Emergency Department Volume, Severity, and Crowding Since the Onset of the Coronavirus Disease 2019 Pandemic

STUDY OBJECTIVE

We describe emergency department (ED) visit volume, illness severity, and crowding metrics from the onset of the coronavirus disease 2019 (COVID-19) pandemic through mid-2022.

METHODS

We tabulated monthly data from 14 million ED visits on ED volumes and measures of illness severity and crowding from March 2020 through August 2022 compared with the same months in 2019 in 111 EDs staffed by a national ED practice group in 18 states.

RESULTS

Average monthly ED volumes fell in the early pandemic, partially recovered in 2022, but remained below 2019 levels (915 per ED in 2019 to 826.6 in 2022 for admitted patients; 3,026.9 to 2,478.5 for discharged patients). The proportion of visits assessed as critical care increased from 7.9% in 2019 to 11.0% in 2022, whereas the number of visits decreased (318,802 to 264,350). Visits billed as 99285 (the highest-acuity Evaluation and Management code for noncritical care visits) increased from 35.4% of visits in 2019 to 40.0% in 2022, whereas the number of visits decreased (1,434,454 to 952,422). Median and median of 90th percentile length of stay for admitted patients rose 32% (5.2 to 6.9 hours) and 47% (11.7 to 17.4 hours) in 2022 versus 2019. Patients leaving without treatment rose 86% (2.9% to 5.4%). For admitted psychiatric patients, the 90th percentile length of stay increased from 20 hours to more than 1 day.

CONCLUSION

ED visit volumes fell early in the pandemic and have only partly recovered. Despite lower volumes, ED crowding has increased. This issue is magnified in psychiatric patients.

The Cost Shifting Economics of United States Emergency Department Professional Services (2016-2019)

STUDY OBJECTIVE

We estimate the economics of US emergency department (ED) professional services, which is increasingly under strain given the longstanding effect of unreimbursed care, and falling Medicare and commercial payments.

METHODS

We used data from the Nationwide Emergency Department Sample (NEDS), Medicare, Medicaid, Health Care Cost Institute, and surveys to estimate national ED clinician revenue and costs from 2016 to 2019. We compare annual revenue and cost for each payor and calculate foregone revenue, the amount clinicians may have collected had uninsured patients had either Medicaid or commercial insurance.

RESULTS

In 576.5 million ED visits (2016 to 2019), 12% were uninsured, 24% were Medicare-insured, 32% Medicaid-insured, 28% were commercially insured, and 4% had another insurance source. Annual ED clinician revenue averaged $23.5 billion versus costs of $22.5 billion. In 2019, ED visits covered by commercial insurance generated $14.3 billion in revenues and cost $6.5 billion. Medicare visits generated $5.3 billion and cost $5.7 billion; Medicaid visits generated $3.3 billion and cost $7 billion. Uninsured ED visits generated $0.5 billion and cost $2.9 billion. The average annual foregone revenue for ED clinicians to treat the uninsured was $2.7 billion.

CONCLUSION

Large cost-shifting from commercial insurance cross-subsidizes ED professional services for other patients. This includes the Medicaid-insured, Medicare-insured, and uninsured, all of whom incur ED professional service costs that substantially exceed their revenue. Foregone revenue for treating the uninsured relative to what may have been collected if patients had health insurance is substantial.

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.

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.

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.