Anyone who has been near an emergency department (ED) in the US since the middle of March 2020 knows that the census decreased precipitously as the coronavirus disease 2019 (COVID-19) pandemic intensified. Pundits in the medical and mass media have speculated on where ED patients, especially those with ST-segment elevation myocardial infarctions, acute strokes, and other serious conditions, had gone.1,2 In this issue, Jeffery et al3 carefully document that in the period preceding the influx of patients with COVID-19, the census of 24 EDs in a 5-state sample decreased between 42% and 64%; with the exception of Mount Sinai Health in New York, the number of admissions from the ED decreased as well.
The findings of Jeffrey et al3 are consistent with 2 recent reports, one from the Centers for Disease Control and Prevention (CDC) by Hartnett et al,4 which used a database that included approximately three-quarters of all US ED visits, and the other from Baum and Schwartz,5 which described nonelective admissions in the entire Department of Veterans Affairs health care system. Harnett et al4 reported that ED visits decreased 42% in the early phase of the pandemic4; Baum and Schwartz5 found that Veterans Affairs admissions also decreased by 42%.5 The CDC and Veterans Affairs reports include data stratified by illnesses and injuries. By studying the changes in admissions in a broad swath of EDs and hospitals with different locations, population densities, and academic statuses, these reports4,5 contribute to a better understanding of the effects of the COVID-19 pandemic on the US health care system in the first and second quarters of 2020.
The authors of the 3 studies advise public health officials, as Jeffries et al3 state, to emphasize to patients “the importance of continuing to visit the ED for serious symptoms, illnesses, and injuries that cannot be managed in other settings.” This is an important message; some patients are likely to have better outcomes if they seek ED care, the COVID-19 pandemic notwithstanding. It would be a mistake, however, to focus solely on very ill patients who may have avoided ED care.
At a time of great social discord in the US and when funding priorities for various government functions are being rethought, a potential silver lining of the COVID-19 pandemic is the opportunity to consider how health care resources could be better used, particularly with respect to emergency care. What might we learn from the patients who avoided or deferred ED care and who did not have a condition thought to benefit unambiguously from that care?
Even if some sicker patients are not presenting to the ED, this does not mean that they are forgoing medical care altogether. Many hospitals and clinics rapidly instituted better access to practitioners and care coordinators via the telephone or telemedicine,6 providing patients with alternatives. For example, at academic hospitals, patients with transplanted organs or those receiving chemotherapy whose acute symptoms previously elicited a recommendation to go immediately to the ED may have instead received better outpatient care coordination from their transplant team.
In addition, many hospitals curtailed elective surgery before their inpatient census increased with COVID-19 cases; consequently, even those facilities that had previously run at maximum capacity had available beds. A likely outcome is that sick outpatients who would have been sent to the ED for evaluation and held there until an inpatient bed became available are now directly admitted to the hospital, further lowering ED volume.
What were the consequences for patients whose medical conditions typically warranted a trip to the ED but who chose not to go? Physicians, understandably biased by their emotional investment in their life’s work and financial incentives to maintain the ED census, may overestimate the value of the omitted care. For example, patients with non–ST-segment elevation myocardial infarctions are admitted for monitoring, assessment, and treatment, but mortality is rare in this group.7 Moreover, most of these patients would do well in the short to medium term even if they received no medical care. Excess morbidity and mortality, if any, resulting from such patients forgoing ED care would be difficult to detect without detailed studies using large and clinically granular data sets.
Finally, what happened to patients for whom ED care is generally accepted to improve outcomes, such as those with ST-segment elevation myocardial infarctions and large-vessel strokes? Currently, we do not know. Without study, we should not discount the possibility that there were fewer of these events. It is also possible that some of the excess cardiac arrests reported by Hartnett et al4 may be a consequence of avoiding the ED.
COVID-19 deaths in the US have been disproportionately concentrated in people of color.8 The report from the CDC4 also provides evidence of more subtle forms of health disparity. It documents that much of the decrease in ED visits was for ambulatory care issues, such as hypertension and episodic childhood illness, whereas there was an increase in visits associated with socioeconomic or social factors and for mental health conditions and substance use disorders in remission. These data suggest that patients who use the ED as a safety net are staying away, likely without an alternative option, whereas those who have lost access to mental health clinics and drug rehabilitation programs because of COVID-19–related closures continue to seek care in the ED because they have no other options.
The changes in the use of the ED during the COVID-19 pandemic are likely to further exacerbate racial/ethnic and socioeconomic level health disparities in the US. They also make more apparent the need for universal health insurance coverage. Although the many failures of the US health care system were evident before the pandemic,9 COVID-19 has added to the evidence of its insufficiencies, inefficiencies, and fundamental unfairness for both emergency services and routine care. By documenting the change in the ED census in response to the pandemic, Jeffery et al3 have provided a starting point for a careful examination of the appropriate use of emergency services in the months and years ahead.
Corresponding Author: David L. Schriger, MD, MPH, Department of Emergency Medicine, University of California, Los Angeles (firstname.lastname@example.org).
Published Online: August 3, 2020. doi:10.1001/jamainternmed.2020.3265
Conflict of Interest Disclosures: None reported.
Funding: This commentary was supported in part by an unrestricted grant from the Korein Foundation.
Role of the Funder/Sponsor: The Korein Foundation had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
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