Patient visits to emergency rooms have dropped precipitously since the onset of the coronavirus pandemic, in some places declining as much as 50%. The results have often been tragic, with some patients waiting too long to visit the ER and doctors scrambling to let patients know that they can’t put off ER visits.
Yet it may also be a sign of something far more benign: ER overuse.
“It’s not a surprise to talk about inappropriate emergency room visits,” said Dr. Ryan Radecki, an ER physician at Kaiser Permanente in Portland, Oregon. “There has always been a problem with people attending the emergency department with nonemergent complaints.”
There were just under 139 million ER visits in 2017, the last year for which data is available. Of those, 3.9 million were considered “nonurgent,” and another 24 million were “semiurgent,” according to the National Hospital Ambulatory Medical Care Survey. That is 20% of all ER visits.
There presently is no data on how many nonurgent or semiurgent cases are among the people who have shunned the ER during the pandemic. But data does show that many patients are terrified of visiting the ER for fearing of contracting COVID-19. Indeed, 29% said they have delayed or avoided getting healthcare because of the coronavirus, according to a recent Morning Consult/American College of Emergency Physicians poll. In April, hospitals in New York saw a 50% drop in ER visits when compared to 2019. Cedars-Sinai in Los Angeles saw a decline of 30%.
“The services provided to some patients in the ER are not necessarily unnecessary. It’s that these patients are in the wrong place,” said Shannon Brownlee, a senior vice president at the Lown Institute and author of the book Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer. “It is unnecessary to provide them with services in the emergency room, which is one of the most expensive places to get treated.”
UnitedHealth Group found in 2019 that $32 billion was spent on unwarranted ER visits. The average per-patient cost of ER treatment was $2,032. That was 12 times higher than what it would cost to treat a patient in a physician’s office.
“I’m sure there are a lot of nonemergent cases that are going to ERs less now as a result of the pandemic,” said Dr. Sam Slishman, an ER physician in San Luis Obispo, California. Slishman runs a telemedicine practice called Pre-R that he started “as a result of the population that uses the ER when they could get things solved in other ways. They aren’t really to blame; they just want to get answers quicker than they might otherwise.”
Slishman said that he has seen a lot fewer nonurgent patients with colds and fevers since the pandemic. “In my last shift, I didn’t see a single patient with a fever, and that’s the first time that’s ever happened,” he said. He emphasized, though, that the decline was likely a mix of patients staying away from the ER and fewer people getting colds due to social distancing.
“We usually have a fair number of patients who come into the ER because they are concerned that their blood pressure has been high for a few days in a row or their blood sugar has been up and down,” said Radecki. “Or they just don’t feel well, they don’t have much energy or feel nauseous, and they don’t know why. These people aren’t sick enough, necessarily, to be in the hospital, but they’d like an answer to their problem.” A lot of those patients haven’t been showing up since March.
Dr. Comilla Sasson, a professor of emergency medicine at the University of Colorado, said she has been seeing many more patients via telemedicine since the pandemic and that only about 10%-30% are ones she refers to the emergency room. Yet, she said she worries that there are patients who should go to the ER and do not.
“One of the unintended consequences is that we have seen a huge decline in emergent patients, like heart attacks and strokes,” she said. “We have a messaging issue. We have to remind people that emergencies still happen in the era of COVID-19, and not everything is about COVID-19, and that we can keep them safe in the ER.”
The rates of ER admissions due to minor strokes dropped 31% in March, according to claims data from the insurer Cigna. Admissions for heart problems fell 11% and for epilepsy and seizures declined 28%. In some cases, that resulted in death. A patient of Dr. Kevin Sheth, a neurologist at Yale New Haven Hospital, delayed visiting the ER and died of a stroke as a result, the Wall Street Journal reported.
But for some patients, staying away from the ER may be beneficial.
“On the one hand, I’m sure there are people out there who have been harmed by not going to the ER,” said Brownlee. “At the same time, some people may have been helped by not having stuff done, like unnecessary CT scans.”
What exactly causes ER overuse is a matter of considerable debate.
“For people who have no insurance or are poorly insured, the ER has been the location for them to receive for a long time,” said Brownlee. “And even with the Affordable Care Act, which has increased insurance for more people, they had gotten into the habit of going to the ER because they didn’t have a primary care doctor.” Brownlee also blamed the way our healthcare system pays doctors, which she believes is responsible for a shortage of primary-care physicians.
Slishman partially blamed the Emergency Medical Treatment and Labor Act, a federal law that requires hospitals to treat anyone who comes through the door.
“If we get a phone call from someone wanting advice, we tell them that they have to come in and [that] we can’t treat them over the phone,” he said. “ER workers are nervous about turning anyone away and being accused of violating EMTALA.”
