Article Text

Original research
Impact of COVID-19 pandemic on utilisation of healthcare services: a systematic review
  1. Ray Moynihan1,
  2. Sharon Sanders1,
  3. Zoe A Michaleff1,
  4. Anna Mae Scott1,
  5. Justin Clark1,
  6. Emma J To2,
  7. Mark Jones1,
  8. Eliza Kitchener3,
  9. Melissa Fox4,
  10. Minna Johansson5,
  11. Eddy Lang2,
  12. Anne Duggan6,
  13. Ian Scott7,
  14. Loai Albarqouni1
  1. 1Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Queensland, Australia
  2. 2Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
  3. 3Faculty of Medicine, Dentistry and Health, Griffith University, Brisbane, Queensland, Australia
  4. 4Health Consumers Queensland, Adelaide, Queensland, Queensland
  5. 5Cochrane Sustainable Healthcare Field, Lund, Sweden
  6. 6Australian Commission on Safety and Quality in Healthcare, Sydney, New South Wales, Australia
  7. 7Internal Medicine and Clinical Epidemiology, Princess Alexander Hospital, Brisbane, Queensland, Australia
  1. Correspondence to Mr Ray Moynihan; raymoynihan{at}


Objectives To determine the extent and nature of changes in utilisation of healthcare services during COVID-19 pandemic.

Design Systematic review.

Eligibility Eligible studies compared utilisation of services during COVID-19 pandemic to at least one comparable period in prior years. Services included visits, admissions, diagnostics and therapeutics. Studies were excluded if from single centres or studied only patients with COVID-19.

Data sources PubMed, Embase, Cochrane COVID-19 Study Register and preprints were searched, without language restrictions, until 10 August, using detailed searches with key concepts including COVID-19, health services and impact.

Data analysis Risk of bias was assessed by adapting the Risk of Bias in Non-randomised Studies of Interventions tool, and a Cochrane Effective Practice and Organization of Care tool. Results were analysed using descriptive statistics, graphical figures and narrative synthesis.

Outcome measures Primary outcome was change in service utilisation between prepandemic and pandemic periods. Secondary outcome was the change in proportions of users of healthcare services with milder or more severe illness (eg, triage scores).

Results 3097 unique references were identified, and 81 studies across 20 countries included, reporting on >11 million services prepandemic and 6.9 million during pandemic. For the primary outcome, there were 143 estimates of changes, with a median 37% reduction in services overall (IQR −51% to −20%), comprising median reductions for visits of 42% (−53% to −32%), admissions 28% (−40% to −17%), diagnostics 31% (−53% to −24%) and for therapeutics 30% (−57% to −19%). Among 35 studies reporting secondary outcomes, there were 60 estimates, with 27 (45%) reporting larger reductions in utilisation among people with a milder spectrum of illness, and 33 (55%) reporting no difference.

Conclusions Healthcare utilisation decreased by about a third during the pandemic, with considerable variation, and with greater reductions among people with less severe illness. While addressing unmet need remains a priority, studies of health impacts of reductions may help health systems reduce unnecessary care in the postpandemic recovery.

PROSPERO registration number CRD42020203729.

  • quality in health care
  • organisation of health services
  • epidemiology
  • public health
  • health policy

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

Statistics from

Supplementary materials


  • Twitter @lnb6des

  • Contributors Conception/design: RM, LA, SS, ZAM, AMS, JC, MaJ, MiJ. Acquisition, analysis or interpretation of data: RM, SS, ZAM, AMS, JC, EJT, MaJ, EK, MF, MiJ, EL, AD, IS, LA. First draft of the manuscript: RM, LA. Manuscript drafting, revision, approval: RM, SS, ZAM, AMS, JC, EJT, MaJ, EK, MF, MiJ, EL, AD, IS, LA. Overall guarantors: RM, LA. The guarantor accepts full responsibility for the work and/or the conduct of the study, had access to the data and controlled the decision to publish.

  • Funding RM is funded by an Australian National Health and Medical Research Council (NHMRC fellowship grant number 1124207), and is a chief investigator of NHMRC Centre for Research Excellence (grant number 1104136).

  • Disclaimer All authors write as individuals and do not necessarily represent the views of their employers or affiliated organisations.

  • Competing interests RM has helped organise the Preventing Overdiagnosis international scientific conferences.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement All data relevant to the study are included in the article or uploaded as supplemental information. We have provided all data about all included studies, and a list of those studies, in the supplemental files.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.