{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,29]],"date-time":"2026-10-29T23:47:07Z","timestamp":1793317627040,"version":"4.5.0"},"reference-count":53,"publisher":"Public Library of Science (PLoS)","issue":"3","license":[{"start":{"date-parts":[[2025,3,6]],"date-time":"2025-03-06T00:00:00Z","timestamp":1741219200000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"the Ottawa Hospital Academic Medical Organization","award":["NA"],"award-info":[{"award-number":["NA"]}]},{"name":"the Ontario Health Data Platform","award":["NA"],"award-info":[{"award-number":["NA"]}]}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS ONE"],"abstract":"<jats:sec id=\"sec001\">\n<jats:title>\nObjectives\n<\/jats:title>\n<jats:p>To assess how changes in outpatient services during the first year of the COVID-19 pandemic were related to acute healthcare use (emergency department or hospitalizations) for individuals with asthma or chronic obstructive pulmonary disease (COPD).<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec002\">\n<jats:title>\nMethods\n<\/jats:title>\n<jats:p>We conducted an observational study using health administrative data in Ontario (Canada) from January 2016 to March 2021 on all adults with diagnosed asthma or COPD. We used monthly time series auto-regressive integrated moving-average (ARIMA) and pre-pandemic monthly rates (January 2016 to February 2020) to calculate projected rates (i.e., a pandemic had not occurred) during the pandemic (March 2020 to March 2021), and Quasi-Poisson models with two-way interaction to estimate crude and adjusted rate ratios.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec003\">\n<jats:title>\nResults\n<\/jats:title>\n<jats:p>In the first pandemic year, in individuals with asthma or COPD, outpatient visit rates started lower than projected (Mar-May 2020), returned to projected in the middle of the year (Jun-Aug 2020) and then rose to higher than projected between Sep 2020 and Mar 2021: observed rates of 80,293 per 100,000 persons vs. projected 74,192 (95% CI: 68,926-79,868) in individuals with asthma, and 92,651 vs. projected 85,871 (95% CI: 79,975-92,207) in individuals with COPD. Acute care rates remained below projected during the first pandemic year. While pulmonary function test (PFT) rates remained below projected during the first pandemic year, in both populations, a decrease in acute care visits during the pandemic, compared to pre-pandemic, was noted during months with the highest PFT rates (interaction p-values\u2009&lt;\u20090.0001).<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec004\">\n<jats:title>\nConclusions\n<\/jats:title>\n<jats:p>Despite asthma and COPD being ambulatory-care sensitive conditions, lower rates of outpatient visits during the beginning of the pandemic were not associated with increased rates of acute care use. Lower PFT rates were associated with higher acute care visit rates, suggesting that access to PFT during pandemic is likely important for individuals with asthma or COPD.<\/jats:p>\n<\/jats:sec>","DOI":"10.1371\/journal.pone.0316553","type":"journal-article","created":{"date-parts":[[2025,3,6]],"date-time":"2025-03-06T18:29:41Z","timestamp":1741285781000},"page":"e0316553","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":5,"title":["Healthcare utilization trends in adults with asthma or COPD during the first year of COVID-19 pandemic in comparison to pre-pandemic: A population-based study"],"prefix":"10.1371","volume":"20","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-5301-1796","authenticated-orcid":true,"given":"Tetyana","family":"Kendzerska","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michael","family":"Pugliese","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Douglas","family":"Manuel","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mohsen","family":"Sadatsafavi","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Marcus","family":"Povitz","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Therese A","family":"Stukel","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7463-3423","authenticated-orcid":true,"given":"Teresa","family":"To","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Shawn D.","family":"Aaron","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sunita","family":"Mulpuru","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Melanie","family":"Chin","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Claire E.","family":"Kendall","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kednapa","family":"Thavorn","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andrea S.","family":"Gershon","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2025,3,6]]},"reference":[{"issue":"6","key":"pone.0316553.ref001","doi-asserted-by":"crossref","first-page":"585","DOI":"10.1016\/S2213-2600(20)30105-3","article-title":"Prevalence and attributable health burden of chronic respiratory diseases, 1990-2017: a systematic analysis for the global burden of disease study 2017","volume":"8","author":"GBD Chronic Respiratory Disease Collaborators.","year":"2020","journal-title":"Lancet Respir Med"},{"issue":"26","key":"pone.0316553.ref002","doi-asserted-by":"crossref","first-page":"809","DOI":"10.15585\/mmwr.mm6926a1","article-title":"Medical expenditures attributed to asthma and chronic obstructive pulmonary disease among workers - United States, 2011-2015","volume":"69","author":"G Syamlal","year":"2020","journal-title":"MMWR Morb Mortal Wkly Rep"},{"issue":"2","key":"pone.0316553.ref003","doi-asserted-by":"crossref","first-page":"169","DOI":"10.1016\/j.puhe.2008.11.001","article-title":"Ambulatory care sensitive conditions: terminology and disease coding need to be more specific to aid policy makers and clinicians","volume":"123","author":"S Purdy","year":"2009","journal-title":"Public Health"},{"issue":"1","key":"pone.0316553.ref004","doi-asserted-by":"crossref","first-page":"6049","DOI":"10.1038\/s41598-020-63064-x","article-title":"Frequent outpatient visits prevent exacerbation of chronic obstructive pulmonary disease","volume":"10","author":"HJ Park","year":"2020","journal-title":"Sci Rep"},{"issue":"6","key":"pone.0316553.ref005","doi-asserted-by":"crossref","first-page":"441","DOI":"10.46747\/cfp.6806441","article-title":"Diagnosing asthma and chronic obstructive pulmonary disease: Importance of pulmonary function testing","volume":"68","author":"S Gupta","year":"2022","journal-title":"Can Fam Physician"},{"key":"pone.0316553.ref006","volume-title":"Evidence to improve care. Asthma in Adults. Care in the Community for People 16 Years of Age and Older: Health Quality Ontario","author":"Health Quality Ontario","year":"2024"},{"key":"pone.0316553.ref007","volume-title":"Evidance to improve care. CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD). Care in the Community for Adults: Health Quality Ontraio","author":"Health Quality Ontraio.","year":"2024"},{"key":"pone.0316553.ref008","volume-title":"Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease (updated 2024)","author":"Global Initiative for Chronic Obstructive Lung Disease (GOLD)"},{"key":"pone.0316553.ref009","doi-asserted-by":"crossref","first-page":"575","DOI":"10.2147\/RMHP.S293471","article-title":"The effects of the health system response to the COVID-19 pandemic on chronic disease management: a narrative review","volume":"14","author":"T Kendzerska","year":"2021","journal-title":"Risk Manag Healthc Policy"},{"issue":"1","key":"pone.0316553.ref010","doi-asserted-by":"crossref","first-page":"1934","DOI":"10.1016\/j.sapharm.2020.06.002","article-title":"Amid COVID-19 pandemic: challenges with access to care for COPD patients","volume":"17","author":"A Elbeddini","year":"2021","journal-title":"Res Social Adm Pharm"},{"issue":"2","key":"pone.0316553.ref011","doi-asserted-by":"crossref","first-page":"215","DOI":"10.1016\/j.ccm.2022.11.005","article-title":"What have we learned about transmission of coronavirus disease-2019: implications for pulmonary function testing and pulmonary procedures","volume":"44","author":"DA Kaminsky","year":"2023","journal-title":"Clin Chest Med"},{"key":"pone.0316553.ref012","doi-asserted-by":"crossref","first-page":"1251020","DOI":"10.3389\/fpubh.2023.1251020","article-title":"Trends in outpatient and inpatient visits for separate ambulatory-care-sensitive conditions during the first year of the COVID-19 pandemic: a province-based study","volume":"11","author":"T Kendzerska","year":"2023","journal-title":"Front Public Health"},{"issue":"3","key":"pone.0316553.ref013","doi-asserted-by":"crossref","first-page":"e222933","DOI":"10.1001\/jamanetworkopen.2022.2933","article-title":"Trends in hospitalizations for ambulatory care-sensitive conditions during the COVID-19 Pandemic","volume":"5","author":"NV Becker","year":"2022","journal-title":"JAMA Netw Open"},{"issue":"2","key":"pone.0316553.ref014","doi-asserted-by":"crossref","first-page":"73","DOI":"10.1080\/24745332.2020.1754027","article-title":"Addressing therapeutic questions to help Canadian physicians optimize asthma management for their patients during the COVID-19 pandemic","volume":"4","author":"C Licskai","year":"2020","journal-title":"Canadian Journal of Respiratory, Critical Care, and Sleep Medicine"},{"issue":"3","key":"pone.0316553.ref015","doi-asserted-by":"crossref","first-page":"869","DOI":"10.1016\/j.chest.2020.05.530","article-title":"Key highlights of the canadian thoracic society\u2019s position statement on the optimization of COPD management during the coronavirus disease 2019 pandemic","volume":"158","author":"M Bhutani","year":"2020","journal-title":"Chest"},{"issue":"35","key":"pone.0316553.ref016","doi-asserted-by":"crossref","first-page":"E1172","DOI":"10.1503\/cmaj.221051","article-title":"Trends in hospital admissions for chronic obstructive pulmonary disease over 16 years in Canada","volume":"195","author":"JE Amegadzie","year":"2023","journal-title":"CMAJ"},{"issue":"9","key":"pone.0316553.ref017","doi-asserted-by":"crossref","first-page":"726","DOI":"10.1002\/jhm.12920","article-title":"Trends in all-cause mortality and inpatient and outpatient visits for ambulatory care sensitive conditions during the first year of the COVID-19 pandemic: a population-based study","volume":"17","author":"T Kendzerska","year":"2022","journal-title":"J Hosp Med"},{"issue":"1","key":"pone.0316553.ref018","doi-asserted-by":"crossref","first-page":"124","DOI":"10.1186\/s12916-021-02000-w","article-title":"Impact of COVID-19 lockdown on the incidence and mortality of acute exacerbations of chronic obstructive pulmonary disease: national interrupted time series analyses for Scotland and Wales","volume":"19","author":"MA Alsallakh","year":"2021","journal-title":"BMC Med"},{"issue":"7","key":"pone.0316553.ref019","doi-asserted-by":"crossref","first-page":"588","DOI":"10.1159\/000515323","article-title":"Reduction in hospitalizations for respiratory diseases during the First COVID-19 wave in Greece","volume":"100","author":"C Kyriakopoulos","year":"2021","journal-title":"Respiration"},{"issue":"1","key":"pone.0316553.ref020","doi-asserted-by":"crossref","first-page":"135","DOI":"10.1016\/j.chest.2020.12.057","article-title":"Clinical consequences of COVID-19 lockdown in patients with COPD: results of a pre-post study in spain","volume":"160","author":"J Gonz\u00e1lez","year":"2021","journal-title":"Chest"},{"key":"pone.0316553.ref021","volume-title":"ICES investigative report Toronto: Institute for Clinical Evaluative Sciences","author":"Improving health care data in Ontario","year":"2005"},{"key":"pone.0316553.ref022","volume-title":"Canada\u2019s Health Care System Government of Canada [Nov 16, 2024]"},{"key":"pone.0316553.ref023","volume-title":"Canadian Institute for Health Information Discharge Abstract Database: A Validation Study Toronto","author":"DPC Juurlink","year":"2006"},{"key":"pone.0316553.ref024","first-page":"xxii","volume-title":"Canadian Medical Association., Institute for Clinical Evaluative Sciences in Ontario. Patterns of health care in Ontario","author":"V Goel","year":"1996"},{"issue":"6","key":"pone.0316553.ref025","doi-asserted-by":"crossref","first-page":"183","DOI":"10.1155\/2009\/963098","article-title":"Identifying patients with physician-diagnosed asthma in health administrative databases","volume":"16","author":"AS Gershon","year":"2009","journal-title":"Can Respir J"},{"issue":"5","key":"pone.0316553.ref026","doi-asserted-by":"crossref","first-page":"388","DOI":"10.1080\/15412550903140865","article-title":"Identifying individuals with physcian diagnosed COPD in health administrative databases","volume":"6","author":"AS Gershon","year":"2009","journal-title":"COPD"},{"key":"pone.0316553.ref027","volume-title":"Ontario government declares state of emergency amid coronavirus pandemic","author":"G Rodrigues","year":"2020"},{"key":"pone.0316553.ref028","volume-title":"Canadian Health Sector: Updates Related to COVID-19 in March 2020: Fasken"},{"key":"pone.0316553.ref029","volume-title":"Variation in the Canadian Provincial and Territorial responses to COVID-19","author":"E Cameron-Blake","year":"2021"},{"key":"pone.0316553.ref030","volume-title":"Guidelines on Person-Level Costing Using Administrative Databases in Ontario","author":"WP Wodchis","year":"2013"},{"key":"pone.0316553.ref031","volume-title":"Consumer price index portal Statistics Canada"},{"key":"pone.0316553.ref032","volume-title":"Health Analyst\u2019s Toolkit","author":"Ontario Ministry of Health and Long-Term Care"},{"issue":"3","key":"pone.0316553.ref033","first-page":"25","article-title":"The Canadian census mortality follow-up study, 1991 through 2001","volume":"19","author":"R Wilkins","year":"2008","journal-title":"Health Rep"},{"issue":"2","key":"pone.0316553.ref034","first-page":"157","article-title":"Use of postal codes and addresses in the analysis of health data","volume":"5","author":"R Wilkins","year":"1993","journal-title":"Health Rep"},{"issue":"2","key":"pone.0316553.ref035","doi-asserted-by":"crossref","first-page":"114","DOI":"10.1007\/BF03405327","article-title":"Prognostic relevance of census-derived individual respondent incomes versus household incomes","volume":"97","author":"DA Southern","year":"2006","journal-title":"Can J Public Health"},{"key":"pone.0316553.ref036","volume-title":"Time series analysis: forecasting and control","author":"GEP Box","year":"2008"},{"key":"pone.0316553.ref037","volume-title":"Reference Manual for X-13ARIMA-SEATS 2017","author":"Time series research staff, Center for Statistical Research and Methodology, U.S. Census Bureau"},{"key":"pone.0316553.ref038","volume-title":"The X11ARIMA\/88 Seasonal Adjustment Method - Foundations and User\u2019s Manual","author":"EB Dagum","year":"1988"},{"key":"pone.0316553.ref039","article-title":"Automatic modeling methods for univariate series.","volume-title":"A Course in Time Series Analysis","author":"V Gomez","year":"2001"},{"issue":"3","key":"pone.0316553.ref040","doi-asserted-by":"crossref","first-page":"392","DOI":"10.1037\/0033-2909.118.3.392","article-title":"Regression analyses of counts and rates: Poisson, overdispersed Poisson, and negative binomial models","volume":"118","author":"W Gardner","year":"1995","journal-title":"Psychol Bull"},{"key":"pone.0316553.ref041","doi-asserted-by":"crossref","first-page":"14799731231172518","DOI":"10.1177\/14799731231172518","article-title":"Disparities in self-reported healthcare access for airways disease in British Columbia, Canada, during the COVID-19 pandemic. Insights from a survey co-developed with people living with asthma and chronic obstructive pulmonary disease","volume":"20","author":"A Collins-Fairclough","year":"2023","journal-title":"Chron Respir Dis"},{"key":"pone.0316553.ref042","doi-asserted-by":"crossref","first-page":"2487","DOI":"10.2147\/COPD.S270448","article-title":"Symptoms, management and healthcare utilization of COPD patients during the COVID-19 epidemic in Beijing","volume":"15","author":"Y Liang","year":"2020","journal-title":"Int J Chron Obstruct Pulmon Dis"},{"key":"pone.0316553.ref043","doi-asserted-by":"crossref","first-page":"811","DOI":"10.2147\/JAA.S360985","article-title":"Epidemiology, healthcare resource utilization, and mortality of asthma and COPD in COVID-19: a systematic literature review and meta-analyses","volume":"15","author":"DMG Halpin","year":"2022","journal-title":"J Asthma Allergy"},{"issue":"11","key":"pone.0316553.ref044","doi-asserted-by":"crossref","first-page":"e0276774","DOI":"10.1371\/journal.pone.0276774","article-title":"Effect of asthma, COPD, and ACO on COVID-19: A systematic review and meta-analysis","volume":"17","author":"Y Uruma","year":"2022","journal-title":"PLoS One"},{"issue":"12","key":"pone.0316553.ref045","doi-asserted-by":"crossref","first-page":"1248","DOI":"10.1136\/thorax-2022-219957","article-title":"Examining the effect of the COVID-19 pandemic on community virus prevalence and healthcare utilisation reveals that peaks in asthma, COPD and respiratory tract infection occur with the re-emergence of rhino\/enterovirus","volume":"78","author":"T Ho","year":"2023","journal-title":"Thorax"},{"issue":"1","key":"pone.0316553.ref046","first-page":"104","article-title":"Epidemiology of respiratory virus before and during COVID-19 pandemic","volume":"30","author":"M Avolio","year":"2022","journal-title":"Infez Med"},{"key":"pone.0316553.ref047","doi-asserted-by":"crossref","first-page":"105823","DOI":"10.1016\/j.atmosres.2021.105823","article-title":"Air quality changes in cities during the COVID-19 lockdown: A critical review","volume":"264","author":"MG Adam","year":"2021","journal-title":"Atmos Res"},{"issue":"7","key":"pone.0316553.ref048","doi-asserted-by":"crossref","first-page":"2384","DOI":"10.1016\/j.jaip.2020.04.053","article-title":"Changes in medication adherence among patients with asthma and COPD during the COVID-19 pandemic","volume":"8","author":"L Kaye","year":"2020","journal-title":"J Allergy Clin Immunol Pract"},{"issue":"3","key":"pone.0316553.ref049","doi-asserted-by":"crossref","first-page":"156","DOI":"10.1080\/24745332.2020.1796211","article-title":"Resumption of pulmonary function testing during the post-peak phase of the COVID-19 pandemic","volume":"4","author":"S Stanojevic","year":"2020","journal-title":"Canadian Journal of Respiratory, Critical Care, and Sleep Medicine"},{"key":"pone.0316553.ref050","doi-asserted-by":"crossref","first-page":"20552076241258390","DOI":"10.1177\/20552076241258390","article-title":"When \u201cvirtual\u201d works and when it doesn\u2019t: A survey of physician and patient experiences with virtual care during the COVID-19 pandemic","volume":"10","author":"JM Hensel","year":"2024","journal-title":"Digit Health"},{"issue":"1","key":"pone.0316553.ref051","first-page":"38","article-title":"The early impact of the COVID-19 pandemic on hospital finances","volume":"68","author":"JH Rhodes","year":"2023","journal-title":"J Healthc Manag"},{"key":"pone.0316553.ref052","volume-title":"Understanding the Impact of COVID-19 on Ontario Hospital Finances: Ontario Hospital Association","year":"2020"},{"issue":"14","key":"pone.0316553.ref053","doi-asserted-by":"crossref","first-page":"E530","DOI":"10.1503\/cmaj.151420","article-title":"Outcomes of patients with chronic obstructive pulmonary disease diagnosed with or without pulmonary function testing","volume":"189","author":"A Gershon","year":"2017","journal-title":"CMAJ"}],"container-title":["PLOS ONE"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0316553","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,3,6]],"date-time":"2025-03-06T18:30:09Z","timestamp":1741285809000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0316553"}},"subtitle":[],"editor":[{"given":"Inge","family":"Roggen","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"editor"}]}],"short-title":[],"issued":{"date-parts":[[2025,3,6]]},"references-count":53,"journal-issue":{"issue":"3","published-online":{"date-parts":[[2025,3,6]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pone.0316553","relation":{},"ISSN":["1932-6203"],"issn-type":[{"value":"1932-6203","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,3,6]]}}}