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Excess Patient Visits for Cough and Pulmonary Disease at a Large US Health System in the Months Prior to the COVID-19 Pandemic: Time-Series Analysis.
J Med Internet Res. 2020 09 10; 22(9):e21562.JM

Abstract

BACKGROUND

Accurately assessing the regional activity of diseases such as COVID-19 is important in guiding public health interventions. Leveraging electronic health records (EHRs) to monitor outpatient clinical encounters may lead to the identification of emerging outbreaks.

OBJECTIVE

The aim of this study is to investigate whether excess visits where the word "cough" was present in the EHR reason for visit, and hospitalizations with acute respiratory failure were more frequent from December 2019 to February 2020 compared with the preceding 5 years.

METHODS

A retrospective observational cohort was identified from a large US health system with 3 hospitals, over 180 clinics, and 2.5 million patient encounters annually. Data from patient encounters from July 1, 2014, to February 29, 2020, were included. Seasonal autoregressive integrated moving average (SARIMA) time-series models were used to evaluate if the observed winter 2019/2020 rates were higher than the forecast 95% prediction intervals. The estimated excess number of visits and hospitalizations in winter 2019/2020 were calculated compared to previous seasons.

RESULTS

The percentage of patients presenting with an EHR reason for visit containing the word "cough" to clinics exceeded the 95% prediction interval the week of December 22, 2019, and was consistently above the 95% prediction interval all 10 weeks through the end of February 2020. Similar trends were noted for emergency department visits and hospitalizations starting December 22, 2019, where observed data exceeded the 95% prediction interval in 6 and 7 of the 10 weeks, respectively. The estimated excess over the 3-month 2019/2020 winter season, obtained by either subtracting the maximum or subtracting the average of the five previous seasons from the current season, was 1.6 or 2.0 excess visits for cough per 1000 outpatient visits, 11.0 or 19.2 excess visits for cough per 1000 emergency department visits, and 21.4 or 39.1 excess visits per 1000 hospitalizations with acute respiratory failure, respectively. The total numbers of excess cases above the 95% predicted forecast interval were 168 cases in the outpatient clinics, 56 cases for the emergency department, and 18 hospitalized with acute respiratory failure.

CONCLUSIONS

A significantly higher number of patients with respiratory complaints and diseases starting in late December 2019 and continuing through February 2020 suggests community spread of SARS-CoV-2 prior to established clinical awareness and testing capabilities. This provides a case example of how health system analytics combined with EHR data can provide powerful and agile tools for identifying when future trends in patient populations are outside of the expected ranges.

Authors+Show Affiliations

Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, United States.Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, United States.Department of Biostatistics, UW School of Public Health, Seattle, WA, United States.Department of Emergency Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, United States.Department of Biostatistics, Fielding School of Public Health, UCLA, Los Angeles, CA, United States.Department of Biostatistics, Fielding School of Public Health, UCLA, Los Angeles, CA, United States.Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, United States.Department of Medicine, UW School of Medicine, Seattle, WA, United States.Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, United States.

Pub Type(s)

Journal Article
Observational Study

Language

eng

PubMed ID

32791492

Citation

Elmore, Joann G., et al. "Excess Patient Visits for Cough and Pulmonary Disease at a Large US Health System in the Months Prior to the COVID-19 Pandemic: Time-Series Analysis." Journal of Medical Internet Research, vol. 22, no. 9, 2020, pp. e21562.
Elmore JG, Wang PC, Kerr KF, et al. Excess Patient Visits for Cough and Pulmonary Disease at a Large US Health System in the Months Prior to the COVID-19 Pandemic: Time-Series Analysis. J Med Internet Res. 2020;22(9):e21562.
Elmore, J. G., Wang, P. C., Kerr, K. F., Schriger, D. L., Morrison, D. E., Brookmeyer, R., Pfeffer, M. A., Payne, T. H., & Currier, J. S. (2020). Excess Patient Visits for Cough and Pulmonary Disease at a Large US Health System in the Months Prior to the COVID-19 Pandemic: Time-Series Analysis. Journal of Medical Internet Research, 22(9), e21562. https://doi.org/10.2196/21562
Elmore JG, et al. Excess Patient Visits for Cough and Pulmonary Disease at a Large US Health System in the Months Prior to the COVID-19 Pandemic: Time-Series Analysis. J Med Internet Res. 2020 09 10;22(9):e21562. PubMed PMID: 32791492.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Excess Patient Visits for Cough and Pulmonary Disease at a Large US Health System in the Months Prior to the COVID-19 Pandemic: Time-Series Analysis. AU - Elmore,Joann G, AU - Wang,Pin-Chieh, AU - Kerr,Kathleen F, AU - Schriger,David L, AU - Morrison,Douglas E, AU - Brookmeyer,Ron, AU - Pfeffer,Michael A, AU - Payne,Thomas H, AU - Currier,Judith S, Y1 - 2020/09/10/ PY - 2020/06/17/received PY - 2020/08/03/accepted PY - 2020/07/31/revised PY - 2020/8/14/pubmed PY - 2020/9/23/medline PY - 2020/8/14/entrez KW - COVID-19 KW - electronic health record KW - forecast KW - pandemic KW - prediction KW - time-series analysis SP - e21562 EP - e21562 JF - Journal of medical Internet research JO - J. Med. Internet Res. VL - 22 IS - 9 N2 - BACKGROUND: Accurately assessing the regional activity of diseases such as COVID-19 is important in guiding public health interventions. Leveraging electronic health records (EHRs) to monitor outpatient clinical encounters may lead to the identification of emerging outbreaks. OBJECTIVE: The aim of this study is to investigate whether excess visits where the word "cough" was present in the EHR reason for visit, and hospitalizations with acute respiratory failure were more frequent from December 2019 to February 2020 compared with the preceding 5 years. METHODS: A retrospective observational cohort was identified from a large US health system with 3 hospitals, over 180 clinics, and 2.5 million patient encounters annually. Data from patient encounters from July 1, 2014, to February 29, 2020, were included. Seasonal autoregressive integrated moving average (SARIMA) time-series models were used to evaluate if the observed winter 2019/2020 rates were higher than the forecast 95% prediction intervals. The estimated excess number of visits and hospitalizations in winter 2019/2020 were calculated compared to previous seasons. RESULTS: The percentage of patients presenting with an EHR reason for visit containing the word "cough" to clinics exceeded the 95% prediction interval the week of December 22, 2019, and was consistently above the 95% prediction interval all 10 weeks through the end of February 2020. Similar trends were noted for emergency department visits and hospitalizations starting December 22, 2019, where observed data exceeded the 95% prediction interval in 6 and 7 of the 10 weeks, respectively. The estimated excess over the 3-month 2019/2020 winter season, obtained by either subtracting the maximum or subtracting the average of the five previous seasons from the current season, was 1.6 or 2.0 excess visits for cough per 1000 outpatient visits, 11.0 or 19.2 excess visits for cough per 1000 emergency department visits, and 21.4 or 39.1 excess visits per 1000 hospitalizations with acute respiratory failure, respectively. The total numbers of excess cases above the 95% predicted forecast interval were 168 cases in the outpatient clinics, 56 cases for the emergency department, and 18 hospitalized with acute respiratory failure. CONCLUSIONS: A significantly higher number of patients with respiratory complaints and diseases starting in late December 2019 and continuing through February 2020 suggests community spread of SARS-CoV-2 prior to established clinical awareness and testing capabilities. This provides a case example of how health system analytics combined with EHR data can provide powerful and agile tools for identifying when future trends in patient populations are outside of the expected ranges. SN - 1438-8871 UR - https://www.unboundmedicine.com/medline/citation/32791492/Excess_Patient_Visits_for_Cough_and_Pulmonary_Disease_at_a_Large_US_Health_System_in_the_Months_Prior_to_the_COVID_19_Pandemic:_Time_Series_Analysis_ L2 - https://www.jmir.org/2020/9/e21562/ DB - PRIME DP - Unbound Medicine ER -