Health Policy Journal Club, Health Policy, Advocacy, Health Care Administration, COVID-19

Health Policy Journal Club: Visits Down; Danger Up

Another study describes emergency department volumes down, especially for dangerous conditions.

Contrary to prior annual trends, emergency departments have seen a dramatic decrease in the number of patients seeking care during the COVID-19 pandemic. Various studies have demonstrated the change in demographics, visit characteristics, and diagnoses in contrast to the days prior to COVID. A recent CDC study showed increases in respiratory complaints for emergency department visits. This is expected given the public’s concern for this novel infectious agent. While public health warnings were effective in educating the public regarding the severity of COVID, they unintentionally prevented patients from receiving necessary care for life-threatening diseases. This study provides an early look at the types of patients who did not seek necessary care during the pandemic and provides suggestions going forward.

The most troubling findings were the dramatic decrease in patients seeking care for non-respiratory life-threatening diseases such as syncope (down 70.5%), strokes (down 58.3), and urolithiasis (down 70%). Public health officials have a responsibility to educate patients regarding the potential seriousness of these conditions and to seek help in the emergency department if they have symptoms of the previously listed conditions – such as weakness, dizziness, and severe back or abdominal pain.

Another concerning finding was the disproportionate decrease in visits for certain demographic groups. Emergency department visits for children, older patients, women, and Medicare recipients decreased compared to the pre-covid era. Many of these groups were previously less likely to seek care and with the pandemic complicating the issue, these communities suffered from a lack of access to health care.

Fortunately, telemedicine has greatly expanded in usage and has helped bridge the gap for many patients, providing a valuable mechanism for care. Triaging patients through video conferences was an excellent approach to providing care for non-acute concerns while still ferrying patients with more concerning symptoms to the emergency department. Policymakers should continue to bolster efforts for telemedicine and to improve the safety of in-person office visits to help triage truly emergent patient complaints into the emergency department. 

ABSTRACT: Westgard BC, Morgan MW, Vazquez-Benitez G, Erickson LO, Zwank MD. An Analysis of Changes in Emergency Department Visits After a State Declaration During the Time of COVID-19. Ann Emerg Med. 2020;76(5):595-601.

STUDY OBJECTIVE: In the initial period of the coronavirus disease 2019 (COVID-19) pandemic, there has been a substantial decrease in the number of patients seeking care in the emergency department. A first step in estimating the impact of these changes is to characterize the patients, visits, and diagnoses for whom care is being delayed or deferred.

METHODS: We conducted an observational study, examining demographics, visit characteristics, and diagnoses for all ED patient visits to an urban level 1 trauma center before and after a state emergency declaration and comparing them with a similar period in 2019. We estimated percent change on the basis of the ratios of before and after periods with respect to 2019 and the decline per week using Poisson regression. Finally, we evaluated whether each factor modified the change in overall ED visits.

RESULTS: After the state declaration, there was a 49.3% decline in ED visits overall, 35.2% (95% confidence interval -38.4 to -31.9) as compared with 2019. Disproportionate declines were seen in visits by pediatric and older patients, women, and Medicare recipients, as well as for presentations of syncope, cerebrovascular accidents, urolithiasis, and abdominal and back pain. Significant proportional increases were seen in ED visits for upper respiratory infections, shortness of breath, and chest pain.

CONCLUSION: There have been significant changes in patterns of care-seeking during the COVID-19 pandemic. Declines in ED visits, especially for certain demographic groups and disease processes, should prompt efforts to understand these phenomena, encourage appropriate care-seeking, and monitor for the morbidity and mortality that may result from delayed or deferred care.

PMID: 33008651 

EMRA + PolicyRx Health Policy Journal Club: A collaboration between Policy Prescriptions and EMRA

As emergency physicians, we care for all members of society, and as such have a unique vantage point on the state of health care. What we find frustrating in our EDs - such as inadequate social services, the dearth of primary care providers, and the lack of mental health services - are universal problems. As EM residents and fellows,  we learn the management of myocardial infarctions and traumas, and how to intubate, but we are not taught how health policy affects all aspects of our experience in the ED. Furthermore, given our unique position in the health care system, we have an incredible opportunity to advocate for our patients, for society, and for physicians. Yet, with so many competing interests vying for our conference education time, advocacy is often not included in the curricula. This is the gap this initiative aims to fill.  Each month, you will see a review of a new health policy article and how it is applicable to emergency physicians.