Delayed emergencies: The composition and magnitude of non-respiratory emergency department visits during the COVID-19 pandemic

Abstract

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.

Exposures: The COVID-19 outbreak beginning March 9, 2020 in Louisiana.

Main outcomes and measures: 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.