key: cord-0875753-rmgpsf57
authors: Friedman, Ari B.; Barfield, Deidre; David, Guy; Diller, Thomas; Gunnarson, Candace; Liu, Miao; Vicidomina, Benjamin V.; Zhang, Ruthann; Zhang, Yuan; Nigam, Somesh C.
title: Delayed emergencies: The composition and magnitude of non‐respiratory emergency department visits during the COVID‐19 pandemic
date: 2021-01-14
journal: J Am Coll Emerg Physicians Open
DOI: 10.1002/emp2.12349
sha: 665bf107a604b346406432d2275ee09e10d3e12a
doc_id: 875753
cord_uid: rmgpsf57

IMPORTANCE: COVID‐19 has been associated with excess mortality among patients not diagnosed with COVID‐19, suggesting disruption of acute health care provision may play a role. OBJECTIVE: To determine the degree of declines in emergency department (ED) visits attributable to COVID‐19 and determine whether these declines were concentrated among patients with fewer comorbidities and lower severity visits. DESIGN: We conducted a differences‐in‐differences analysis of all commercial health insurance claims for ED visits in the first 20 weeks of 2018, 2019, and 2020. The intervention period began March 9 (week 11) of 2020, following state stay‐at‐home orders. SETTING: We analyzed claims from Blue Cross Blue Shield of Louisiana (BCBSLA), located in a state with an early US COVID‐19 outbreak. Visit and patient risk was assessed through comorbidities previously described as increasing the risk of COVID‐19 decompensation, the hospital location's COVID‐19 outbreak status, and the Ambulatory Care Sensitive Condition algorithm. PARTICIPANTS: The study population comprised all ED visits from all BCBSLA members, whether admitted or discharged. There were 332,917 ED visits over the study period. The study population spanned member demographics including sex, age, and geography. Uninsured adults were not included due to data limitations. EXPOSURE(S): The COVID‐19 outbreak beginning March 9, 2020 in Louisiana. MAIN OUTCOME(S) AND MEASURE(S): The main outcome of interest for this analysis is the difference (percent change) in all ED visits, categorized as either respiratory or non‐respiratory, from week 1–20 in 2019 and week 1–10 in 2020, compared to week 11–20 in 2020. RESULTS: In this differences‐in‐differences study using data from a commercial health insurer, we found that non‐respiratory ED visits declined by 39%, whereas respiratory visits did not experience a significant decline. Visits that were potentially deferrable or from lower risk patient populations showed greater declines, but even high‐risk patients and non‐avoidable visits experienced large declines in non‐respiratory ED visits. Non‐respiratory ED visits declined by only 18% in areas experiencing COVID outbreak. CONCLUSIONS AND RELEVANCE: COVID‐19 has resulted in significant avoidance of ED care, comprising a mix of deferrable and high severity care. Hospital and public health pronouncements should emphasize appropriate care seeking.

The COVID-19 coronavirus pandemic is ongoing. As the number of COVID-19 cases and hospitalizations began to increase in March 2020, news media, politicians, and health officials initially cautioned the public to avoid hospitals for "unnecessary" care. Public health warnings and stay-at-home orders, despite explicitly allowing medical visits, may have contributed to fears that emergency departments (EDs) in hospitals are places of particularly high risk for contracting the virus. 1 

Existing data on this early overall decline leave significant gaps in our understanding of how the pandemic affected ED visits and the broader implications of these declines for patients and health systems. ED visits span a broad range of severities, from low acuity to imminently lethal. 3, 4 There may be significant health consequences to avoiding emergency care for severe conditions, contributing to the estimated 87,000 excess non-COVID deaths thus far. 5 For example, these deaths may be caused by failure to receive important care such as emergent cardiac catheterizations for ST-segment-elevation myocardial infarctions (STEMI). 6 Whether catheterization laboratory activations declined because of more stringent activation criteria (reducing semielective activations), or because fewer patients presented to EDs for their chest pain remains unknown. Alternatively, telemedicine use increased, 7 and given that 14% to 27% of ED visits are diagnosed with a condition treatable at an alternative care site, these missed ED visits may have saved health system costs 8 while having minimal consequences for health. Elective procedures also declined, 5 meaning fewer ED visits for complications. 9 Furthermore, existing data are not divided by acuity or granular disease categories.

Because COVID-19 induces a variety of chief complaints, most notably respiratory complaints, the aggregation in previous studies may have masked an even more substantial decline in non-respiratory disease.

Moreover, the initial decline may have been temporary. After an initial message to stay away from hospitals, calls to not avoid emergency care have become prominent, 10 once the probability of overwhelming hospital capacity decreased, raising the possibility that visits have since increased. Finally, the data on overall declines do not reveal whether patients are responsive to local capacity constraints compared to more diffuse fears.

To provide insight into these mechanisms, we use insurance data from one of the first states to see a major outbreak, Louisiana, where patient morbidity is high 11 and which surpassed 1000 cases of COVID-19 by March 20, 2020. 12 These cases were not distributed evenly throughout the state; rather, denser areas were first affected, and New Orleans saw cases and hospitalizations increase before Baton

Rouge. 13 A statewide stay-at-home order was put in place on March 22. We use this differential timing to analyze how the COVID-19

pandemic has affected the magnitude and composition of ED visits for non-COVID related (non-respiratory) diseases when compared to the same weeks in the previous years. 

The main outcome of interest for this analysis is the difference (percent change) in all ED visits, categorized as either respiratory or nonrespiratory, from week 1-20 in 2019 compared to week 1-20 in 2020.

As a falsification test, week 1-20 of 2019 is compared to week 1-20 for 2018. Among non-respiratory ED visits, the following subcategories were analyzed separately: cardiac, diabetes, ear conditions, gastrointestinal, headache, mental health, orthopedic, and urinary system.

Primary variables included in this analysis were as follows: (1) patient demographics -age (18-44, 45-64, 65-79, 80+) and sex (male, female); (2) whether a member had any 1 of the following comorbid conditions that were considered to be "high risk" for COVID, (3) whether the members hospital was located in a COVID area, and (4) whether the members ED visit was avoidable or not as determined by

Billings' Ambulatory Care Sensitive Conditions algorithm. 14 To apply the algorithm, we translated ICD-9 to ICD-10 codes using a crosswalk combined with guidance from the insurer's medical director. An ED visit was considered avoidable if it had at least 1 primary diagnosis code from facility and professional claims matching the list. When defining conditions considered high risk for COVID we drew from available preprint data at the time of study initiation 15 and mapped those onto risk factors available in our claims data. Members were considered high risk for COVID if they had a previous diagnosis of chronic obstructive pulmonary disease; asthma; diabetes; end-stage renal disease; congestive heart failure; primary diagnosis of acute myocardial infarction within the most recent 6 months; any diagnosis of coronary artery disease and had bypass, stent, or catheterization procedure within the most recent 6 months; liver disease, or body mass index ≥ 40.

An analysis of more than 300,000 ED visits among commercially insured patients in the southern United States showed that non-respiratory ED visits declined by 39%, whereas respiratory visits did not experience a significant decline during the initial weeks of the COVID-19 pandemic. These results suggest that COVID-19 resulted in significant avoidance of ED care, comprising a mix of deferrable and high severity care

The main methodology for this research was the differences-in- Our multiple regression analysis includes controls for member demographics and characteristics. The structure of our count data lends itself to a high number of zero counts, mostly in smaller visit categories. These are due to the way we partitioned our counts into relatively restrictive bins and not because we have separate data generating processes for zeros and for positive counts. Therefore, we have not used zero inflated models or hurdle models, as the zeros are likely to come from the same data generating process as the positive values.

The models were estimated using a negative binomial distribution as follows:

where the number of visits for sex, COVID-19 risk and age group i, year and week t, condition c, avoidable/non-avoidable visit v, and hospital being in COVID-19 affected area h, are regressed against these categories as well as a DID variable that received a value of 1 after week 10 of 2020 when stay-at-home measures were put in place. All models were generated using Stata Version 15. (1) High Risk COVID defined as whether or not member had 1 of the following comorbid conditions: chronic obstructive pulmonary disease; asthma; diabetes; end-stage renal disease; congestive heart failure; primary diagnosis of acute myocardial infarction within most recent 6 months; any diagnosis of coronary artery disease and had bypass, stent, or catheterization procedure within the most recent 6 months; liver disease, or body mass index ≥ 40.

(2) Facility in COVID Region defined as whether the members hospital was located in a COVID area. males (58% vs 42%) and over a third (37%) having 1 or more of the "high-risk" COVID comorbid conditions. There was a significant difference when it comes to avoidable versus non-avoidable ED visits with 32% of non-respiratory visits being avoidable versus 67% for respiratory. Although not displayed, similar declines were seen by age and sex with the sharpest decline in adults age 65+ (over 50%) and females (over 40%).

Visits that were potentially deferrable or from lower risk patient populations showed greater declines across the entire state ( Figure 2 ).

Members possessing a "high-risk" COVID risk factor reduced their nonrespiratory visits less than those at lower risk during weeks 12-17.

These differences resolved by week 18. ED visits resulting in diagnoses classified as avoidable showed significantly greater declines than "not avoidable" visits, but "not avoidable" non-respiratory visits still declined by ≈35%. Hospitals not in COVID areas experienced significantly greater declines both before and after week 10. 

The results of the adjusted DID regression models for non-respiratory, 

TA B L E 2 Incidence rate ratios from Negative Binomial Count Models (DID) for all non-respiratory ED visits and the 9 selected conditions in Figure 3 and S1

Ear condition

Differences-indifferences 

These analyses have a few limitations. First, this is a retrospective database analysis and therefore we cannot account for potential differences that are unobservable. Second is the generalizability of the findings. Although we included members employed in a variety of industries and regions, Louisiana is our sample, so our results reflect only one state and patients without insurance are not considered. As a result, our analysis likely underestimates effects owing to job loss given previous evidence that health insurance increases ED visits. 16 

Using a large database of insurance claims in a state with an early There are numerous potential pathways by which the decline in ED visits we observe could occur, with differential impacts on public health. 25 The incidence or severity of disease could decrease, promoting health, as with fewer pedestrians hit by cars causing a decline in orthopedic visits, or fewer surgical procedures leading to fewer complications. Patients could change their care-seeking behavior, either staying home or seeking care from their usual primary care physician or nurse practitioner rather than ED services. Similarly, outpatient surveillance and diagnostic intensity may have changed, as outpatient physicians and nurse practitioners seek to keep patients out of the ED.

ED visits declined precipitously in the first months of the COVID-19 pandemic in the United States. ED visits for care potentially amenable to other care settings experienced greater declines than non-avoidable visits. However, even high-risk ED visits and visits from high-risk patients declined substantially. This may have contributed to the increase in non-coronavirus-related deaths in the United States during this period. 26 Health systems should continue efforts to make patients feel safe during this pandemic so that patients seek evaluation and care in all appropriate settings. 27 

Fear: majority of Americans avoiding treatment for heart attack and stroke due to COVID-19. GlobeNewsWire

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