The COVID-19 pandemic was the most concerning health problem in 2020 because it caused not only healthy disorders but also extensive restrictions of daily life worldwide. During our study period, Taiwan was exempted from the pandemic due to the implementation of broad public health infrastructure and domains of effective screening, isolation/quarantine, and facial mask use.[18] Although Taiwan’s government did not implement travel restrictions and the medical supply was competent, this study demonstrated a higher rate of ACA and a longer length of hospital stays in patients with AA during the COVID-19 study period. Notably, the number of confirmed COVID-19 was positively correlated with the ACA rate. Therefore, the patients’ fear of being contaminated by the COVID-19 influenced the HSB and deteriorated the clinical outcomes.
In our study, the symptom duration from the ER presentation to > 48 h thereafter was significantly associated with ACA, which was similar to that of a previous report.[19] Prolonged appendicitis without prompt treatment might deteriorate the inflammation of the appendiceal wall and result in perforation or abscess formation.[20] Furthermore, one significant association was observed between patients with AA during the COVID-19 period and ACA as compared with that in the last 3 3 years. Our finding coincided with that of published reports in children [12, 21] and adults.[22]
In addition to the impact of clinical and socioeconomic determinants on outcomes, poor HSB has been proven to increase morbidity and mortality.[23] Patients’ behaviors should be understood at their level to improve their clinical outcomes.[24] Based on our findings, one epidemic communicable disease could interfere with the need of seeking medical services even in a resource-competent community. We consider that some fake news or information in social media causes fear of the people, who diminish the travel and need of seeking medical services.[25] Conversely, scientific information and medical knowledge can help improve the HSB, which in turn enhances the healthy condition.[23] Although social media can rapidly disseminate any information, some false information can confuse and distract people. Therefore, reliable evidence is the cornerstone of promoting health awareness and implementing health policy, especially during the COVID-19 pandemic. Moreover, educated scientists and physicians will be leaders in delivering information to the public, [25, 26] and the government should implement anti-misinformation actions to minimize the adverse effects.
Although healthcare system, disparities of medical supplies, and socioeconomic status are the main barriers to medical services,[27, 28] an extensive health crisis during the COVID-19 pandemic may become the additional obstacle to providing timely surgical intervention, a basis of any healthcare system with both elective and emergency procedures. To overcome the shortage of medical services, healthcare systems should rapidly prioritize available resources and adopt new policies to deliver clinical services.[29, 30] Although surgical management widely varies in terms of regional culture and healthcare system worldwide, each institution customizes associated plans to maintain appropriate surgical services when surgical staff are sufficiently protected.
This study had some limitations. The study design was retrospective and was conducted in one universal healthcare system, which alleviates part of the barrier of access to healthcare services. Second, from January 1 to June 30, 2020, was selected because the dissemination of COVID-19 is severer during this period. Different periods might interfere with the results. Third, the referral policy was associated with delayed medical visits but was consistent during the study period in Taiwan. Some studies addressed that general practitioners preferred medical treatment for patients with AA without referring them to the ER.[31] From our findings, the number of patients with AA (145) was higher than the average number during the control period (around 107). Therefore, we considered that the number of patients who were not referred for or received no medical treatment was rather low.