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Figure.  Hospital Admissions by Noncommunicable Disease Type From January to June of Each Year, 2017-2020, São Paulo, Brazil
Hospital Admissions by Noncommunicable Disease Type From January to June of Each Year, 2017-2020, São Paulo, Brazil

Disease types are based on the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision.

Table.  Linear Regression of Hospital Admissions in São Paulo, Brazil, From January to June of Each Year, 2017-2020, by Noncommunicable Disease Type
Linear Regression of Hospital Admissions in São Paulo, Brazil, From January to June of Each Year, 2017-2020, by Noncommunicable Disease Type
1.
De Filippo  O, D’Ascenzo  F, Angelini  F,  et al.  Reduced rate of hospital admissions for ACS during COVID-19 outbreak in northern Italy.   N Engl J Med. 2020;383(1):88-89. doi:10.1056/NEJMc2009166 PubMedGoogle ScholarCrossref
2.
Baldi  E, Sechi  GM, Mare  C,  et al; Lombardia CARe Researchers.  Out-of-hospital cardiac arrest during the COVID-19 outbreak in Italy.   N Engl J Med. 2020;383(5):496-498. doi:10.1056/NEJMc2010418 PubMedGoogle ScholarCrossref
3.
Metzler  B, Siostrzonek  P, Binder  RK, Bauer  A, Reinstadler  SJ.  Decline of acute coronary syndrome admissions in Austria since the outbreak of COVID-19: the pandemic response causes cardiac collateral damage.   Eur Heart J. 2020;41(19):1852-1853. doi:10.1093/eurheartj/ehaa314 PubMedGoogle ScholarCrossref
4.
Barten  DG, Latten  GHP.  Re: “non-COVID-19 visits to emergency departments during the pandemic: the impact of fear. ”  Public Health. 2020;185:47. doi:10.1016/j.puhe.2020.05.063 PubMedGoogle ScholarCrossref
5.
Rosenbaum  L.  The untold toll—the pandemic’s effects on patients without COVID-19.   N Engl J Med. 2020;382(24):2368-2371. doi:10.1056/NEJMms2009984 PubMedGoogle ScholarCrossref
6.
Oseran  AS, Nash  D, Kim  C,  et al.  Changes in hospital admissions for urgent conditions during COVID-19 pandemic.   Am J Manag Care. 2020;26(8):327-328. doi:10.37765/ajmc.2020.43837 PubMedGoogle ScholarCrossref
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    Research Letter
    Global Health
    March 8, 2021

    Hospital Admissions Associated With Noncommunicable Diseases During the COVID-19 Outbreak in Brazil

    Author Affiliations
    • 1Laboratório de Epidemiologia e Análise de Dados, Centro Universitário Saúde ABC, Santo André, São Paulo, Brasil
    • 2Oncológica do Brasil Ensino e Pesquisa, Belém, Pará, Brasil
    • 3Universidade Federal de São Paulo, Escola Paulista de Medicina, Departamento de Medicina Preventiva, São Paulo, Brasil
    • 4Laboratório de Análises Clínicas, Centro Universitário Saúde ABC, Santo André, São Paulo, Brasil
    • 5Universidad de Santiago de Chile, Escuela de Ciencias de la Actividad Fisica, el Deporte y la Salud, Chile
    JAMA Netw Open. 2021;4(3):e210799. doi:10.1001/jamanetworkopen.2021.0799
    Introduction

    High-income countries have reported reductions in hospital admissions associated with cardiovascular diseases (CVDs) during the coronavirus disease 2019 (COVID-19) pandemic.1,2 However, the overall association of the COVID-19 pandemic with hospital admissions for noncommunicable diseases (NCDs) in low- and middle-income countries is still unclear. We assessed the number of hospital admissions for neoplasms, metabolic diseases, CVDs, and musculoskeletal diseases in São Paulo, Brazil, between January and June 2020 compared with the corresponding periods in the previous 3 years.

    Methods

    In this cross-sectional study, hospital admissions for NCDs were obtained from the Hospital Information System, a publicly available official database of hospital admissions in the Brazilian Unified Health System (Sistema Único de Saúde). The number of hospital admissions for neoplasms (C00-D48), metabolic diseases (E00-E90), CVDs (I00-I99), and musculoskeletal diseases (M00-M99), according to the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, was collected from January to June of each year from 2017 to 2020. Data were collected by 2 of the authors, and any incompatibility led to a new collection of data. Because the study used secondary data, ethical approval and informed consent were not required according to resolution 510 of the Brazilian National Health Council. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.

    Linear regression was used to describe the changes in hospital admissions throughout the selected months for each year. We also compared the number of hospital admissions in June 2020 vs January 2020 (before the first case of COVID-19 was reported in São Paulo on February 26, 2020). Statistical significance was set at 2-tailed P < .05, and data analysis was performed using Stata, version 11.0 (StataCorp LLC).

    Results

    The number of hospital admissions for NCDs between January and June was stable from 2017 to 2019. However, we observed a decrease in the absolute numbers of hospital admissions for NCDs between January and June 2020, with mean reductions in hospital admissions per month of 505 (95% CI, 126-884) for CVDs, 332 (95% CI, 95-569) for neoplasms, 136 (95% CI, 46-227) for musculoskeletal diseases, and 76 (95% CI, 1-151) for metabolic diseases (Table). During June 2020 compared with January 2020, there was a decrease of 543 hospital admissions (68%) for musculoskeletal diseases, 332 admissions (44%) for metabolic diseases, 2129 admissions (38%) for CVDs, and 1454 admissions (35%) for neoplasms (Figure).

    Discussion

    In this cross-sectional study, we observed a reduction in hospital admissions for NCDs from January to June 2020 compared with the corresponding period in each of the 3 previous years in São Paulo, Brazil. Social and physical distancing measures and the fear of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection may have been associated with the reduction. A decrease in hospital admissions could be associated with an increase in the number of deaths and complications owing to a lack of medical follow-up. Future studies on the association between the COVID-19 pandemic and deaths from NCDs are warranted.

    This study has limitations, including its cross-sectional design and the possibility of incomplete or inaccurate registration of hospital admissions in the official hospital admission system during the pandemic. To minimize these issues, we compared data from the first 6 months of 2020 with those from the same period in each of the previous 3 years. To our knowledge, few studies have quantified the change in hospital admissions for NCDs during the COVID-19 pandemic in low- to middle-income countries.3,4 In the US, however, studies5 have reported that patients not infected with SARS-CoV-2 may have avoided medical care because of fear or the recommendation of a health care professional, both of which should be assessed to avoid future complications.6 This study’s results may be considered by decision-makers when planning the hospital capacity of the Brazilian Unified Health System for treatment of NCDs. The reduction in hospital admissions observed during the pandemic could lead to a collapse of the hospital system because of an increase of patients with worse clinical conditions. Adequate funding of the Brazilian Unified Health System is imperative to address the COVID-19 pandemic and the potential indirect association of the pandemic with the number of admissions for NCDs.

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    Article Information

    Accepted for Publication: January 12, 2021.

    Published: March 8, 2021. doi:10.1001/jamanetworkopen.2021.0799

    Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Maselli-Schoueri JH et al. JAMA Network Open.

    Corresponding Author: Fernando Adami, PhD, Laboratório de Epidemiologia e Análise de Dados, Centro Universitário Saúde ABC, Av Lauro Gomes 2000, Vila Sacadura Cabral, Santo André, São Paulo, SP 09060-870, Brazil (fernando.adami@fmabc.br).

    Author Contributions: Drs Maselli-Schoueri and Adami had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Maselli-Schoueri, Rezende, Affonso Fonseca, Ferrari, Adami.

    Acquisition, analysis, or interpretation of data: Maselli-Schoueri, de Carvalho, Adami.

    Drafting of the manuscript: Maselli-Schoueri, Rezende, Ferrari, Adami.

    Critical revision of the manuscript for important intellectual content: Maselli-Schoueri, de Carvalho, Rezende, Affonso Fonseca, Adami.

    Statistical analysis: Maselli-Schoueri, Affonso Fonseca, Adami.

    Administrative, technical, or material support: de Carvalho, Ferrari, Adami.

    Supervision: Maselli-Schoueri, Rezende, Affonso Fonseca, Ferrari, Adami.

    Conflict of Interest Disclosures: None reported.

    References
    1.
    De Filippo  O, D’Ascenzo  F, Angelini  F,  et al.  Reduced rate of hospital admissions for ACS during COVID-19 outbreak in northern Italy.   N Engl J Med. 2020;383(1):88-89. doi:10.1056/NEJMc2009166 PubMedGoogle ScholarCrossref
    2.
    Baldi  E, Sechi  GM, Mare  C,  et al; Lombardia CARe Researchers.  Out-of-hospital cardiac arrest during the COVID-19 outbreak in Italy.   N Engl J Med. 2020;383(5):496-498. doi:10.1056/NEJMc2010418 PubMedGoogle ScholarCrossref
    3.
    Metzler  B, Siostrzonek  P, Binder  RK, Bauer  A, Reinstadler  SJ.  Decline of acute coronary syndrome admissions in Austria since the outbreak of COVID-19: the pandemic response causes cardiac collateral damage.   Eur Heart J. 2020;41(19):1852-1853. doi:10.1093/eurheartj/ehaa314 PubMedGoogle ScholarCrossref
    4.
    Barten  DG, Latten  GHP.  Re: “non-COVID-19 visits to emergency departments during the pandemic: the impact of fear. ”  Public Health. 2020;185:47. doi:10.1016/j.puhe.2020.05.063 PubMedGoogle ScholarCrossref
    5.
    Rosenbaum  L.  The untold toll—the pandemic’s effects on patients without COVID-19.   N Engl J Med. 2020;382(24):2368-2371. doi:10.1056/NEJMms2009984 PubMedGoogle ScholarCrossref
    6.
    Oseran  AS, Nash  D, Kim  C,  et al.  Changes in hospital admissions for urgent conditions during COVID-19 pandemic.   Am J Manag Care. 2020;26(8):327-328. doi:10.37765/ajmc.2020.43837 PubMedGoogle ScholarCrossref
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