The Indirect Impact of COVID-19 on Major Clinical Outcomes of People With Parkinson's Disease or Parkinsonism: A Cohort Study

Abstract

Background: The indirect impact of the COVID-19 epidemic on major clinical outcomes of people with Parkinson's disease (PD) or other parkinsonism is unknown.

Objectives: The study aimed to (1) describe changes in healthcare services during the first epidemic bout in people with PD or parkinsonism; (2) compare the occurrence of hospitalization for any PD-related major clinical outcomes in 2020 with 2019; (3) investigate the factors, including changes in healthcare services, associated with major clinical outcomes and death.

Methods: All healthcare services of the province of Bologna and major clinical outcomes were assessed through a record linkage study (ParkLink Bologna) using clinical data and health databases. Same analyses were performed in a random cohort of controls matched for age, sex, district of residence, and comorbidities with the ParkLink cohort (ratio of 1:10).

Results: A cohort of subjects with PD (759) or other parkinsonism (192) was included together with a cohort of controls (9,226). All indicators of healthcare services dropped at least below 50% during the lockdown period in all cohorts, mostly impacting physiotherapy in people with PD (-93%, 95% CI 88-96%). In 2020, compared to 2019, a three-fold risk of major injuries (RR 3.0, 95% CI 1.5-6.2) and infections (RR 3.3, 95% CI 1.5-7.2), excluding COVID-19, was observed only in people with PD, and neither in people with parkinsonism nor in controls. Decreased physiotherapy was associated with the occurrence of at least one major clinical outcome (OR 3.3, 95% CI 1.1-9.8) in people with PD. Experiencing at least one major clinical outcome was the strongest risk factor for death (OR 30.4, 95% CI 11.1-83.4) in people with PD.

Conclusions: During the first COVID-19 epidemic peak, healthcare services were drastically reduced in a province of northern Italy, regardless of the disease condition. However, compared to 2019, in 2020, only people with PD had a higher risk of major clinical outcomes, that were associated with higher mortality. Strategies to maintain physical activity in people with PD should be implemented in possible future health emergencies.

Keywords: COVID-19; Parkinson's disease; cohort studies; parkinsonism; physiotherapy.

Figure 1

The study analysis plan of the study is according to the three aims. Aim 1—Healthcare services change: interrupted time-series (ITS) design applied to the four cohorts (PD, AP, VP, and controls) from July 1, 2019, to September 30, 2020. Aim 2—Impact analysis: historical cohort design applied to the three cohorts comparing the period March to September 2020 with the same period of 2019. Aim 3—Prognostic analysis: historical cohort design applied to the PD cohort from June 1, 2020, to December 31, 2020. The absolute number of SARS-CoV-2 infected people is reported in orange color in the time scale.

Figure 2

Interrupted time-series (ITS) design, from July 1, 2019, to September 30, 2020, evaluating the healthcare services change in the PD and control cohorts. The pre-intervention period was from July 1, 2019, to March 8, 2020; the intervention (index week change) was set in the week of March 9 to 15, 2020; the post-intervention period was from March 16, 2020, to September 30, 2020. (A) Any outpatient visit change is reported. (B) Any non-urgent hospital admission change is reported.

Figure 3

Interrupted time-series (ITS) design, from July 1, 2019, to September 30, 2020, evaluating the healthcare services change in the PD and control cohorts. The pre-intervention period was from July 1, 2019, to March 8, 2020; the intervention (index week change) was set in the week of March 9–15, 2020; the post-intervention period was from March 16, 2020, to September 30, 2020. (A) Outpatient neurologic visit change is reported. (B) Outpatient physiotherapy evaluation or treatment change is reported.