Infect. 2020;106(2):387-389. doi:1016/j.jhin.2020.07.023
  24. Koff WC, Williams MA. COVID-19 and immunity in aging populations - a new research agenda. N Engl J Med. 2020;383(9):804-805. doi:1056/NEJMp2006761
  25. Mueller AL, McNamara MS, Sinclair DA. Why does COVID-19 disproportionately affect older people? Aging (Albany NY). 2020;12(10):9959-9981. doi:18632/aging.103344
  26. Fischer SH, David D, Crotty BH, Dierks M, Safran C. Acceptance and use of health information technology by community-dwelling elders. Int J Med Inform. 2014;83(9):624-635. doi:1016/j.ijmedinf.2014.06.005
  27. Ningxia Healthcare Security Administration. Notice of the office of the national healthcare security administration on optimizing the medical care service to promote the prevention and control of COVID-19 infection [in Chinese]. Accessed February 1, 2021. Updated February 5, 2020.
  28. Zhang T, Chen Y. Meeting the needs of elderly people in China. BMJ. 2006;333(7564):363-364. doi:1136/bmj.333.7564.363
  29. Thomas SA, Qiu Z, Chapman A, Liu S, Browning CJ. Editorial: chronic illness and ageing in China. Front Public Health. 2020;8:104. doi:3389/fpubh.2020.00104
  30. Notice on the issue of the guideline for health care institutions to provide the medical and health services for the elderly patients with chronic diseases during the prevention and control period of COVID-19 pandemic. National Health Commission of the People’s Republic of China website. Accessed June 20, 2021. Updated February 24, 2020.
  31. Monaghesh E, Hajizadeh A. The role of telehealth during COVID-19 outbreak: a systematic review based on current evidence. BMC Public Health. 2020;20(1):1193. doi:1186/s12889-020-09301-4
  32. Health care considerations for older people during COVID-19 pandemic. World Health Organization website. Accessed June 20, 2021.
  33. Liang J, Zheng X, Chen Z, et al. The experience and challenges of healthcare-reform-driven medical consortia and Regional Health Information Technologies in China: a longitudinal study. Int J Med Inform. 2019;131:103954. doi:1016/j.ijmedinf.2019.103954
  34. Wang X, Sun X, Gong F, et al. The Luohu model: a template for integrated urban healthcare systems in China. Int J Integr Care. 2018;18(4):3. doi:5334/ijic.3955
Volume 11, Issue 9
September 2022
Pages 1926-1933
  • Receive Date: 12 March 2021
  • Revise Date: 02 August 2021
  • Accept Date: 25 August 2021
  • First Publish Date: 31 August 2021