The Effect of the COVID-19 Pandemic on the Economics of United States Emergency Care.

STUDY OBJECTIVE: We describe how the coronavirus disease 2019 (COVID-19) pandemic affected the economics of emergency department care (ED). METHODS: We conducted an observational study of 136 EDs from January 2019 to September 2020, using 2020-to-2019 3-week moving ratios for ED visits, complexity, revenue, and staffing expenses. We tabulated 2020-to-2019 staffing ratios and calculated hour and full-time-equivalent changes. RESULTS: Following the COVID-19 pandemic's onset, geriatric (age ≥65), adult (age 18 to 64), and pediatric (age <18) ED visits declined by 43%, 40%, and 73%, respectively, compared to 2019 visits and rose thereafter but remained below 2019 levels through September. Relative value units per visit rose by 8%, 9%, and 18%, respectively, compared to 2019, while ED admission rates rose by 32%. Both fell subsequently but remained above 2019 levels through September. Revenues dropped sharply early in the pandemic and rose gradually but remained below 2019 levels. In medium and large EDs, staffing and expenses were lowered with a lag, largely compensating for lower revenue at these sites, and barely at freestanding EDs. Staffing and expense reductions could not match revenue losses in smaller EDs. During the pandemic, emergency physician and advanced practice provider clinical hours and compensation fell 15% and 27%, respectively, corresponding to 174 lost physician and 193 lost advanced practice provider full-time-equivalent positions. CONCLUSION: The COVID-19 pandemic adversely impacted the economics of ED care, with large drops in overall and, in particular, low-acuity ED visits, necessitating reductions in clinical hours. Staffing cutbacks could not match reduced revenue at small EDs with minimum emergency physician coverage requirements.

How emergency department visits for substance use disorders have evolved during the early COVID-19 pandemic.

OBJECTIVE: Higher opioid overdoses and drug use have reportedly occurred during the COVID-19 pandemic. We provide evidence on how emergency department (ED) visits for substance use disorders (SUD) changed in the early pandemic period. METHODS: Using retrospective data from January-July 2020 compared to January-July 2019, we calculated weekly 2020/2019 visit ratios for opioid-related, alcohol-related, other drug-related disorders, and all non-COVID-19 visits. We assess how this ratio as well as overall visit numbers changed after the mid-March 2020 onset of general pandemic restrictions. RESULTS: In 4.5 million ED visits in 2020 and 2019 to 108 EDs in 18 U.S. states, SUD visits were higher in early 2020 compared to 2019. During the peak-pandemic restriction period (March 13-July 31), non-COVID-19, non-SUD visits fell by approximately 45% early on, and then partly recovered with an average decline of 33% relative to 2019 levels. Visits for opioid-related, alcohol-related, and other drug-related disorders also declined, although less sharply, with an average drop of 17%, which was similar across SUD types. The visit ratios for 2020/2019 partially or fully recovered later in our sample period, depending on SUD type, but did not exceed early-2020 levels. However, substantial variation occurred across SUD types and across states. SUD visit declines were most prominent in the 65+ age group, except for alcohol-related visits where trends were similar across ages. SUD visits arriving by ambulance declined less or increased relative to self-transport visits, and ED deaths were rare. CONCLUSIONS: The 2020/2019 ratios of SUD ED visits fell substantially early in the COVID-19 pandemic, yet less than non-SUD, non-COVID ED visits. SUD ED visit ratios partly or fully recovered to 2019 levels by early June 2020, but did not exceed early 2020 ratios.

The effect of the COVID-19 pandemic on emergency department visits for serious cardiovascular conditions.

OBJECTIVE: We examine how emergency department (ED) visits for serious cardiovascular conditions evolved in the coronavirus (COVID-19) pandemic over January-October 2020, compared to 2019, in a large sample of U.S. EDs. METHODS: We compared 2020 ED visits before and during the COVID-19 pandemic, relative to 2019 visits in 108 EDs in 18 states in 115,716 adult ED visits with diagnoses for five serious cardiovascular conditions: ST-segment elevation myocardial infarction (STEMI), non-ST-segment elevation myocardial infarction (NSTEMI), ischemic stroke (IS), hemorrhagic stroke (HS), and heart failure (HF). We calculated weekly ratios of ED visits in 2020 to visits in 2019 in the pre-pandemic (Jan 1-March 10), early-pandemic (March 11-April 21), and later-pandemic (April 22-October 31) periods. RESULTS: ED visit ratios show that NSTEMI, IS, and HF visits dropped to lows of 56%, 64%, and 61% of 2019 levels, respectively, in the early-pandemic and gradually returned to 2019 levels over the next several months. HS visits also dropped early pandemic period to 60% of 2019 levels, but quickly rebounded. We find mixed evidence on whether STEMI visits fell, relative to pre-pandemic rates. Total adult ED visits nadired at 57% of 2019 volume during the early-pandemic period and have only party recovered since, to approximately 84% of 2019 by the end of October 2020. CONCLUSION: We confirm prior studies that ED visits for serious cardiovascular conditions declined early in the COVID-19 pandemic for NSTEMI, IS, HS, and HF, but not for STEMI. Delays or non-receipt in ED care may have led to worse outcomes.

Characterizing pediatric emergency department visits during the COVID-19 pandemic.

OBJECTIVE: We determine how pediatric emergency department (ED) visits changed during the COVID-19 pandemic in a large sample of U.S. EDs. METHODS: Using retrospective data from January-June 2020, compared to a similar 2019 period, we calculated weekly 2020-2019 ratios of Non-COVID-19 ED visits for adults and children (age 18 years or less) by age range. Outcomes were pediatric ED visit rates before and after the onset of pandemic, by age, disposition, and diagnosis. RESULTS: We included data from 2,213,828 visits to 144 EDs and 4 urgent care centers in 18 U.S. states, including 7 EDs in children's hospitals. During the pandemic period, adult non-COVID-19 visits declined to 60% of 2019 volumes and then partially recovered but remained below 2019 levels through June 2020. Pediatric visits declined even more sharply, with peak declines through the week of April 15 of 74% for children age < 10 years and 67% for 14-17 year. Visits recovered by June to 72% for children age 14-17, but to only 50% of 2019 levels for children < age 10 years. Declines were seen across all ED types and locations, and across all diagnoses, with an especially sharp decline in non-COVID-19 communicable diseases. During the pandemic period, there was 22% decline in common serious pediatric conditions, including appendicitis. CONCLUSION: Pediatric ED visits fell more sharply than adult ED visits during the COVID-19 pandemic, and remained depressed through June 2020, especially for younger children. Declines were also seen for serious conditions, suggesting that parents may have avoided necessary care for their children.