Effect of widespread restrictions on the use of hospital services during an outbreak of severe acute respiratory syndrome

Abstract

Background: Restrictions on the nonurgent use of hospital services were imposed in March 2003 to control an outbreak of severe acute respiratory syndrome (SARS) in Toronto, Ont. We describe the impact of these restrictions on health care utilization and suggest lessons for future epidemics.

Methods: We performed a retrospective population-based study of the Greater Toronto Area (hereafter referred to as Toronto) and unaffected comparison regions (Ottawa and London, Ont.) before, during and after the SARS outbreak (April 2001-March 2004). We determined the adjusted rates of hospital admissions, emergency department and outpatient visits, diagnostic testing and drug prescribing.

Results: During the early and late SARS restriction periods, the rate of overall and medical admissions decreased by 10%-12% in Toronto; there was no change in the comparison regions. The rate of elective surgery in Toronto fell by 22% and 15% during the early and late restriction periods respectively and by 8% in the comparison regions. The admission rates for urgent surgery remained unchanged in all regions; those for some acute serious medical conditions decreased by 15%-21%. The rates of elective cardiac procedures declined by up to 66% in Toronto and by 71% in the comparison regions; the rates of urgent and semi-urgent procedures declined little or increased. High-acuity visits to emergency departments fell by 37% in Toronto, and inter-hospital patient transfers fell by 44% in the circum-Toronto area. Drug prescribing and primary care visits were unchanged in all regions.

Interpretation: The restrictions achieved modest reductions in overall hospital admissions and substantial reductions in the use of elective services. Brief reductions occurred in admissions for some acute serious conditions, high-acuity visits to emergency departments and inter-hospital patient transfers suggesting that access to care for some potentially seriously ill patients was affected.

Fig. 1: Hospital services utilization in Toronto and comparison regions in Ontario (Ottawa and London) during the 2003 outbreak of severe acute respiratory syndrome (SARS). Adjusted relative changes (and 95% confidence intervals) are presented in the rates of hospital admissions, cardiac procedures, emergency department visits and inter-hospital patient transfers during the early (Mar. 15 to May 14, 2003) and late (May 15 to July 14, 2003) hospital utilization restriction periods compared with baseline rates during the pre-SARS period (March 2000 to March 2003). Note: CABG = coronary artery bypass graft, PCI = percutaneous coronary intervention.

Fig. 2: Weekly rates of all-cause hospital admissions in Toronto and 2 comparison regions (Ottawa and London, Ont.) before the 2003 outbreak of severe acute respiratory syndrome (SARS; Mar. 14, 2000, to Mar. 14, 2003), during the early (Mar. 15, 2003, to May 14, 2003) and late (May 15, 2003, to July 14, 2003) restriction periods, and after the restrictions had been lifted (July 2003 to March 2004).