What is the impact of the COVID-19 pandemic epoch on IPD (Inpatient Department) hospital admissions in India-A 41 months comparative, quantitative, deductive Cross-Sectional Research Study?

The inpatient department or IPD is the dedicated unit of a hospital/healthcare facility for admitting patients from the OPD (outpatient department), ED (emergency department), or a referred patient usually from lower facilities for a planned care/procedure, for special medical problems that necessitate suitable care and consideration. The index case of SARS-CoV-2 virus infection in India was �rst suspected (based on clinical grounds) on 27th January 2020, an assumed case of covid-19 in Kerala with a current voyage history of Wuhan, china which was subsequently a�rmed as SARS-CoV-2 virus infection positive case by the NIV (National Institute of Virology) situated at Pune in Maharashtra, on January 30th, 2020 as positive for COVID-19. As per the constitution of India Health is a subject matter of state, hence different states had reserved different percentages of beds in pre-existing health facilities for COVID-19 IPD patients, for example, the Delhi government had reserved 50% of pre-existing ICU (intensive care unit) and ward beds for COVID-19 IPD patient's. Besides the other factors such as fear etc, mentioned above this new arrangement of hospital care delivery and prioritization of needs of COVID-19 patients may have resulted in the general cancellations of other IPD patients elective procedures leading to a reduced IPD number of patients with diseases other than COVID-19, as priority was shifted to COVID-19 admitted patient's and cases. The �rst author researcher of this study has found unusual prevalence in the �gure of IPD (Inpatient Department) hospital admissions during his normal course of duties at health centres throughout the current ongoing COVID-19(coronavirus disease-2019) era. To know about the real scenario a good sample size is a requirement for any epidemiological study. Hence this deductive study was done to con�rm that, does the COVID-19 era have affected the number of IPD hospital admissions (positively or negatively). This study was started and designed to get an answer to the above question. The aim of this 41months comparative, quantitative, deductive, Cross-Sectional Research Study is to assess the direct impacts of COVID-19 on the number of IPD hospital admissions in India (other than COVID-19), across all public

on 27th January 2020, an assumed case of COVID-19 in Kerala with a current voyage history of Wuhan, china which was subsequently a rmed as SARS-CoV-2 virus infection positive case by the NIV (National Institute of Virology) situated at Pune in Maharashtra, on January 30th, 2020 as positive for COVID-19 [3].
The Government of India, to contain the COVID-19 outbreak announced and enforced an obligatory nationwide lockdown from 25th march 2020 to 31st may 2020 to trim down the Incidence of new cases by putting lockdown intervention as a fence in the community spread [4].This lockdown intervention with other factors such as fear, and apprehension of contracting COVID-19 disease had disrupted the scheduled -normal functioning of the health system delivery of various essential health services utilization in India [3, 5, and 6].The stipulation of health services delivery is of major trepidation in India due to elevated as well as dense population with scanty resources, old twisted poor infrastructure amidst massive demand on the healthcare system.Newborn children, older citizens, and pregnant women are especially susceptible to the ongoing crisis impacted due to COVID-19 because of their extraordinary requirements of health needs [7].
The ongoing SARS-CoV-2 infection pandemic challenged the healthcare systems globally and India is not an exception [8].The majority of resources of healthcare facilities including infrastructure, ambulance services, etc. medical personnel's, have been predominantly deployed to deal with the COVID-19 pandemic which has negatively affected various essential health services utilization [9, 10, and 11].Added to this there are wide variations in healthcare delivery services among different states and union territories of India which is quite evident from the NITI (National Institution for Transforming India) AAYOG annual state health index [12].The lack of dedicated and exclusive PUBLIC HEALTH MANAGEMENT CADRE (PHMC) in several states of India with poor governance especially in poor states like Bihar aggravated the crisis that erupted due to COVID-19 [13].The WHO had also raised a question on the mortality count provided by the Government of India [14].
The Government of India response to the COVID-19 pandemic essentially followed procedures adopted by other global nations that included shutting down borders, restraining social interaction, and creating new COVID-19 segregation wards within mostly pre-existing hospitals wards as it is practically impossible to construct new dedicated COVID-19 healthcare facilities overnight to cater the needs of about 140 crores population of India [15].The total COVID-19 cases Prevalence in INDIA as on 09th September 2022, 03:29 GMT were 44,482,411, mortality 528,090 [16].As per the constitution of India Health is a subject matter of state, hence different states had reserved different percentages of beds in pre-existing health facilities for COVID-19 IPD patients, for example, the Delhi government had reserved 50% of pre-existing ICU (intensive care unit) and ward beds for COVID-19 IPD patients [17].Besides the other factors such as fear etc, mentioned above this new arrangement of hospital care delivery and prioritization of needs of COVID-19 patients may have resulted in the general cancellations of other IPD patients elective procedures leading to reduced IPD number of patients of diseases other than COVID-19, as priority was shifted to COVID-19 admitted patients and cases.
The rst author researcher of this study has found unusual prevalence in the gure of IPD (Inpatient Department) hospital admissions during his normal course of duties at health centres throughout the current ongoing COVID-19(coronavirus disease-2019) era.To know about the real scenario a good sample size is a requirement for any epidemiological study.Hence this deductive study was started to con rm that, does the COVID-19 era has affected the number of IPD hospital admissions (positively or negatively).This study was started and designed to get an answer to the above question.Through the presentation of the whole story and gures, the researcher hopes that it will facilitate depicting a real scenario of the situation with the purpose to draw the consideration of policy and decision makers to contemplate measures of alleviation and providing relief in form of standard health services delivery to IPD patients in the situation of distress like COVID-19.This research study especially highlights the COVID-19 impacts on IPD health service utilization and access of people to IPD healthcare services during the COVID-19 era.

Aim & Objectives
The aim of this 41months comparative, quantitative, deductive, Cross-Sectional Research Study is to assess the indirect impacts of COVID-19 on the number of IPD hospital admissions in India (other than COVID-19), across all public/private/rural/urban health facilities of 36 states and union territories registered on HMIS (Health Management Information System) of Ministry of Health and Family Welfare (MoHFW), Government of India on a cumulative basis.This unique study will also do a brief analysis of COVID-19 impact on IPD health service utilization of some important and more prevalent diseases in India.Any person in India who has been registered on HMIS for use of IPD services related to above mentioned purpose during study period were included in this study.

Follow up and Data collection
The data was constantly collected, observed and checked for SMART (speci city, measurability, accuracy, reproducibility and timeliness) objective.The Microsoft o ce and stata15.1 software were utilized for this data collection and analysis.

Participants
Inclusion criteria -Any person in India who has been registered on HMIS for utilization of IPD services related to Operational De nition given above.
Exclusion criteria -Any person in India who has not been registered on HMIS for utilization of IPD services related to Operational De nition given above.All other diseases not related to Operational De nition were also excluded from this research study.
Sources and methods of selection of participants -The investigator has done purposive sampling for assortment of participants and the resource of data is HMIS of MoHFW.

Variables
Variables for this research study are mentioned above under Exposure section.

Data sources / measurement
The Source of Data is -HMIS-MoHFW and link is given below.
-https://hmis.nhp.gov.in/#!/standardReportsFor the evaluation of impact of COVID-19 induced situation on number of IPD patients in India the pandemic epoch is compared to pre-pandemic epoch, Data investigation were done with Microsoft o ce and stata 15.1 software.

Bias
To reduce the bias the mean were compared for calculating prevalence of IPD patients in India for different variables.

Study size (Sample Size and Sampling Technique)
The total numbers of IPD registered on HMIS for operational de nition mentioned above were included in this study with a purposive sampling technique, see table-1.The data essential for this study was collected from HMIS of the MoHFW, which is the most endorsed and certi ed data source in India.The total quantity of indicators included for this research study was 12.The data composed and analyzed with Microsoft o ce and stata 15.1.

The size of different variables for study period is given in Table-1below: Ethical Consideration
This study did not require any informed consent or ethical endorsement since the data used were absolutely and publicly obtainable from HMIS and in compliance with Indian data protection policy.

Quantitative variables
The quantitative variables for this research study are mentioned below in Table -1and -2 and Figure -2.We utilized HMIS data with the intention of determining the extent to which, IPD cases altered after the onset of the pandemic compared to the pre-COVID-19 pandemic across the hospital network in India.In the subsequent step of the investigation we calculated the changes to mean IPD hospital admissions for 12 variables mentioned above; see Table -3 and Figure-3.For both time periods (2018-2019 and 2020-2021) the period prevalence (mean) was calculated for IPD hospital admissions as a number of events (inpatient admissions) during speci ed period divided by the whole population during the two individual time epochs (population estimate based on the World Bank Estimate for India 2018-2021 [19]).12. Inpatient -Hepatitis -The pre-pandemic period prevalence per 10000 population was 0.10 whereas during COVID-19 period it was reduced to 0.06 (see- pre-existing medical as well as social morbidities like domestic violence had been reported to be increased too as indirect effect of COVID-19 [20].Certainly there are wide geographical variations in prevalence of COVID-19 among different states and union territories of India but all the states and UTs were affected by this pandemic [1].Added to this the mortality count at emergency ward of hospital in India had also increased signi cantly, inducing a sense of panic and fear among the population [11].The prevalence of certain sexually transmitted disease (STD) had also been altered during COVID-19 epoch [21,22].The IPD admissions are also critical for several NCD (non-communicable diseases) such as cancer and the incidence of NCDs are also increasing every year such as cancer [23].Despite above mentioned facts it is very di cult to think that the IPD hospital admissions decreased during COVID-19 epoch as compared to prepandemic epoch.How? Why? Naturally such question mark is coming to researcher mind.Few factors which may be responsible for this signi cant reduction in IPD admissions may be:-1.Lockdown leading to reduced mobility.
2. Fear of contracting COVID-19 if admitted at hospital.The reluctance of public with healthcare requirements to seek hospital IPD care due to perceived hazard of acquiring a COVID-19 disease in a hospital setting 3. Reduced OOPE (out of pocket expenditure) capacity due to loss of jobs as indirect COVID-19 impact.
4. Lack of bed for IPD general admissions as a large portion was reserved for COVID-19 cases.
5. Self-Ignorance as well as family and social ignorance or negligence.
6. Lack of medical doctors and staff for medical conditions other than COVID-19 cases.
7. The Hospital medical staff shortages due to COVID-19 illness and mortality among the healthcare workforce.
8. Commotion within the hospital system in order to tackle the perceived obligations of the pandemic.9. Decrease in the IPD admission referral rate as a result of the reduction in (OPD) outpatient hours.
This research study revealed that India experienced a decrease in inpatient hospital admissions for conditions which prevalence or incidence is not related to the COVID-19 pandemic, which can pose a grave health risk if left untreated.For an explanation consider the case of Inpatient -Asthma, Chronic Obstructive Pulmonary Disease (COPD), Respiratory infections, we calculated a 32.85% diminution in IPD admissions for such medical condition over the study period.
The question arises what happened to these patients?A huge number of dead bodies were found oating in the sacred holy rivers of India (especially in the states of Bihar and Uttar Pradesh) during the ongoing COVID-19 epoch [24].Now it is quite possible that these dead bodies are of people with serious conditions other then COVID-19 who failed to get IPD admissions for treatment and died subsequently without treatment.Added to this the relatives of these deceased people had thrown them in holy rivers with purpose to avoid visiting graveyard or funeral grounds due to fear as well as panic of contracting COVID-19 from these places as they think that only COVID-19 deceased are reaching these places.
This novel research study also revealed a distraction in number of male-female IPD of all ages, malaria, dengue, typhoid, Inpatient -Asthma, Chronic Obstructive Pulmonary Disease (COPD), Respiratory infections, Inpatient -Pyrexia of unknown origin (PUO), Inpatient -Diarrhoea with dehydration and hepatitis care during the COVID-19 study period.
In brief, like other nations, the natural response of healthcare authorities in India to the unexpected onset of COVID-19 was to tackle and mitigate the perceived priority requirements of COVID-19 patients.Investigation of HMIS data revealed that, as the pandemic outspread, this response resulted in a universal reduction of hospital IPD services, for the treatment of non COVID-19 precedence needs.The prospective consequences of this crash in IPD services in India may result in augmented mortality rates over the approaching years for diseases other than COVID-19.
Future VERSION of this research study using HMIS data can reveal to what magnitude IPD activity recovers over the upcoming years from the COVID-19 epoch.
The in uence on patients of chronic medical conditions such as NCDs who require regular IPD care for improved health and good quality of life may be of grave consequences.India being a LMICs, it is predictable that the majority of the population underneath poverty line could not manage to pay for private hospitals IPD or received public hospitals IPD care during the COVID-19 epoch.Patients with recently diagnosed NCDs may not be capable to get the IPD treatment, while the previous chronic NCDs patients may have not received their regular therapy.It is quite obvious from this research study that majority of patients with medical conditions other than COVID-19 faced an ampli ed risk of complications, morbidity and mortality owing to reduced access to IPD healthcare.It's also a well recognized fact that deferred initiations and interruption of treatment may augment disease progression, reappearance, stress, concern, and premature mortality with morbidity.
This negative impact of COVID-19 epoch on IPD is due to countless factors, such as health workers being shifted for scheming the COVID-19 pandemic, etc.
The number of IPD decline may be explained by a prospect that prior information of COVID-19 through media and channels may have prejudiced prior healthseeking behaviour.
Strength and Limitations of this study The fundamental strength of this research study is the utilization of a data set on IPD activity for all HMIS (MoHFW) registered hospitals in India.It is furthermore the rst systematic endeavour to describe the bearing of SARS-CoV-2 pandemic on IPD hospital admissions in India.The prime limitations of this study are lack of data availability from any other source as well as lack of discrete data for several other signi cant medical conditions.

Conclusions And Recommendations
The more regular and frequent publication of HMIS data can provide opportunities for judicious decision making in responding to unfolding emergencies such as COVID-19.Moreover, an in-depth study of the HMIS data set can make available insights into epidemiology, utilization patterns, and burden outcomes, including mortality rates.Though it appears India has responded reasonably well to the COVID-19 emergency, there is room for further improvement.The lesson India can learn from this incident is the need to advance strategies and processes whereby the reaction to pandemics is not unavoidably at the expense of other and similarly important other community health care needs.One area for upgrading is that while the reaction should be timely, health authorities need to respond proportionally, taking into description the population-wide health needs as the pandemic evolves and notify the public accordingly.The strategy should take account of an evaluation of the consequences to population health needs if existing resources are enthused from one care need to another.For hospitals, it would denote that their pandemic reaction is phased-in as well as likely in line with de nite clinical need and prearranged around specialist task force with the aim of reducing disruption to the prerequisite of other medical services.This tactic however, would require the orderliness of hospitals to become more exible in their ability to react to altering conditions, and to offer a safe patient environment at times of contagion/distress.In addition, better use of telemedicine would improve access to care at a time when estrangement measures are in place, and a well-targeted information drive would educate the community of the harmful consequences of not seeking care.
In the light of conclusion of this research study we recommend the following: • Governments of India should think of strategies on priority basis to trim down the burden of morbidity and mortality to reap the bene ts of Demographic Dividend.The COVID-19 management should be prioritized, but not at the cost of other NCDs and CDs.
• Government need a more robust and exible health framework to respond to COVID-19/distress with due considerations of rigorous restrictions which can interrupt routine essential other health services, leading to a vicious cycle and overwhelming effect on the health need of population.
• Government of India should give more focus on proper and timely data collection.-This version of paper has not been previously published in any peer reviewed journal and is not currently under consideration by any journal.The document is Microsoft word with English (India) language and 8427 words Total including all.
-Ethics approval and consent to participate: Not applicable.This study has not involved any human or animals in real or for experiments.The submitted work does not contain any identi able patient/participant information.
-Consent for publication: The author provides consent for publication.
-Availability of data and materials: Electronic records from HMIS (health management information system) of MoHFW (ministry of health and family welfare), Government of India.
- -Acknowledgements-I am thankful to Advocate Anupama my wife and daughters Aathmika-Atheeva for cooperation.
-Author information: The author is currently working as Senior General Medical O cer for the government of Bihar.

Figure- 1 .
Data and Statistical Analysis Stata 15.1 and Microsoft o ce software were utilized for statistical analysis.As the foremost step of the data investigation we calculated changes in IPD hospital admissions and compared the mean number of IPD cases over a 2-year pre-pandemic epoch (2018-2019) with the mean number of IPD cases over a 17-month pandemic epoch in 2020-2021, see Table

AbbreviationsOPD-
Abbreviations OPD-Outpatient Department; COVID-19-Coronavirus disease2019; SARS-CoV-2-severe acute respiratory syndrome coronavirus 2; (NIV) National Institute of Virology; (World Health Organization) WHO; Health Management Information System (HMIS); Ministry of Health and Family Welfare (MoHFW); IPD (Inpatient Department); ED (emergency department); IHR (International Health Regulations); NITI (National Institution for Transforming India); PUBLIC HEALTH MANAGEMENT CADRE (PHMC); ICU (intensive care unit); Con icts of Interest/ Competing Interest: There are no con icts / competing of interest -Funding-Self sponsored.No aid taken from individual or agency etc. -Authors' contributions: The whole work is done by the Authors -Dr Piyush Kumar, M.B.B.S., E.M.O.C., P.G.D.P.H.M., -Senior General Medical O cer-Bihar Health Services-Health Department-Government of Bihar, India and Advocate Anupama, Senior Lawyer, Bar-council, Patna, Bihar.

Figures
Figures

Figure 1 Total
Figure 1 Total different IPD registered on HMIS in India during study period

Figure 2 Comparison 3
Figure 2 Comparison of mean number of various IPD hospital admissions during study period

Figure 4 Comparison
Figure 4 Comparison of Period prevalence (mean) of IPD admission in India for different variables

Table - 1
-Total IPD registered during study period (study size of variables)The total numbers of different IPD during the 41 months study period is elaborated in table − 1 and gure-1 with a little emphasis on lockdown in the gure-1.The GoI (Government of India) responded to this novel COVID-19 by enforcing nationwide lockdown from 25th March 2020 ending on 31st May 2020 and gure-1 shows a sharp decline in IPD admissions during this period specially shown with an arrow[3].The total registered IPD during the 41 months study Inpatient -Dengue -The pre-pandemic period prevalence per 10000 population was 0.09 whereas during COVID-19 period it was reduced to 0.02 (see-Table-4, 5 and gure-4).Table-4-Period prevalence (mean) of IPD admission in India for different variables 5415845, 742661,7173524,7603860,505806 respectively for Inpatient -Malaria, Inpatient -Dengue, Inpatient -Typhoid, Inpatient -Asthma, Chronic Obstructive Pulmonary Disease (COPD), Respiratory infections, Inpatient -Tuberculosis, Inpatient -Pyrexia of unknown origin (PUO), Inpatient -Diarrhoea with dehydration, Inpatient -Hepatitis See table-1.This research study revealed that there is a signi cant decrease in IPD hospital admissions for various medical conditions other than COVID-19 during the COVID-19 pandemic epoch which is a matter of concern for policy and decision makers.Outcome dataThe outcome data of this exploration study are presented as table-2, 3, 4 and gure-2, 3, 4. For the 17 months (2020-2021) COVID-19 pandemic epoch, the total mean numbers of IPD admissions were 5387311 compared to total mean7435770 numbers of IPD admission for the previous pre-pandemic 2 years (2018-2019).The total mean numbers of IPD admission decreased by 2048459 numbers during COVID-19 pandemic epoch i.e.27.55% decrease in IPD hospital admission were observed during COVID-19 as compared to pre-pandemic epoch; see table-2 and gure-2.Table -2-Mean number of IPD cases during Pre-pandemic and Pandemic epoch Mean number of various IPD hospital admissions during Pre-pandemic and Pandemic period 1. Inpatient (Male) -Children<18yrs-During the Pre-pandemic Epoch -January 2018 to December 2019 the mean number of IPD hospital admissions in India for Inpatient (Male) -Children<18yrs was 763047.7 (Std.Err.-17692.6;95%conf.Interval-726447.6 -799647.7)whereasduringPandemic Epoch -January 6.8.Inpatient -Asthma, Chronic Obstructive Pulmonary Disease (COPD), Respiratory infections -The pre-pandemic period prevalence per 10000 population was 1.1 whereas during COVID-19 period it was reduced to 0.7 (see-Table-4, 5 and gure-4).9.Inpatient -Tuberculosis -The pre-pandemic period prevalence per 10000 population was 0.2 whereas during COVID-19 period it was reduced to 0.09 (see-Table-4, 5 and gure-4).10.Inpatient -Pyrexia of unknown origin (PUO) -The pre-pandemic period prevalence per 10000 population was 1.7 whereas during COVID-19 period it was reduced to 0.7 (see-Table-4, 5 and gure-4).11.Inpatient -Diarrhoea with dehydration -The pre-pandemic period prevalence per 10000 population was 1.7 whereas during COVID-19 period it was reduced to 0.8 (see-Table-4, 5 and gure-4).

Table -
This deductive research study revealed that the entirety IPD of all medical admissions in indoor have shown a radical reduction in numbers and percentages of IPD during COVID-19 period as shown in various tables and gures above.It's a well acknowledged fact that population and diseases is mounting by leaps and bounds in India.Hence it is apparent from this research study that the novel COVID-19 induced state of affairs in India tends to have a disadvantageous and deleterious impact on other medical conditions IPD health services delivery and utilization.
DiscussionAn initial massive drop down in IPD hospital admissions were observed in April 2020, soon after imposition of lockdown in India as well as after declaration of COVID-19 as a pandemic by the WHO.The total mean numbers of IPD admission decreased by 2048459 numbers during COVID-19 pandemic epoch i.e.27.55% decrease in IPD hospital admission were observed during COVID-19 as compared to pre-pandemic epoch.The general IPD admissions of medical conditions other than COVID-19 in Indian hospitals fell by 27.55% over the investigation period despite the fact that COVID-19 has been found to aggravate