Non-COVID hospital visits down amid COVID-19 pandemic

Visits to hospitals in New York and California for both non-COVID medical emergencies and chronic diseases fell sharply amid the COVID-19 pandemic from previous years, suggesting avoidance of medical settings for fear of infection or financial concerns—even when confronted with life-threatening conditions, according to two research letters published today in JAMA Internal Medicine.

Emergency department visits for deadly conditions

The first study details emergency department visits for heart attack, ischemic stroke, nontraumatic subarachnoid hemorrhage (a type of bleeding in the brain), ectopic pregnancy, and appendicitis at Stanford University Medical Center and New York-Presbyterian (NYP)/Weill Cornell Medical Center from Mar 1 to May 22.

Compared with before the pandemic, the researchers estimated a 39% drop in daily visits for heart attack at NYP after accounting for underlying trends (relative risk [RR], 0.61) and a 26% decrease at Stanford (RR, 0.74). Visits for ischemic stroke were down 49% at NYP (RR, 0.51) and 16% at Stanford (RR, 0.84). NYP reported a 33% decrease in visits for brain hemorrhage (RR, 0.67), while Stanford saw a 21% decrease (RR, 0.79).

There were 42% fewer visits for appendicitis at NYP (RR, 0.58), but Stanford reported no difference. Neither hospital reported a decrease in visits for ectopic pregnancy. The authors attributed the more substantial decreases in daily caseloads at NYP to the severity of the pandemic in New York City.

"Recent data suggest that deaths resulting from COVID-19 account for only half of the excess number of at-home deaths during the pandemic," the researchers wrote. "The combination of fewer patients presenting with medical emergencies and an increased number of non–COVID-19–related at-home deaths is concerning. Fear of exposure to patients with COVID-19 may lead individuals to defer care for acute conditions."

Weekly hospitalizations for common conditions

In the second study, researchers at New York University (NYU) and the University of Michigan at Ann Arbor evaluated weekly non–coronavirus-related admissions to four hospitals in the NYU Langone Health system from Mar 1 to May 9 in 2018, 2019, and 2020.

In 2020, there were 3,657 hospitalizations unrelated to COVID-19, down from 5,368 in 2018 and 6,411 in 2019. Weekly rates of admission were similar to baseline early in the pandemic (604.3 in 2020 vs 584.5 in the previous years), decreased during the first pandemic peak (247.0), and later rose slightly (309.3).

While weekly admission rates declined in all categories during the pandemic peak, they fell significantly for common conditions such as septicemia (blood infection; 25.3 in 2020 vs 51.1 in previous years), heart failure (9.0 vs 25.6), heart attack (4.0 vs 16.3), stroke (7.0 vs 14.7), biliary tract disease (3.0 vs 11.7), epilepsy (3.7 vs 11.5), skin infections (2.7 vs 11.5), complications of care (3.7 vs 10.7), abnormal heart rhythms, (2.3 vs 10.6), appendicitis (2.7 vs 8.6), and chronic obstructive pulmonary disease (COPD; 2.3 vs 8.6).

Later in the pandemic, rates of hospitalizations for heart attack, biliary tract disease, and appendicitis started to normalize, but not significantly, while those of septicemia, diabetes, and COPD did not increase.

The authors said the declines could have been influenced by fear of infection, lost health insurance, physicians' higher threshold for hospitalization amid limited resources, and changes in patient lifestyles and self-treatment while needing to physical distance.

Noting that hospitalizations for chronic conditions did not begin to normalize later in the pandemic like those for emergencies did, the researchers said that the possibility that ill patients are not seeking necessary hospitalizations is concerning, although it could reflect previous overuse of hospitalization or better patient self-treatment.

"In an epicenter of COVID-19, we found that the pandemic was associated with substantial changes in hospitalization patterns for non–COVID-19 conditions," they said. "The long-term effects of hospitalization reductions on both patient outcomes and the health care system remain to be seen."

Harm, more at-home deaths

In an editor's note in the same journal, Colette DeJong, MD, and Kenneth Covinsky, MD, of the University of California at San Francisco, and Mitchell Katz, MD, of NYC Health and Hospitals, said that while treatment of some conditions can be skipped without harm, deferral of treatment for stroke and other medical emergencies causes harm and contributes to increased at-home deaths.

In addition to the risk of infection, some people may not seek care because of lost income, loss of employer-sponsored health insurance, childcare or eldercare responsibilities, or inertia due to grief, anxiety, or depression.

The use of physical distancing floor markers, universal screening, and wearing of face coverings can help patients feel safe in hospitals and clinics, DeJong and colleagues said.

"The importance of seeking urgent and preventive care (eg, age-appropriate immunizations, cancer screening) should be publicized by departments of health and reinforced by primary care clinicians and triage lines," they wrote.

"The pandemic can provide an opportunity for us to teach patients which parts of medical care are of highest value and encourage them to seek that care, as we simultaneously maximize our use of non–hospital-based options for health care delivery."

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