Decreased Emergency Department Utilization by Lower Socioeconomic Status Population as a Result of the COVID-19 Pandemic

ABSTRACT

Study Objective: The SARS-CoV-2 (which causes COVID-19) pandemic has resulted in lower emergency department (ED) volumes. It has precipitated business and school closures along with the implementation of physical distancing measures, which culminated in a Shelter in-Place Order (SIPO) issued for a major urban area county in March 2020. The objective of this study was to determine the effect on access to healthcare by patients of different socioeconomic status by examining differences in ED volume by zip code stratified by the SocioNeeds Index. Methods: This retrospective chart review examines whether there was a quantitative change in patient visits to an urban, tertiary county hospital ED from 2019-2020 by zip codes. The inclusion criterion was any ED visits from a county resident, and the exclusion criterion was any blank, alphanumeric, or PO box zip codes including zip codes located outside of Dallas County. We mapped daily patient visits by zip code for four phases Phase 1 was the 3 months preceding the first COVID-19 case’s announcement in Dallas, Phase 2 began with the first COVID case, Phase 3 encompassed when the SIPO was in effect for Dallas County, and Phase 4 included the three months following the expiration of the SIPO. The SocioNeeds Index rates each zip code by socioeconomic status, specific to this county. We compared this data to records over the same time period from the previous year to control for seasonal variation in the absence of a pandemic. Results: There were 275,756 ED patient visits included in this study. The results indicate a statistically significant decrease in ED visits occurred in all zip codes during the pandemic 24% between Phase 1 and 4 (p<0.0001) in 2020. Additionally, there was a decrease in visits after the first case in Dallas Phase 2 (-14%, p<0.0001), Phase 3 (-41%, p<0.0001) and Phase 4 (-25%, p<0.0001) when compared to 2019 but an increase in visits (36%, p<0.0001) in 2020 once the SIPO expired. Zip codes with highest need based on poverty, income, unemployment, occupation, education and language (weighted to correlate with preventable hospitalization and premature death rates) were found to have greater reductions in visits whereas zip codes which with the lowest needs saw a 15% increase in visits during the SIPO. The geographic distribution of visits indicate that most zip codes saw a reduction in visits over Phases 2 and 3 (especially zip codes further from the ED) and an increase in visits during Phase 4 but never recovered to pre-pandemic values. Conclusion: Overall, a significant decrease in ED visits per zip code was observed relative to a non-pandemic year in most zip codes except those with the highest socioeconomic status, suggesting that the virus and SIPO deterred patients disproportionately from the higher needs communities from accessing healthcare. These results could have implications for future pandemic public health messaging and targeted outreach to communities with barriers to healthcare access. [Formula presented]