Changes in the medical treatment status of Japanese outpatients during the coronavirus disease 2019 pandemic

Abstract Background The coronavirus disease 2019 (COVID‐19) has a tremendous influence in general public's behaviors; however, changes in the status of regularly scheduled outpatient visits in Japan during COVID‐19 pandemic are still unknown. Methods This cross‐sectional study was conducted in May 2020. Participants were recruited by an Internet‐based survey company. A total of 659 patients (54% male, average age 60 ± 14 years) who had regularly scheduled outpatient visits prior to the onset of COVID‐19 were enrolled. Participants answered four questions (“decrease in medical visit frequency,” “inability to take regular medication,” “deterioration of a chronic disease,” and “utilization of telephone/online medical care”) and stated whether they had a fear of acquiring infection at a medical facility. The associations between answers, fear of infection, and socio‐demographic factors were examined. Results Among the participants, 37.8% had decreased their medical visits, 6.8% were unable to take regular medications, 5.6% experienced a deterioration of chronic disease, and 9.1% utilized telephone/online medical care. Fear of being infected by COVID‐19 at medical facilities was strongly associated with a reduced frequency of medical visits and lack of regular medications even after adjusting for socio‐demographic factors and current medical histories. Conclusions During the first wave of COVID‐19, approximately 40% of participants reduced their frequency of medical visits. It is important to continue implementing thorough infection control measures at facilities and educating the public the importance of keeping chronic diseases in good condition, as well as promoting telephone/online medical care.


| INTRODUC TI ON
The coronavirus disease 2019 (COVID-19) epidemic has become a global challenge. Because of the nationwide spread of  infections and the increasing number of deaths, 1,2 a state of emergency was declared in April 2020 by the Japanese Ministry of Health, Labor and Welfare (JMHLW). As COVID-19 spreads, there have been clusters of COVID-19 reported at medical facilities, 3 and patients have refrained from visiting them. Under the current circumstances, even though many citizens practice infection prevention measures, COVID-19 cases are not decreasing.
Studies have shown that COVID-19 is more serious in the elderly and those with hypertension, diabetes, heart disease, chronic respiratory disease, and cancer. [4][5][6][7][8][9] Therefore, it is particularly important that these patients keep their diseases under control to prevent death. During the COVID-19 pandemic, the number of outpatient visits at many medical facilities decreased, according to aggregated data from outpatient billing receipts. 10 Changes in the medical treatment status of Japanese outpatients (decrease in visit frequency, inability to take regular medications, and deterioration of chronic disease) and socio-demographic factors that influenced outpatient status are not well understood. Therefore, this study was conducted to examine changes in the treatment behavior and health status of patients undergoing regular outpatient visits and to identify the factors that influenced those behaviors during the COVID-19 pandemic.

| Study design and subjects
This study was a cross-sectional study utilizing the data obtained for some studies, [11][12][13] which has been conducted to examine the influence of the COVID-19 on general Japanese population. Participants were recruited from a Japanese Internet-based survey company that has approximately 1.12 million registrants as of January 2020. We collected data from 2400 people aged 20-79 years (sampling by gender and 10-year age group; 12 groups, n = 200 in each group) who were living in the Tokyo metropolitan area. The company randomly chosen potential respondents from the registrants. The number of potential respondents in each stratified sample group was determined by dividing 200 by the response rate for the corresponding socio-demographic group. The response rate was then computed based of the results of past surveys conducted by the research company. The company sent an email on February 25, 2020, inviting registrants to participate in the survey (n = 8156).
Survey questions were sent via a URL in an email. Once 200 people in each group responded, we closed the group. The first survey was completed on February 27. Participants were given points equivalent to 50 Japanese yen (JPY) per response. The third survey, which included items regarding the status of outpatient visits, was conducted between May 12 and 17 with 2400 subjects. This third survey was conducted after the state of emergency, that had been declared in seven prefectures on April 7 and was expanded nationwide on April 16,14 was lifted in some prefectures.
In the third survey, we asked participants whether they had had regular outpatient visits before the onset of COVID-19 (as of fall 2019). Participants who answered "I had regular visits to the hospital outpatient department" or "I had regular visits to the clinic" were included in the study. We excluded respondents who only selected pollinosis (hay fever) from the list of potential current medical conditions, as pollinosis is often treated with over-the-counter medication and does not necessarily lead to an outpatient visit. Respondents who were missing socio-demographic information or whose answers were of suspect accuracy or honesty were also excluded. Participants also rated their health (very good, good, not very good, and not good) and reported their current illnesses (hypertension, diabetes, heart disease, stroke, respiratory disease, and cancer).

| Statistical analysis
The prevalence of those who answered yes to 4 medical treatment status, that is, "decrease in medical visit frequency," "inability to take regular medication," "deterioration of chronic illness," and "utilization of telephone/online medical care," was calculated for each sociodemographic attribute and compared using the chi-square test.
Multivariable logistic regression analysis was performed to clarify the factors independently related to the medical treatment situation. The dependent variables were four measurement of medical treatment status. The independent variables of model 1 were gender, age, residential area, marital status, living arrangement, education, working status, annual household income, lifestyle (smoking, alcohol consumption, and exercise habits), self-rated health, type of medical facility, and fear of being infected at medical facilities. In model 2, in addition to the independent variables in model 1, the presence or absence of a current illness (hypertension, diabetes, heart disease, stroke, respiratory disease, or cancer) (yes/no format) was added. In model 3, in addition to the independent variables discussed in model 2, decrease in medical visit frequency was included as an independent variable.
Statistical analyses were performed using IBM SPSS Statistics for MAC, version 26 (IBM Japan). The significance level was set at P < .05.

| RE SULTS
A total of 877 people met the inclusion criteria of "visited hospitals or clinics" before the fall of 2019. Respondents were excluded as follows: only reporting pollinosis for their current medical history (n = 207), lacking basic information (n = 8), and suspect credibility (n = 3) (specifically, 3 men in their 20s who answered that they had a history of ≥4 diseases when asked about their current medical history; the validity of the data was judged to be low by two researchers independently). As a result, 659 people (75.1%) were included in the study (Figure 1). Table 1 shows the socio-demographic characteristics of the participants. In total, 54.2% of the participants were male. Sixty-one percentage of the participants were 60-79 years, 33.8% lived in the Tokyo Metropolis. The location of visits was divided fairly equally between hospitals (55.8%) and clinics (44.2%). Three-quarters (75.3%) of the respondents answered that they were afraid of being infected with COVID-19 at a medical facility.
Treatment-related behavior and status of all participants are shown in Table 2. A decrease in medical visit frequency was reported by 37.8%, but an inability to take regular medication was reported by only 6.8% of participants and deterioration of a chronic illness by 5.6%. Furthermore, 9.1% utilized telephone/online medical care.
The status of medical visits/behaviors by socio-demographic factors is presented in Table 3.
The rate of "decrease in medical visit frequency" was significantly different by gender (P < .001), residential area (P = .035), presence or absence fear of being infected at medical facilities (P < .001), presence or absence of hypertension (P = .031), and respiratory illness (P = .045). The rate of "decrease in medical visit frequency" was higher among women, respondents living in the Tokyo Metropolis, respondents with a fear of being infected at medical facilities, respondents without current hypertension, and respondents with respiratory illness.
The rate of "inability to take regular medication" was significantly different with age (P = .001), presence or absence of fear of being infected at medical facilities (P = .004), and the presence or absence of hypertension (P = .028). The rate of "inability to take regular medication" was highest in respondents aged 20-30 years, respondents who were afraid of being infected at medical facilities, and respondents without hypertension. The rate of "deterioration of chronic illness" was highest in respondents aged 20-30 years, respondents whose self-rated health was poor (P < .001), and respondents who regularly visited the hospital (P = .031). The rate of utilization of telephone/online medical care was significantly higher in participants aged 20-30 years (P = .017) and those who regularly exercised (P < .001).

F I G U R E 1 Participant flow
The factors related to "decrease in medical visit frequency" and "inability to take regular medication" are shown in Table 4A.

TA B L E 3 Prevalence of treatment-related behaviors and status by socio-demographic and lifestyle-related factors
Respondents whose visiting medical institution was a hospital (OR = 1.79; 95% CI = 0.99-3.23; P = .054) had a nonsignificantly higher tendency to use telephone/online medical care than those who had visited a clinic. .332

| D ISCUSS I ON
Clinic (ref) .223 Living with others (ref) .001 Less than 3 d/wk (ref) In model 2, in addition to the independent variables discussed in model 1, the presence or absence of a current illness (hypertension, diabetes, heart disease, stroke, respiratory disease, and cancer) was input as an independent variables. c In model 3, in addition to the independent variables discussed in model 2, decrease in visit frequency was input as an independent variable. *P-value was calculated by a multivariable logistic regression analysis.
COVID-19 pandemic, it is also important to consider the appropri- to take regular medication, and deterioration of chronic illness were not associated with any specific diseases.
This study found that patients undergoing regular outpatient visits were "afraid of being infected with COVID-19 at medical facilities," and that this was strongly associated with a decrease in medical visit frequency and an inability to take regular medications.
To reduce the number of patients who drop out of regular medical visits owing to a fear of being exposed to COVID-19, it is import- The limitations of our study are as follows. First, participants in this study were recruited via an Internet research company and the survey was conducted via email. This may have resulted in selection bias, as the target population was based on people with relatively high IT literacy. Fewer than 10% of respondents reported utilizing telephone or online care; the actual utilization in the general population may be even lower. Furthermore, in this study, "telephone medical care" and "online medical care" were collectively investigated as "telephone/online medical care." Therefore, it is not possible to discuss the utilization status of telephone medical care and online medical care separately. At the time of the study, online medical care was not widely used in Japan and most of the answers likely reflected telephone medical care.
Second, the participants' ages were in the 20s to 70s. Although it has been indicated that advanced age is a risk factor for COVID-19 aggravation, this study could not clarify the outpatient status of elderly people >80 years old.
Third, the evaluation of the deterioration of a chronic disease is self-reported and may lack objectivity. In addition, this study may have been conducted too early in the course of COVID-19 to accurately assess the degree of deterioration. Finally, this study was conducted during the first wave of COVID-19 in Japan. If this study was to be conducted during subsequent waves of COVID-19, it is unclear whether the results would be the same. It is also unclear whether the results of this study can be applied to patients in different countries.
Despite the above limitations, this study clarified the medical treatment status and related factors of outpatients at risk of COVID-19 aggravation during the first wave of COVID-19. As of fall 2020, COVID-19 has not disappeared. As the pandemic continues, medical facilities will need to thoroughly prevent infections and promote telephone/online medical care to mitigate the decrease in inperson visits, and the inability to take regular medications.

| CON CLUS ION
This cross-sectional study found that the frequency of outpatient visits decreased approximately 40% during the first wave of COVID-19, but that fewer than 10% of the respondents had run out of their regular medications or had a deterioration of a chronic disease. Fear of being infected with COVID-19 at medical facilities was strongly associated with a decrease in medical visit frequency and inability to take regular medications. It is important to continue implementing thorough infection control measures at medical facilities and to inform the public the importance of keeping chronic diseases in good condition as well as promoting telephone/online medical care to avoid decreases in medical visit frequency.

ACK N OWLED G EM ENTS
We express our sincere thanks to all the participants who enrolled in this study.

CO N FLI C T O F I NTE R E S T
The authors have stated explicitly that there are no conflicts of interest in connection with this article.

AUTH O R CO NTR I B UTI O N S
TTakakubo, YO, and SI designed the study. MM and SI participated in the data collection. TTakakubo and YO undertook the statistical analysis and wrote the manuscript. TTakamiya, NF, HK, SA, IN, and HW assisted in the revision of the manuscript. All authors contributed to and approved the final manuscript.

E TH I C A L A PPROVA L
This study was approved by the Ethics Committee of Tokyo Medical University, Tokyo, Japan (No: T2019-0234). Informed consent was obtained from all respondents.