COVID-19 Bed Surge and Rationing of Rehabilitation Services in Japan: A Seasonal Autoregressive Integrated Moving Average (SARIMA) Analysis of Care Utilization with 10 years claims data

ObjectiveTo explore the effect of COVID-19 and associated medical resource prioritization called "rationing" on the provision of rehabilitation services in Japan, focusing on cerebrovascular, musculoskeletal, and respiratory rehabilitation in the pre-COVID-19, during-COVID-19, and post-COVID-19 periods. DesignRetrospective study using seasonal autoregressive integrated moving average model to predict expected values, which were compared with actual values to calculate observed-to-expected ratios. SettingAcute care hospitals in Kanagawa Prefecture, which has the second largest population in Japan after Tokyo, covering April 2014 to March 2024. ParticipantsPatients aged 0-74 years who were enrolled in the National Health Insurance of Kanagawa Prefecture and underwent the studied types of rehabilitation. ExposureCOVID-19 pandemic waves and associated bed utilization rates, with multiple distinct peaks. Outcome measuresThe difference between the predicted and actual values of the volume of rehabilitation services provided and the number of patients per insured person calculated as observed-to-expected ratios in response to the peak of bed utilization against COVID-19. ResultsThe observed-to-expected ratio of inpatient rehabilitation services for cerebrovascular showed a significant decrease after five waves at -14.3%, and musculoskeletal conditions showed a similar decline during periods of high COVID-19 bed utilization. Outpatient services experienced sharp declines initially but showed differential recovery patterns. Respiratory rehabilitation displayed unique patterns, with inpatient services increasing up to 62.4% above expected levels until September 2021, before sharply declining. By March 2024, musculoskeletal rehabilitation demonstrated complete recovery, cerebrovascular rehabilitation showed partial recovery, while respiratory rehabilitation exhibited mixed patterns with persistent outpatient deficits. ConclusionsThe COVID-19 pandemic significantly impacted rehabilitation services in Japan, with inpatient services for cerebrovascular and musculoskeletal conditions being particularly vulnerable to disruptions during high COVID-19 bed utilization periods. The differential recovery patterns across rehabilitation types, with some structural changes persisting beyond the acute pandemic phase, indicate the need for flexible healthcare systems to deal with future healthcare crises. These findings underscore the importance of developing strategies to maintain essential rehabilitation services during public health emergencies, especially considering the aging global population and rising demand for rehabilitation. Article SummaryO_ST_ABSStrengths and Limitations of this studyC_ST_ABSO_LIThis study is the first to use 10 years of large-scale claims data (Apr 2014-Mar 2024) to show how COVID-19 bed surges disrupted rehabilitation services across multiple waves, including the post-Category 5 period. C_LIO_LIThe study findings indicate that service disruption varied by type: cerebrovascular and musculoskeletal rehab were more vulnerable, while respiratory rehab showed unique patterns of increase during the pandemic. C_LIO_LIA Seasonal Autoregressive Integrated Moving Average model using 72 months of pre-COVID data enabled accurate prediction of expected service levels across pre-, during-, and post-pandemic periods. C_LIO_LIThe study design could not identify the causal relationship between healthcare resource constraints and changes in patient care-seeking behaviors as primary drivers of decreased service utilization. C_LIO_LIThe study focused on a single prefecture, which may limit generalizability to other regions with different healthcare infrastructure. C_LI