Emergency Department Access During COVID-19: Disparities in Utilization by Race/Ethnicity, Insurance, and Income

Abstract

Introduction In March 2020, shelter-in-place orders were enacted to attenuate the spread of coronavirus 2019 (COVID-19). Emergency departments (EDs) experienced unexpected and dramatic decreases in patient volume, raising concerns about exacerbating health disparities. Methods We queried our electronic health record to describe the overall change in visits to a two-ED healthcare system in Northern California from March–June 2020 compared to 2019. We compared weekly absolute numbers and proportional change in visits focusing on race/ethnicity, insurance, household income, and acuity. We calculated the z-score to identify whether there was a statistically significant difference in proportions between 2020 and 2019. Results Overall ED volume declined 28% during the study period. The nadir of volume was 52% of 2019 levels and occurred five weeks after a shelter-in-place order was enacted. Patient demographics also shifted. By week 4 (April 5), the proportion of Hispanic patients decreased by 3.3 percentage points (pp) (P = 0.0053) compared to a 6.2 pp increase in White patients (P = 0.000005). The proportion of patients with commercial insurance increased by 11.6 pp, while Medicaid visits decreased by 9.5 pp (P < 0.00001) at the initiation of shelter-in-place orders. For patients from neighborhoods <300% federal poverty levels (FPL), visits were −3.8 pp (P = 0.000046) of baseline compared to +2.9 pp (P = 0.0044) for patients from ZIP codes at >400% FPL the week of the shelter-in-place order. Overall, 2020 evidenced a consistently elevated proportion of high-acuity Emergency Severity Index (ESI) level 1 patients compared to 2019. Increased acuity was also demonstrated by an increase in the admission rate, with a 10.8 pp increase from 2019. Although there was an increased proportion of high-acuity patients, the overall census was decreased. Conclusion Our results demonstrate changing ED utilization patterns circa the shelter-in-place orders. Those from historically vulnerable populations such as Hispanics, those from lower socioeconomic areas, and Medicaid users presented at disproportionately lower rates and numbers than other groups. As the pandemic continues, hospitals should use operations data to monitor utilization patterns by demographic, in addition to clinical indicators. Messaging about availability of emergency care and other services should include vulnerable populations to avoid exacerbating healthcare disparities.

Increased emergency cardiovascular events among under-40 population in Israel during vaccine rollout and third COVID-19 wave

“…The large increase in the incidence of CA and ACS events in the population of age 16-39 parallel to the vaccination rollout and its association with the vaccination rates could be consistent with the known causal relationship between the mRNA vaccines and incidents of myocarditis in young people 14,17,19,56 , as well as the fact that myocarditis is often misdiagnosed as ACS [28][29][30] , and that asymptomatic myocarditis is a frequent cause for unexplained sudden death among young adults from CA 26,[31][32][33] . This is further supported by more anecdotal reports describing sudden cardiac death following COVID-19 vaccination 16,57 .…”

COVID-19 Pandemic-Associated Changes in the Acuity of Brain MRI Findings: A Secondary Analysis of Reports Using Natural Language Processing

“…Of note, however, such racial and insurance disparities in the acuity levels of imaging findings did not increase in 2020 compared with pre-pandemic levels. In contrast other studies have shown an exacerbation in health disparities and their underlying social determinants of heath during the pandemic [ 36 , 37 ]. Our analysis only included examinations during the first six months of the COVID-19 pandemic and only focused on acuity of brain MRI examinations.…”

Do Non-COVID-19 Patients’ Behaviour Towards Emergency Changed During the COVID-19 Outbreak? A Severity-Based Approach

“…Some papers have included data on ESI patterns of ED visits during this period in the tables or appendix, but they have mixed COVID-19 and non-COVID-19 patients.Those have not reported the trends in patient characteristics that we observed in this study. [17][18][19] The number of visits to the ED decreased worldwide during pandemic beginning, and our ED did not deviate from the rule. 20 This confirms our hypothesis that, in our ED, the number of visits decreased during the COVID-19 first wave and the non-COVID-19 patient visits were more urgent, based on the ESI triage tool.…”