Slower recovery of outpatient clinics than inpatient services for stroke and other neurological diseases after COVID‐19 Pandemic

Abstract Background In this brief report, we investigated the impact of COVID‐19 on outpatient stroke clinics and inpatient services and their recovery process. Methods We sent a survey to physicians worldwide through the network of the World Stroke Organization to investigate the impact of COVID‐19 on stroke clinics. To farther along in recovering from the outbreak, we reviewed stroke and other neurology outpatient clinic visits (approximately 50% were stroke related) and the number of inpatient services from December 2019 to July 2020 in a large neurology department in Shanghai, China, where there was no official city lockdown. Results We received 112 valid survey responses from 46 countries, representing all continents except for Antarctica. Only seven of the survey responders (7/112, 6.3%) reported that they have kept their outpatient clinics open as usual, but they did exercise increased precautions for COVID‐19 by following recent guidelines regarding use of personal protective equipment and isolation techniques. The remainder of the respondents have either reduced outpatient clinic services or suspended outpatient clinics completely. Telephone consultation or telemedicine with video capability was used for new patients or follow‐ups, with limited in‐person evaluations when necessary. Outpatient clinic visits and inpatient services from a large tertiary hospital in China decreased dramatically during the peak period of the outbreak, but then rebounded back quickly following the partial or full recovery from the outbreak. Compared with the recovery process of inpatient services, outpatient clinic visits decreased faster and recovered much slower. This is consistent with our global survey data which indicates that some outpatient clinics have rescheduled their outpatient visits for 3 to 6 months. Conclusions The COVID‐19 pandemic caused a significant drop of in‐person outpatient visits and inpatient services. Clinic visits recovered slower than inpatient services in stroke and other neurological diseases after the pandemic.

tient stroke clinics and inpatient services and their recovery process.

Methods:
We sent a survey to physicians worldwide through the network of the World Stroke Organization to investigate the impact of COVID-19 on stroke clinics. To farther along in recovering from the outbreak, we reviewed stroke and other neurology outpatient clinic visits (approximately 50% were stroke related) and the number of inpatient services from December 2019 to July 2020 in a large neurology department in Shanghai, China, where there was no official city lockdown.

Results:
We received 112 valid survey responses from 46 countries, representing all continents except for Antarctica. Only seven of the survey responders (7/112, 6.3%) reported that they have kept their outpatient clinics open as usual, but they did exercise increased precautions for COVID-19 by following recent guidelines regarding use of personal protective equipment and isolation techniques. The remainder of the respondents have either reduced outpatient clinic services or suspended outpatient clinics completely. Telephone consultation or telemedicine with video capability was used for new patients or follow-ups, with limited in-person evaluations when necessary. Outpatient clinic visits and inpatient services from a large tertiary hospital in China decreased dramatically during the peak period of the outbreak, but then rebounded back quickly following the partial or full recovery from the outbreak.
Compared with the recovery process of inpatient services, outpatient clinic visits decreased faster and recovered much slower. This is consistent with our global survey data which indicates that some outpatient clinics have rescheduled their outpatient visits for 3 to 6 months.

Conclusions:
The COVID-19 pandemic caused a significant drop of in-person outpatient visits and inpatient services. Clinic visits recovered slower than inpatient services in stroke and other neurological diseases after the pandemic.

K E Y W O R D S
clinic, COVID-19, global impact, hospitalization, stroke, stroke care

| INTRODUC TI ON
We and others have reported recently that a significant drop of stroke admissions, evaluations, and related stroke care delivery occurred during the peak period of the novel coronavirus disease (COVID-19) outbreak. [1][2][3][4][5] As we continue monitoring the situation, we observed that many outpatient clinics have reduced or completely stopped in-person outpatient visits, and there is possible significant difference in recovery process for clinic visits and inpatient services which may have a profound impact on disease management and prevention. In this brief report, we compared the impact of COVID-19 pandemic on outpatient stroke clinics and inpatient services and their potential difference in recovery process.

| MATERIAL S AND ME THODS
There is no patient or individual information involved in this study; therefore, no Internal Review Board approval was needed. We sent a survey, during the last two weeks of April 2020, through the network of the World Stroke Organization to ask two simple questions: "(a) Which country are you in? and (b) How are you handling outpatient stroke-related visits now?". Since China is the place where COVID-19 was initially reported, and is therefore farther along in recovering from the outbreak, we reviewed stroke and other neurology outpatient clinic visits (of which approximately 50% were stroke related) and inpatient services from January 2019 to July 2020 from one large neurology department in Shanghai, China, where there had been no city lockdown.

| Statistical analysis
This was a survey-based study. All statistical analyses are descriptive, or reported as the actual numbers of observations. The graph is generated using Prism GraphPad (Version 8.

| RE SULTS
We received 112 valid survey responses from 46 countries representing all continents except for Antarctica. The list of countries and the number of responses, and the summary of the responses are presented in Table 1. Only seven of the survey responders (7/112, 6.3%) reported that they have kept their outpatient clinics open as usual, but with increased precautions for COVID-19 and following recent guidelines regarding personal protective equipment and isolation techniques. The remainder of the respondents reduced outpatient clinic services or suspended outpatient clinics completely. Telephone consultation or telemedicine with video capability was used for new patients or follow-ups with limited in-person evaluations when necessary. Two respondents reported that they have rescheduled their outpatient visits for 3 to 6 months. One reported from Australia that they are changing to telemedicine or phone follow-up for approximately 80% of their patients. Transient ischemic attack patients are triaged and reviewed by a consultant, and telemedicine or phone visits are arranged with appropriate investigations. Inpatient stroke patients who are discharged are provided with detailed summaries for their family doctors to follow, to reduce postadmission reviews. New medical home visits are provided by some centers in the UK. One survey response from South Korea indicated that telemedicine was allowed during the pandemic, despite not being allowed prior to the pandemic.
As indicated in Figure 1A, outpatient clinic visits to a large tertiary hospital in China decreased dramatically by 36.6% during the peak period of the outbreak in February but then returned to 60.5%, 78.3%, 77.6%, 89.0%, and 78.8% in March, April, May, June, and July, respectively, as compared to the same month in 2019 (Table 2). This is consistent with our global survey data, which indicated that some of the outpatient clinics have rescheduled their outpatient visits for 3 to 6 months. As shown in Figure 1B Table 2.
Compared with the recovery process of clinic visits, inpatient services recovered faster, and the number of visits did not fully recover at the end of this investigation.

| D ISCUSS I ON
Outpatient clinic visits play a critical role in patient education and stroke (and other neurological disease) prevention, and documenting patient characteristics related to stroke outcome. 6 Secondary stroke TA B L E 1 The impact on outpatient clinics from COVID-19 pandemic and the usage of telemedicine   The stroke-related hospitalization recovered quite quickly since hospitalization for stroke therapy is necessary. This also reflects successful efforts from stroke neurologist in managing stroke patients in the era of COVID-19 pandemic.
As hospitals and clinics are preparing to reopen to a full "routine" schedule, patients and accompanying person(s) will likely be required to wear masks to avoid hospital acquired COVID-19, as we proposed recently as a "new normal." 8 Some hospitals and clinics have already implemented such a universal mask policy, for now and for as long as we still see COVID-19 patients in the hospital or clinic settings.
The major limitation of this study is that we included only one center to indicate the trend of clinic visit and inpatient services recovery. We did not investigate the key factors that will drive the recovery and mechanisms of future clinic visits and inpatient services, so further studies are needed to investigate these issues. Another limitation is that the survey responses consist of those from only one center in some of the countries, which may not reflect the whole picture of the impact COVID-19 has had on stroke clinics in these countries.
In conclusion, the COVID-19 pandemic caused a significant drop of in-person outpatient visits and inpatient services. The recovery process of clinic visits and inpatient services was different, and clinic visits recovered slower than inpatient services in stroke and other neurological diseases after the pandemic.

ACK N OWLED G M ENTS
The authors appreciate the editing assistance from Dr John R.
Grothusen at the University of Pennsylvania.

CO N FLI C T O F I NTE R E S T
None of the authors have any conflicts to report.