The impact of SARS on hospital performance

Abstract

During the SARS epidemic, healthcare utilization and medical services decreased significantly. However, the long-term impact of SARS on hospital performance needs to be further discussed.
A municipal hospital in Taipei City was shut down for a month due to SARS and then became the designated SARS and infectious disease hospital for the city. This study collected the outpatient, inpatient and emergency service volumes for every year from April to March over four years. Average monthly service amount +/- standard deviation were used to compare patient volume for the whole hospital, as well as the outpatient numbers accessing different departments. The ARIMA model of outpatient volume in the pre-SARS year was developed.
The average monthly service volume of outpatient visits for the base year 2002 was 52317 +/- 4204 visits per month, and number for 2003 and the following two years were 55%, 82% and 84% of the base year respectively. The average emergency service volume was 4382 +/- 356 visits per month at the base year and this became 45%, 77% and 87% of the base year for the following three years respectively. Average inpatient service volume was 8520 +/- 909 inpatient days per month at the base year becoming 43%, 81% and 87% of the base year for the following three years respectively. Only the emergency service volume had recovered to the level of a non-significant difference at the second year after SARS. In addition, the departments of family medicine, metabolism and nephrology reached the 2002 patient number in 2003. The ARIMA (2,1,0) model was the most suitable for outpatient volume in pre-SARS year. The MAPE of the ARIMA (2,1,0) model for the pre-SARS year was 6.9%, and 43.2%, 10.6%, 6.2% for following 3 years.
This study demonstrates that if a hospital is completely shut down due to SARS or a similar disease, the impact is longer than previous reported and different departments may experience different recover periods. The findings of this study identify subspecialties that are particularly vulnerable in an infectious disease designated hospital and such hospitals need to consider which subspecialties should be included in their medical structure.

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BMC Health Services Research
Open Access
Research article
The impact of SARS on hospital performance
Dachen Chu
†1,3
, Ran-Chou Chen*
†2,3
, Chia-Yu Ku
3
and Pesus Chou
†1
Address:
1
Community Medicine Research Center and Institute of Public Health, National Yang-Ming University, Taipei, Taiwan,
2
Department of
Biomedical Imaging and Radiological Sciences, National Yang-Ming University, Taipei, Taiwan and
3
Taipei City Hospital, 33 Sec. 2 Chun Hwa
Road, Taipei, Taiwan
Email: Dachen Chu - dad57@tpech.gov.tw; Ran-Chou Chen* - chenranchou@yahoo.com.tw; Chia-Yu Ku - A2414@tpech.gov.tw;
Pesus Chou - pschou@ym.edu.tw
* Corresponding author †Equal contributors
Abstract
Background: During the SARS epidemic, healthcare utilization and medical services decreased
significantly. However, the long-term impact of SARS on hospital performance needs to be further
discussed.
Methods: A municipal hospital in Taipei City was shut down for a month due to SARS and then
became the designated SARS and infectious disease hospital for the city. This study collected the
outpatient, inpatient and emergency service volumes for every year from April to March over four
years. Average monthly service amount ± standard deviation were used to compare patient volume
for the whole hospital, as well as the outpatient numbers accessing different departments. The
ARIMA model of outpatient volume in the pre-SARS year was developed.
Results: The average monthly service volume of outpatient visits for the base year 2002 was 52317
± 4204 visits per month, and number for 2003 and the following two years were 55%, 82% and 84%
of the base year respectively. The average emergency service volume was 4382 ± 356 visits per
month at the base year and this became 45%, 77% and 87% of the base year for the following three
years respectively. Average inpatient service volume was 8520 ± 909 inpatient days per month at
the base year becoming 43%, 81% and 87% of the base year for the following three years
respectively. Only the emergency service volume had recovered to the level of a non-significant
difference at the second year after SARS. In addition, the departments of family medicine,
metabolism and nephrology reached the 2002 patient number in 2003. The ARIMA (2,1,0) model
was the most suitable for outpatient volume in pre-SARS year. The MAPE of the ARIMA (2,1,0)
model for the pre-SARS year was 6.9%, and 43.2%, 10.6%, 6.2% for following 3 years.
Conclusion: This study demonstrates that if a hospital is completely shut down due to SARS or a
similar disease, the impact is longer than previous reported and different departments may
experience different recover periods. The findings of this study identify subspecialties that are
particularly vulnerable in an infectious disease designated hospital and such hospitals need to
consider which subspecialties should be included in their medical structure.
Published: 6 November 2008
BMC Health Services Research 2008, 8:228 doi:10.1186/1472-6963-8-228
Received: 3 June 2008
Accepted: 6 November 2008
This article is available from: http://www.biomedcentral.com/1472-6963/8/228
© 2008 Chu et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0
),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Background
Severe Acute Respiratory Syndrome (SARS) is a viral respi-
ratory disease caused by a coronavirus (SARS-CoV). SARS
has caused a significant impact on psychosocial and legis-
lative regulation [1-4]. SARS brought about not only rela-
tively discernable economic losses [5], but also observable
damage to healthcare organizations, and this has resulted
in a lower healthcare utilization rate [6,7].
During the SARS epidemic, there were many reports that
looked into healthcare utilization and decreases in medi-
cal service volume [8]. However, most of them explored
only one department of the hospital or over a very short
period of time. No reports have studied the influence on
whole hospital performance and followed the long-term
impact on the recovery. A municipal hospital in Taipei
was shut down for a month due to SARS [3], and after-
wards became the designated SARS and infectious disease
hospital for the city in addition to its general regional hos-
pital's character. This study collects the service volumes of
all departments in this hospital from one year before and
for three years after the SARS outbreak. No similar study
has been published previously.
Methods
The municipal hospital in Taipei City studied here is a
general and teaching hospital with 450 beds. The depart-
ments in this hospital include internal medicine, surgery,
OBS/GYN, pediatrics, radiology and pathology. The hos-
pital underwent a SARS outbreak during April 2003. Fifty-
nine hospital workers were infected and this led to seven
deaths [1,3]. To halt the outbreak of SARS infection, the
hospital was shut down to allow evacuation of hospital-
ized patients and workers gradually over 10 days. Twenty-
five days after that, the hospital was fully vacated and ster-
ilization carried out. Outpatient services were first reo-
pened after 35 days of quarantine. Inpatient and
emergency services were reopened after 65 days. Subse-
quently, in addition to its general regional hospital func-
tion, the hospital became the infectious disease
designated hospital for the Taipei area, and receives infec-
tious disease patients, undergoes preparedness exercises
and admits tuberculosis patients.
In order to compare the recovery situation after SARS, this
study follows the numbers of outpatients, emergency
patients and inpatients from 2002 to 2006. The patient
numbers for emergency and outpatient services, and
number of patient days for inpatient service were used as
quantitative evaluations and are expressed as the average
monthly services amount ± standard deviation. The hos-
pital was shut down during April 2003, and therefore the
study collected the services volume from every April to
next March. Year 2002 was selected as the base year of this
study. The service volume of 2003, which is when SARS
was occurred, and of the two years after that, were com-
pared to the 2002 data. The study was approved by the
ethics committee of the Taipei City Hospital Hoping
branch.
Statistically analysis by repeat measurement ANOVA
(SPSS for Windows 15.0) was utilized in this study to
compare the variation over 4 years. If the service volume
for a specific area and year was less than the base year, and
showed a significant difference (p < 0.05), then this year
was considered to be still recovering. Based on this recov-
ery situation, all the departments can be divided into four
groups; these are departments that recovered in the year
SARS happened, departments that recovered in the first
year after SARS, departments that recovered in the second
year after SARS, and finally departments still not yet recov-
ered. The autoregressive integrated moving average
(ARIMA) model of outpatient volume in the pre-SARS
year was developed. Various permutations of the order of
correlation and order of integration (I) were computed to
choose the optimal combination of parameters based on
the mean square error. Partial correlogram graphs and
correlograms were used to select the order of moving aver-
age (MA) and autoregressive (AR) terms in the model.
Based on the best model selected, the mean absolute per-
centage error (MAPE) was used to measure the quality of
fit of the service volume of outpatients during the SARS,
and two years after SARS period [9].
During the four years of this study, the economic aspects
that affected the hospital's performances remained the
same, include beds and medical specialties. Furthermore,
the number of similar hospitals in local area did not
change. The organization of the healthcare system and its
reimbursement still come from the Taiwan National
Health Insurance (NHI) system [10]. In addition, there
were also no significant policy changes with respect to
NHI payment policy in these four years. Moreover, the
neighborhood population of this hospital underwent no
obvious change (the neighborhood population was
173,637 in 2002 and had become 171,092 in 2006) [11].
However, in addition to the general regional hospital, the
hospital was also now designated as an infectious disease
hospital.
Results
The average monthly number of outpatient visits at base
year was 52317 ± 4204. The numbers for the year SARS
that happened and the following two years were 55%
(28950 ± 11731), 82% (42906 ± 4047) and 84% (43715
± 2758) of the base year respectively (Table 1). Average
emergency numbers was 4382 ± 356 visits per month at
base year. This number decreased to 45% (1975 ± 1242)
of the base year for the year SARS happened, and came
back to 77% (3395 ± 345) during the first year after SARS,

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and 87% (3824 ± 346) of the base year during the second
year after SARS. The average inpatient service volume was
8520 ± 909 inpatient days per month at base year. The
number decreased to 43% (3678 ± 2350) of base year for
the year SARS happened, and came back to 81% (6863 ±
486) and 87% (7371 ± 471) of the base year for the fol-
lowing two years. Only the emergency service volumes
recovered to the level of non-significant difference at the
second year after SARS. Services volumes for outpatients
and inpatients were still significant different (p < 0.05).
Using the pre-SARS year as the training dataset in the
ARIMA model, the ARIMA IAR (2,1,0) model was the
most suitable. Similar result about the delayed recovery of
outpatient services is noted (figure 1). The MAPE of the
ARIMA (2,1,0) model for the pre-SARS year was 6.94%.
The MAPE for the year of SARS was 43.24%, improving to
10.58% for the 1
st
post-SARS year, and to 6.20% for the
2
nd
post-SARS year.
On examining the various outpatient departments, family
medicine, metabolism and nephrology recovered during
the year that SARS happened. Family medicine was even
higher than the base year during the first and second years
after SARS. Nephrology was also higher than the base year
during the second year after SARS. The departments that
recovered during the first year after SARS included neurol-
ogy, cardiology, infectious diseases, neurosurgery, urol-
ogy, plastic surgery, dentistry and psychiatry. Among
these, psychiatry was even higher than the base year. Pedi-
atrics recovered during the second year after SARS. The
departments that still have not recovered include general
surgery, ophthalmology, orthopedics, ENT, internal med-
icine, pulmonary medicine, gastroenterology, OBS/GYN,
dermatology, rehabilitation and Chinese medicine (Table
2). The numbers of physicians were 165 for the base year,
162 for the SARS year, 170 for the first year after SARS, and
173 for the second year after SARS. The numbers of physi-
cians in each department were also similar for these years
with differences ranging from 0 to 2 physicians.
Discussion
The SARS crisis at this municipal hospital during April
2003 resulted in a reduction in outpatient, emergency and
inpatient services to 45%, 55% and 57% respectively,
The ARIMA (2,1,0) model was the most suitable by using the pre-SARS year as the training datasetFigure 1
The ARIMA (2,1,0) model was the most suitable by using the pre-SARS year as the training dataset. Delayed
recovery of out-patient services is noted. The MAPE of the ARIMA (2,1,0) model for the pre-SARS year was 6.9% , 43.2% for
the year during SARS attack, 10.6% of the 1
st
post-SARS year, and improving to 6.2% of the 2
nd
post-SARS year.

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compared to the previous year. The delayed recovery of
outpatient service was also noted during and in the first
year after SARS by the ARIMA model. After the SARS epi-
demic, the hospital became the infectious disease desig-
nated hospital for the Taipei area in additional to
retaining its character as a general regional hospital. Many
factors caused the changes in hospital performance, such
as patient transfer to other hospitals, reduction of health-
care manpower due to death, sequelae to staff infection
and staff turnover. In addition, the publicity related to the
change in the hospital status to an infectious disease unit
influenced performance. In the few years since SARS, hos-
pital performance has improved continuously. However,
only emergency services had recovered by the second year
after SARS. Outpatient and inpatient services had still not
recovered by 2006.
If we consider outpatient services, in the neighboring
countries, certain reports have indicated a 20% to 59%
decrease during the SARS epidemic only [12-14]. Vlantis
reported that the weekly outpatient clinic attendance
showed a decline of 59% and the daily admission rate by
84% for the division of otorhinolaryngology head and
neck surgery at an academic tertiary referral hospital in
Hong Kong [14]. None of the reported hospitals were shut
down during the event. The outpatient service volume in
Table 1: Average monthly service volumes of the outpatient, inpatient and emergency services before, during and after the SARS
epidemic
Year Pre-SARS mean ± SD During SARS mean ±
SD
% Post SARS (1
st
yr)
mean ± SD
% Post SARS (2
nd
yr)
mean ± SD
%
Outpatients
$
52317 ± 4204 28950 ± 11731* 55 42906 ± 4047* 82 43715 ± 2758* 84
Emergency services
$
4382 ± 356 1975 ± 1242* 45 3395 ± 345* 77 3824 ± 346 87
Inpatients
$
8520 ± 909 3678 ± 2350* 43 6863 ± 486* 81 7371 ± 471* 87
* p < 0.05, significantly less than the Pre-SARS year (2002)
$
Outpatient and emergency service volumes: number of visits, inpatient service volumes: number of inpatient days.
Table 2: The average monthly numbers for outpatients using different departments. (mean ± SD)
Recovery yr. Department Pre-SARS During SARS Post SARS (1
st
yr) Post SARS (2
nd
yr)
1
st
-year recovery
Nephrology 1522 ± 375 1486 ± 829 1589 ± 703 2855 ± 134 †
Family medicine 2103 ± 873 1510 ± 797 3674 ± 975 † 3739 ± 945 †
Metabolism 2151 ± 623 1674 ± 670 2131 ± 266 1894 ± 273
2
nd
-year recovery
Psychiatry 1093 ± 298 815 ± 325 * 1341 ± 142 † 1239 ± 131
Neurosurgery 545 ± 207 355 ± 159 * 626 ± 49 611 ± 59
Urology 1701 ± 443 1028 ± 446 * 1699 ± 142 1807 ± 132
Neurology 1900 ± 117 1239 ± 467 * 1877 ± 160 1876 ± 143
Plastic surgery 329 ± 73 128 ± 87 * 337 ± 51 316 ± 40
Cardiology 3723 ± 748 2790 ± 1091* 3699 ± 286 3498 ± 270
Dentist 852 ± 516 462 ± 198 * 638 ± 83 790 ± 161
Infectious diseases 1144 ± 991 303 ± 286 * 677 ± 94 633 ± 112
3
rd
-year recovery
Pediatrics 1867 ± 215 764 ± 387* 1144 ± 190 * 1518 ± 728
No recovery by the 4
th
year
Ophthalmology 4207 ± 443 2627 ± 1032 * 3169 ± 358 * 3578 ± 339 *
Orthopedics 2808 ± 251 1537 ± 593 * 2274 ± 200 * 2366 ± 142 *
General surgery 1812 ± 217 982 ± 435 * 1506 ± 192 * 1461 ± 101*
ENT 3592 ± 410 1750 ± 752 * 2194 ± 213 * 2104 ± 117 *
Gastroenterology 3071 ± 818 1801 ± 629 * 1911 ± 381 * 1799 ± 243 *
Dermatology 2244 ± 398 1070 ± 373 * 1720 ± 264 * 1735 ± 132 *
Chinese medicine 3510 ± 386 1466 ± 805 * 3126 ± 778 2647 ± 281 *
Rehabilitation 1619 ± 132 702 ± 360* 964 ± 139* 919 ± 83*
Internal medicine 6414 ± 1159 2380 ± 1073 * 3513 ± 398 * 3542 ± 189 *
Pulmary medicine 602 ± 175 370 ± 171 * 301 ± 213* 327 ± 75 *
Obs/Gyn 3177 ± 429 1562 ± 670 * 2392 ± 314 * 2259 ± 691*
* p < 0.05: significant less than the pre-SARS year (2002).
† p < 0.05: significant higher than the pre-SARS year (2002)

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this study shows a longer recovery period and the reason
maybe relate to the 35 days of shut down.
There were also huge recovery differences between the dif-
ferent departments even though the physicians' numbers
are similar over these four years. Family medicine, metab-
olism and nephrology departments have recovered
quickly. Moreover, patient visits to family medicine and
nephrology were even higher than before SARS. This indi-
cates that chronic patients who need long-term treatment
tend to go back to their former local hospital to receive
their treatments. The patient visits to psychiatry decreased
during the year SARS happened, and were obviously
increased the year after SARS. This suggests that people
may have needed to rely on psychiatry treatment after the
SARS epidemic. Outpatient visits to surgery recovered
slower. Only urology, plastic surgery and neurosurgery
recovered in the year after SARS, and all others have not
recovered as yet. Thus, the general public may not wish to
receive surgery from an infectious disease designated hos-
pital that once underwent an emergency shut down. As a
result, the recovery of inpatient services is definitely
affected. Inpatient services usually come from outpatient
and emergency transfers. Therefore, recovery of the inpa-
tient service volume is much slower than outpatient and
emergency services.
We observe recovery differences across different depart-
ments. However, the limitation of this study is that we are
unable to explain the failure of certain departments to
return to normal service levels in terms of the quantitative
and statistical measurements of some variables that may
affecting the performance of the hospital. A population
based survey of patient's willingness and physicians' atti-
tude such as the KAP (knowledge, attitude, practice)
might help in this.
Emergency department (ED) visits during SARS were
decreased worldwide when the available literature is con-
sidered [6,8,13,15]. The duration of the impact on each
hospital as described in these papers is not the same, with
one decreased for three months [16], another had recov-
ered by the end of year 2003 after SARS [17], and another
had recovered during the second year after SARS [18]. In
this study, ED visits only recovered during the second year
after SARS. There was no change in the ED numbers in the
local area. Some papers have suggested that the decrease
in ED visits can have different impacts on different subdi-
visions. For example, non-critical ED patient visits may
decrease more than the critical patient visits [17,19]. One
possible reason for the delay in ED service recovery at this
hospital is that non-critical patient chose to go to other
hospitals, and this needs further research. Alternatively, a
patient response to the emergency whole hospital shut
down may have occurred or there may be a mixture of
both factors.
The impacts caused by SARS were very serious, especially
on global economics and health care. In order to control
the epidemic, the Department of Health, Executive Yuan,
Taiwan, designated some public hospitals to admit major
infectious disease patients. This measure had a positive
effect on controlling the epidemic [3], and reminds peo-
ple of the importance that public hospitals have in public
health, preventive medicine, and the prevention of infec-
tious diseases. Even three years after SARS, the nation still
maintains the ideology of a designated hospital, and has
expanded the prevention network national wide. Under
the threat of new epidemics, an infectious disease desig-
nated hospital has to face the issue of losses in its operat-
ing performance. The medical standards and ideology of
the designated hospital are always affected.
At present, medical expenditure is increasing dramatically
everywhere in the world. It is very important for an infec-
tious disease designated hospital to maintain its self-suffi-
cient operation when the public health budget is under
threat. Self-sufficient operation can reduce the need for a
government subsidy and allow the maintenance of an
adequate number of physicians as well as the quality of
medical services at such a general hospital. Although the
outpatient and inpatient services did not completely
recovered from SARS during first year, the hospital had
reached 84% to 86% of the baseline service volume dur-
ing the second year after SARS. Therefore, the hospital
should be capable of self-sufficiency as a designated hos-
pital. In particular, the family medicine, metabolism and
nephrology departments were hardly influenced by the
shut down. In addition, some other departments had
recovered by the second year. Therefore, these depart-
ments were able to maintain a sufficient number of physi-
cians in the absence of an infection emergency. If another
outbreak of major infectious disease occurs, the physi-
cians in the above mentioned departments would be able
to participate directly in prevention tasks. An adequate
number of physicians are essential for the success of an
infectious disease designated hospital. Thus, the findings
of this study should provide a direction for other infec-
tious disease designated hospitals to consider when decid-
ing what subspecialties should be included in their
makeup. If an infectious disease designated hospital
includes a certain subspecialty and the physicians can
operate self-sufficiently during ordinary times, the govern-
ment only has to subside such a hospital during the year
of the epidemic and the year after that. The hospital can
become self-sufficient again quickly once everyday opera-
tions return.

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Conclusion
In conclusion, this study demonstrates that if the whole
hospital is shut down during an infectious disease out-
break, the impact is much longer than other studies have
shown. The outpatient and inpatient services in this exam-
ple had not completely recovered by the second year after
SARS. Emergency services were the fastest recovering
department, but even this unit did not recover until the
second year after SARS. Among outpatient services, family
medicine, metabolism and nephrology recovered better
than the others. Surgery needs a longer recovery period.
This study provides the decision maker with information
regards choices when managing an infectious disease des-
ignated hospital and is a reference resource for future pub-
lic policy crisis management decisions during acute
infectious disease outbreaks.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
DC conceived of the study, performed the statistical anal-
ysis, and wrote the manuscript. RCC participated in study
design, coordination, and interpretation of the manu-
script. CYK drafted the manuscript and collected data. PC
participated in the design of the study, interpretation of
the statistical analysis, and coordination. All authors read
and approved the final manuscript.
Acknowledgements
We would like to thank all the members of Hoping Hospital, Taipei, who
were present during the SARS outbreak in 2003.
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