A 40% decline in emergency department visits for emergent, nonpreventable conditions indicates that many patients with serious health problems avoided emergency rooms during the first phase of the pandemic, researchers find.
An examination of emergency department visits before and during the coronavirus pandemic at a St. Louis-based health system found an overall 35% reduction in ED visits, according to a new research article.
Declines in ED visits during the pandemic have been widely reported across the country. Reasons for ED avoidance include fear of contracting the coronavirus in healthcare settings, stay-at-home orders, and increased childcare linked to school closures.
The new research article, which was published today by Health Affairs, examined data from more than 1.2 million ED visits for non-COVID-19 conditions at BJC HealthCare from January 2018 to June 2020. The research included assessing whether decreases in ED visits were associated with insurance status or race.
"Understanding whether ED avoidance differed in association with race or insurance status is imperative to ensuring that already vulnerable populations do not suffer from worse outcomes from non-COVID-19 conditions as the pandemic continues to wax and wane across the country," the research article's co-authors wrote.
The research includes several key data points:
- The number of non-COVID-19 ED visits decreased 35% after St. Louis city and county stay-at-home orders.
- Non-COVID-19 ED visits decreased across all acuity levels in the first phase of the pandemic. Nonemergent visits fell 52%; primary care-treatable visits fell 47%; emergent, preventable visits fell 46%; and emergent, nonpreventable visits fell 40%.
- Visits for mental health conditions fell 32%. Visits for alcohol and drug use did not experience a statistically significant decline.
- There were large decreases in ED visits based on insurance status. ED visits by privately insured patients fell 46%. ED visits by Medicaid patients fell 44%. ED visits by uninsured patients fell about 40%. ED visits by Medicare patients fell 31%.
- There were no significant differences in the decline of ED visits by race. The vast majority of the patients in the study were either White or Black.
"The COVID-19 pandemic was associated with a large drop in non-COVID-19 ED visits across all acuity levels, a smaller decrease in visits due to mental health, and no decrease in visits due to substance use issues. These findings suggest a need to inform the public of health conditions that require timely ED care and to improve access to alternative, lower-risk settings of care, especially for populations with social or medical risk factors," the research article's co-authors wrote.
Interpreting the data
It is likely that many patients with serious health problems avoided the ED during the first phase of the pandemic, the co-authors wrote. "The 40 percent decline in ED visits of the highest acuity suggests that there were many 'missing' patients who should have sought ED care for conditions such as heart attacks and strokes. Fear of contracting COVID-19 may have overshadowed even serious symptoms for many."
The behavioral health characteristics of the pandemic likely explain why there was a relatively modest decline in ED visits for mental health conditions and no decline in ED visits for substance abuse, the co-authors wrote.
"As a result of the high levels of anxiety and stress associated with the pandemic and its disruption of daily life, mental health and substance use issues may have been exacerbated to the point of offsetting decreases in these visits that might have otherwise occurred as a result of ED aversion. It is also possible that decreased access to outpatient care for these health issues precluded significant decreases in related ED visits," they wrote.
The relatively high frailty of Medicare patients likely explains why they experienced the smallest decline of ED visits classified by insurance coverage, the co-authors wrote. "This may be explained by the relatively high prevalence of chronic conditions among Medicare patients and the lower threshold for primary care or telehealth clinicians to refer older patients for ED evaluation."
Overall health also is a likely explanation for why privately insured patients experienced the biggest decline of ED visits classified by insurance coverage, the co-authors wrote. "Although the privately insured population is a diverse group in terms of age, income, and medical risk factors, they are younger and have fewer comorbidities than Medicare patients, on average."
The finding that decreases in ED visits were not associated with race was unexpected, the co-authors wrote.
"National survey data have found that fears of contracting COVID-19 are high among Black patients and that Black patients reported a higher likelihood of avoiding emergency care even for serious medical conditions compared with White patients. However, in our particular sample, we did not find differences by race in terms of ED use patterns. Whether these findings are related to the unique characteristics of our patient population is unclear; further study using other databases is warranted."
Christopher Cheney is the senior clinical care editor at HealthLeaders.
There were large decreases in emergency department visits based on insurance status, with Medicare patients experiencing the smallest decline.
There was a relatively modest decrease in emergency department visits associated with mental health conditions and no significant decrease in visits associated with substance abuse.