TRENDS IN AVOIDABLE AND UNAVOIDABLE U.S. EMERGENCY DEPARTMENT VISITS DURING THE COVID-19 PANDEMIC, 2019-2021

ABSTRACT

BACKGROUND: Following early reductions in U.S. emergency department (ED) care after the COVID-19 pandemic's onset, it is unclear whether avoidable and unavoidable ED visits returned to expected rates, particularly for socioeconomically disadvantaged Medicaid and dual eligible MedicareMedicaid patients. Further, the degree to which avoidable and unavoidable ED visits are associated with hospitalizations during the pandemic is unknown. METHODS: In a retrospective cohort study of ED care patterns from Jan 1, 2019-Feb 28, 2021, we analyzed claims data from multiple U.S. payers from MedInsight's research database. Using difference-in-differences methods, we assessed the degree to which ED use during the pandemic differed from expected rates had the pandemic not occurred. We compared rate changes between Jan-Feb 2020 and each subsequent 2-month timeframe during the pandemic vs changes in the corresponding months in the year prior. We stratified visits by avoidable vs unavoidable using MediCal avoidable ED visit criteria, which flags visits that generally could have been managed by a primary care physician (e.g., rhinitis, cystitis, administrative exams) had patients had access to one. We tested the relationship between avoidable vs unavoidable ED visits and hospitalization, and estimated age-sex adjusted Poisson regressions of monthly use counts, offsetting for total patient-months and stratifying by insurance. RESULTS: We studied 14.5 million U.S. adults (mean age 53;55% female) using 11 million ED visits (6% avoidable, 94% unavoidable) in 2019-21. Unavoidable visits had higher odds of hospitalization than avoidable visits in each insurance group (for all groups OR 2.8 [2.7-2.8]). In Mar-Apr 2020, avoidable and unavoidable ED visits respectively declined similarly, to 68.1% [67-69%] and 68.9% [68-69%] of expected rates. By Nov-Dec 2020, avoidable visits declined further to 52.0% [51-53%], while unavoidable visits returned to 93.7% [93-94%] of expected rates. During pandemic wave 2 in Jan-Feb 2021, avoidable and unavoidable visits declined to 45.1% [44-46%] and 82.2% [82-83%] respectively and varied by insurance (Table). CONCLUSIONS: Following declines early in the pandemic, unavoidable ED visits nearly returned to expected rates by Nov-Dec 2020, only to decline again during pandemic wave 2 in Jan-Feb 2021. In contrast, avoidable visits consistently declined without rebound. While reductions in avoidable visits lower unnecessary costs, persistent declines in unavoidable visits raise concern that patients with more serious conditions may be delaying needed ED care, particularly among socioeconomically disadvantaged groups.