key: cord-0814248-zgki0wa0 authors: Niforatos, Joshua D.; Chaitoff, Alexander; Zheutlin, Alexander R.; Feinstein, Max M; Raja, Ali S. title: Barriers to emergency department usage during the COVID‐19 pandemic date: 2020-11-12 journal: J Am Coll Emerg Physicians Open DOI: 10.1002/emp2.12316 sha: b276183bcc043ea6c8da470d06b28974cd91bb47 doc_id: 814248 cord_uid: zgki0wa0 OBJECTIVE: The objective of this study was to determine the public's likelihood of being willing to use an emergency department (ED) for urgent/emergent illness during the coronavirus disease 2019 (COVID‐19) pandemic. METHODS: An institutional review board–approved, cross‐sectional survey of a non‐probability sample from Amazon Mechanical Turk was administered May 24–25, 2020. Change in self‐reported willingness to use an ED before and during the pandemic (primary outcome) was assessed via McNemar's test; COVID‐19 knowledge and perceptions were secondary outcomes. RESULTS: There were 855 survey participants (466 [54.5%] male; 699 [81.8%] White; median age 39). Proportion reporting likelihood to use the ED pre‐pandemic (71% [604/855]) decreased significantly during the pandemic (49% [417/855]; P < 0.001); those unlikely to visit the ED increased significantly during the pandemic (41% [347/855] vs 22% [417/855], P < 0.001). Participants were unlikely to use the ED during the pandemic if they were unlikely to use it pre‐pandemic (adjusted odds ratio, 4.55; 95% confidence interval, 3.09–6.7) or correctly answered more COVID‐19 knowledge questions (adjusted odds ratio, 1.37; 95% confidence interval, 1.17–1.60). Furthermore, 23.4% (n = 200) of respondents believed the pandemic was not a serious threat to society. Respondents with higher COVID‐19 knowledge scores were more likely to view the pandemic as serious (odds ratio, 1.57; 95% confidence interval, 1.36–1.82). CONCLUSIONS: This survey study investigated the public's willingness to use the ED during the COVID‐19 pandemic. Only 49% of survey respondents were willing to visit the ED during a pandemic if they felt ill compared with 71% before the pandemic. Aggressive mitigation strategies were implemented nationally to decrease transmission of the severe acute respiratory syndrome coronavirus 2 (coronavirus disease 2019 States. 1 Along with reports of hospitals operating at capacity, the U.S. Centers for Disease Control and Prevention (CDC) reported that emergency department (ED) visits nationwide decreased by 42% during the early part of the pandemic. 2 Simultaneously, there were decreases in acute ischemic stroke imaging, 3 hospitalizations for common acute presentations to the ED (acute myocardial infarction, heart failure, chronic obstructive pulmonary disease, and pneumonia), 4, 5 and emergency medical services-reported cardiac arrests. 6 These decreases are in contrast to CDC reports of increases in COVID-19 and non-COVID-19 excess mortality. [7] [8] [9] Whether excess deaths were caused by deferred care, a lack of non-COVID-19 hospital capacity, underreporting of out-of-hospital COVID-19 cases, or other mechanisms remains to be determined. 10 The American College of Emergency Physicians conducted a national survey of the public's concerns around seeking medical care during the pandemic. 11 The results revealed that people are avoiding emergency or urgent medical care to avoid hospital exposure. What remains unknown are what factors may be associated with increased comfort with ED usage during a pandemic. To inform actions that EDs might take to encourage and reassure patients in need of care during a pandemic, we sought to survey the general public regarding their perspectives and willingness to use the ED during a pandemic. A cross-sectional survey was distributed to participants on Amazon MTurk is an online labor marketplace where individuals anonymously complete tasks and in return receive a nominal fee for the completion of tasks (in this case, $1). Behavioral experiments using MTurk survey data are considered reliable sources for high-quality survey data. [12] [13] [14] [15] [16] MTurk is increasingly used to study healthcare questions. [16] [17] [18] [19] [20] [21] [22] [23] [24] The Bottom Line The survey contained 3 quality assurance questions to ensure meaningful responses. Respondents not appropriately responding to these questions were excluded from analyses. The primary outcome was comparison between individuals' selfreported willingness to use an ED before versus during the COVID-19 pandemic. We hypothesized that there would be a decrease in participants' willingness to use an ED during the pandemic. Secondary outcomes were self-reported factors associated with willingness to use an ED during the pandemic and the association between knowledge of COVID-19 and pandemic severity perception. Survey items were coded as continuous, ordinal, or categorical variables in accordance with their survey presentation. The 5-point Likert scale used to assess likeliness to visit an ED before and during the pandemic was collapsed into a nominal variable with 3 levels (likely, neutral, unlikely). Respondents' perceptions of the pandemic were dichotomized (severe, non-severe) and coded as non-severe if respondents indicated that they believed society was overreacting to the pandemic, that they were not worried about the pandemic, or that they did not believe the pandemic was a threat to society. 29, 30 In addition, survey respondents were given a score for "knowledge of COVID-19," which was the summation of 1 point for each question answered correctly of 8 possible points. Finally, rank-order scores for the question regarding actions to increase ED comfort were created by assigning points to each rank with a better rank corresponding with a higher point total (ie, rank 1 receives 9 points, rank 2 receives 8 points, and so forth). Demographics were assessed with descriptive statistics. The McNemar test was used to assess the change in likelihood of visiting the ED before versus during the pandemic. A multivariable multinomial regression model was constructed that assessed the association of self-reported likeliness to visit an ED during the pandemic when compared with a respondent's reported likeliness to visit an ED before the pandemic, adjusting for age, race, sex, income, education, health insurance status, pandemic severity perception, and knowledge of COVID-19. There are ≈209 million U.S. adults aged ≥18 years. To achieve a 95% confidence interval (CI) with a ±3% margin of error, a sample size of 1067 respondents was desired, calculated using the following When we were unable to recruit the full number of respondents in the older age brackets, 3 sensitivity analyses were conducted to ensure integrity of the results. For these analyses, age was transformed into a dichotomous categorical variable (< 55 or ≥55 years). For the first 2 sensitivity analyses, the association between age and before/during COVID-19 likeliness of visiting an ED, and age and pandemic severity perception, were assessed with binomial logis- Studies in Epidemiology guidelines. 31 All statistical analyses were conducted using Jamovi is the manufacture version 1.2.14.0 (Sydney, Australia). The 855 respondents included were primarily men (54.5%, n = 466) Of the respondents, >72% (n = 623) were very confident or somewhat confident that hospitals and medical centers are able to handle the medical needs of people who are seriously ill during the pandemic. A total of 23.4% (n = 200) of respondents did not believe the pandemic was serious. Those who believed the pandemic is less severe were more likely to not know that severe acute respiratory syndrome coronavirus 2 is the virus that causes COVID-19 (72.5% vs 80%; P = 0.05) and did not know the definition of case fatality rate (66% vs 77%; P < 0.0001). This group was also less likely to think asymptomatic carriers were contagious (78.5% vs 91.1%; P < 0.0001) and were less likely to know the Before the pandemic, the most frequently cited barrier of 1322 selected responses was affordability of health care (24.2%, n = 320) ( Factors associated with increased comfort to use an ED during the pandemic Table 4 provides the overall rank-ordered list of steps respondents said would increase their comfort in going to the ED. The most frequently chosen factor was telemedicine screening to determine necessity of an in-person visit (20.1%, n = 172). The overall top-ranked factor associated with increased comfort was orienting chairs >6 feet apart in the waiting room. The sensitivity analyses revealed no significant differences between dichotomized age groups and the primary outcome and did not significantly change the results of the regression model. Limitations are noted with this study. MTurk is a non-probability sample of U.S. adults, and although existing studies suggest that MTurk results are generalizable for the purposes of behavioral research, [12] [13] [14] [15] [16] at least one study suggests that MTurk workers are not generalizable to health status and behaviors. 32 Participants in this survey had a median age of 39, which is younger than the group of highest ED users nationally. 26 However, the sensitivity analyses address this latter concern and suggest potential generalizability with regard to agerelated perceptions. In addition, the sample population was predominantly White with college degrees, which does not fully represent the race, ethnic, and educational demographics of the United States. Survey results demonstrate that U.S. adults reduced their willingness to use the ED during the pandemic. Furthermore, respondents who perceived the pandemic as "severe" were less likely to be willing to use the ED compared with respondents who believed the pandemic was not severe, although on the order of ≈10%. Survey respondents who scored higher on COVID-19 knowledge questions were both more likely to view the pandemic as severe and to report being unlikely to use the ED during the pandemic. These results are consistent with other research that demonstrates an association between perception of COVID-19 severity and a variety of health-related behaviors. 33, 34 The most important reported barriers to ED usage before the pandemic were ED costs, ED wait time, lack of transportation, and lack of insurance, which is consistent with prior research. 35, 36 During the pandemic, the most important barriers were concern related to personal exposure to COVID-19, healthcare costs, and a desire to help "flatten the curve" by avoiding the ED. The most important intervention identified to alleviate concern about personal exposure to COVID-19 during an ED visit was placing waiting room chairs >6 feet apart, followed by telemedicine screening by phone and/or video to determine the necessity of an in-person visit. Ideally, interventions to allay patient concerns about COVID-19 exposure, as well as to help screen for appropriateness of an ED visit, may reduce time to diagnosis/treatment and perhaps all-cause mortality from emergency medical conditions unrelated to COVID-19. Increase of ED telemedicine, as well as making this information known to the public, may help assuage fear. It is conceivable that barriers to ED usage during the ongoing and future pandemics could be mitigated by the interventions identified in this study (Table 4 ). Given the concern for a prolonged COVID-19 pandemic, hospitals have an obligation to restructure their ED in such a way that individuals, especially those at high risk of emergency conditions, are not deterred from seeking medical care. In summary, self-reported willingness to use the ED for an urgent/emergent illness decreased during the pandemic compared with before the pandemic. Perceived pandemic severity was inversely related to knowledge of COVID-19. During the pandemic, barriers to ED usage included concerns related to COVID-19 exposure. Hospitals should implement strategies to reduce COVID-19-related barriers to ED usage as well as informing the public about these efforts to potentially prevent unnecessary morbidity and mortality from ED avoidance. The authors declare no conflict of interest. 19 Response Team. 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Additional supporting information may be found online in the Supporting Information section at the end of the article.