News & Updates

  • 7 Jul 2020 9:48 PM | Matt Zavadsky (Administrator)

    This may also be the future for most EMS agencies…  Tough fiscal times ahead…

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    Hospitals will take $320B hit this year, AHA says

    MICHAEL BRADY

    June 30, 2020

    https://www.modernhealthcare.com/finance/hospitals-will-take-320b-hit-this-year-aha-says

    Hospitals and health systems will lose over $320 billion in 2020 due to the COVID-19 pandemic, according to an American Hospital Association report Tuesday.

    More than $200 billion in financial losses occurred from March to June. But the AHA expects hospitals to lose another $120 billion—about $20 billion per month—through year-end, mostly driven by lower patient volumes.

    The report probably underestimates 2020's total financial losses because "the analysis does not account for currently increasing case rates in certain states or potential subsequent surges of the pandemic occurring later this year," the AHA said in a statement.

    "Hospitals and health systems are in the midst of the greatest financial crisis in our history," AHA CEO Rick Pollack said.

    "While we appreciate the support to date from Congress and the (Trump) administration, this report clearly shows that we are not out of the woods. More action is needed urgently to support our nation's hospitals and health systems and front-line staff."

    According to the report, average inpatient volume is down about 20% compared with 2019, while average outpatient volume has slipped nearly 35% relative to last year.

    "Most hospitals and health systems do not expect volume to return to baseline levels in 2020," the AHA said in a news release.

    The AHA's report doesn't account for hospitals' direct COVID-19 treatment costs or other expenses like higher acquisition costs for drugs and non-PPE supplies and equipment.

    Nearly all providers rely on payments closely tied to fee-for-service models. When the COVID-19 pandemic struck the U.S. in March, patient volumes fell off a cliff, dragging down hospitals' revenue. The lack of fee-for-service revenue led many hospitals and group practices to lay off or furlough staff, slash office hours, cut pay, and delay or cancel investments, just as the crisis ramped up and the economy cratered.

    Congress passed a series of financial relief packages to make sure providers would be able to keep their doors open during the public health emergency. But many hospitals and group practices have had trouble getting hold of the money, and some of the funds are starting to dry up. If the federal government doesn't step up with more aid soon, hospitals and health systems will have to make more tough decisions.

    In the long term, providers may shift more of their business to value-based arrangements and take on added financial risk to stabilize their revenue streams and guard against future declines in patient volume, which have proven catastrophic. Providers that rely more heavily on capitation and other value-based arrangements report that their businesses have experienced less financial distress than those dependent on traditional fee-for-service payments.

    Experts say that while value-based payments aren't a cure-all solution, the pandemic has shown that volume-based payments aren't as safe as many providers thought.


  • 7 Jul 2020 9:46 PM | Matt Zavadsky (Administrator)

    This is important as the continuation of some of the innovations that have been implemented require a PHE being declared.

    The article mentions that the CMS waivers are actually authorized under the Presidential declaration of an emergency, activating the Stafford Act.  Some of us were concerned about the potential ‘expiration’ of either declaration.

    One of NAEMT’s Government Relations groups, Winning Strategies Washington, provides some commentary on that process that we’ve included in the section below the article.

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    HHS will renew public health emergency

    June 29, 2020 08:09 PM

    RACHEL COHRS

    https://www.modernhealthcare.com/government/hhs-will-renew-public-health-emergency

    HHS spokesperson Michael Caputo on Monday tweeted that HHS intends to extend the COVID-19 public health emergency that is set to expire on July 25.

    The extension would prolong the emergency designation by 90 days. Several payment policies and regulatory adjustments are attached to the public health emergency, so the extension is welcome news for healthcare providers.

    "[HHS] expects to renew the Public Health Emergency due to COVID-19 before it expires. We have already renewed this PHE once," Caputo said.

    Provider groups including the American Hospital Association have urged HHS to renew the distinction.

    Some notable policies attached to the public health emergency are the Medicare inpatient 20% add-on payment for COVID-19 patients, increased federal Medicaid matching rates, requirements that insurers cover COVID-19 testing without cost-sharing, and waivers of telehealth restrictions.

    Adjustments CMS made to the Medicare Shared Savings Program for accountable care organizations are also connected to the length of the public health emergency. The number of months the emergency lasts affects the amount of shared losses an ACO must pay back to CMS.

    Even if HHS maintains the public health emergency, some changes the Trump administration has made to help healthcare providers are also dependent on a separate Stafford Act national emergency declaration staying active. These changes include CMS Medicaid waivers that allow bypassing some prior authorization requirements, temporarily enrolling out-of-state providers, delivering care in alternative settings, and pausing fair hearing requests and appeal times.

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    From Winning Strategies:

    The National Emergency declared by the President does not have a set expiration. A national emergency issued pursuant to the NEA can be terminated by a subsequent presidential proclamation or by a joint resolution of Congress.

     

    Please see below a few more details in the situation. 

     

    Charla

     

    A top spokesman for HHS tweeted Monday night the department "expects to renew" the public health emergency for COVID-19 currently set to expire at the end of next month.

     

    HHS did not respond to requests for further comment Tuesday morning. No official statement from the department has addressed the issue, but the tweet from Michael Caputo uses the official account of the HHS assistant secretary for public affairs.

     

    Extending the emergency will allow providers to continue to use flexibilities and waivers meant to help them respond to the COVID-19 pandemic, including those that promote the use of telehealth and adjust requirements for CMS value-based payment models.

     

    There are two emergencies currently in effect:

    • The first one, a Public Health Emergency issued pursuant to Section 319 of the Public Health Services Act, is a Public Health Emergency initially issued by HHS Secretary Azar on January 31, 2020.   The PHS was extended by Secretary Azar on April 21, renewed effectively on April 26, 2020. This PHE is set to expire on July 25. 

     

    • The second one is the President's declaration under the National Emergencies Act pursuant to Section 501(b) of the Stafford Disaster Relief and Emergency Assistance Act, issued on March 13, 2020. But the National Emergency declared by the President does not have a set expiration. A national emergency issued pursuant to the NEA can be terminated by a subsequent presidential proclamation or by a joint resolution of Congress. https://www.lawfareblog.com/whats-trumps-national-emergency-announcement-covid-19

     

    The PHE declaration by the Secretary is not contingent on a Presidential NEA declaration.

     

    The question is what HHS related waivers are tied to which Emergency Declaration, Sec. Azar’s PHE or the President's NEA. 

    • The 1135 Medicaid waivers, both individual and blanket waivers, issued by HHS need BOTH the National Emergency and the Public Health Emergency declarations. 
    • The CARES Act had provisions about telehealth that are linked to the duration of the PHE.  So, some of the telehealth flexibilities are linked only to the PHE and others need both types of declaration to continue.
      • However, there is a special dispensation in the CARES statute that ties the telehealth-related waivers specifically to the public health emergency for Covid-19. (See (g)(1)(B) of SSA Section 1135).
      • Azar could probably keep extending the Covid-19 public health emergency declaration for 90-days at a time and keep the telehealth-related waivers in effect. The other 1135 waivers likely would expire if/when POTUS ends the national emergency declaration, but telehealth is a special case.
    • The NEA permits FEMA to provide assistance under Sections 502 and 503 of the Stafford Act, which describe the scope and amount of federal emergency assistance. The declaration also instructs the FEMA administrator to coordinate and direct other federal agencies in providing assistance under the Stafford Act.


  • 23 Jun 2020 9:14 AM | AIMHI Admin (Administrator)

    Fierce Healthcare Source Article | Comments Courtesy of Matt Zavadsky

    The same analysis could be applied to the EMS delivery model. 

    Many have shared a similar concern about the payer mix of the future!

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    Moody's: Patient volume recovered a bit in May, but providers face long road to recovery

    by Robert King | Jun 22, 2020

     

    https://www.fiercehealthcare.com/hospitals/moody-s-patient-volume-recovering-may-but-providers-face-long-road-to-recovery

    Patient volumes at hospitals, doctors' and dentists' offices recovered slightly in May but lagged well behind pre-pandemic levels, according to a new analysis from Moody’s Investors Service.

    In all, the ratings agency estimated total surgeries at rated for-profit hospitals declined by 55% to 70% in April compared with the same period in 2019. States required hospitals to cancel or delay elective procedures, which are vital to hospitals' bottom lines.

    “Patients that had been under the care of physicians before the pandemic will return first in order to address known health needs,” officials from the ratings agency said in a statement. “Physicians and surgeons will be motivated to extend office or surgical hours in order to accommodate these patients.”

    Those declines narrowed to 20% to 40% in May when compared to 2019.

    Emergency room and urgent care volumes were still down 35% to 50% in May.

    “This could reflect the prevalence of working-from-home arrangements and people generally staying home, which is leading to a decrease in automobile and other accidents outside the home,” the analysis said. “Weak ER volumes also suggest that many people remain apprehensive to enter a hospital, particularly for lower acuity care.”

    The good news:  The analysis estimated it is unlikely there will be a return to the nationwide decline of volume experienced in late March and April because healthcare facilities are more prepared for COVID-19.

    For instance, hospitals have enough personal protective equipment for staff and have expanded testing, the analysis said.

    For-profit hospitals also have “unusually strong liquidity to help them weather the effects of the revenue loss associated with canceled or postponed procedures,” Moody’s added. “That is largely due to the CARES Act and other government financial relief programs that have caused hospital cash balances to swell.”

    However, the bill for one of those sources of relief is coming due soon.

    Hospitals and other providers will have to start repaying Medicare for advance payments starting this summer. The Centers for Medicare & Medicaid Services doled out more than $100 billion in advance payments to providers before suspending the program in late April.

    Hospital group Federation of American Hospitals asked Congress to change the repayment terms for such advance payments, including giving providers at least a year to start repaying the loans.

    Another risk for providers is the change in payer mix as people lose jobs and commercial coverage, shifting them onto Medicaid or the Affordable Care Act’s (ACA's) insurance exchanges.

    “This will lead to rising bad debt expense and a higher percentage of revenue generated from Medicaid or [ACA] insurance exchange products, which typically pay considerably lower rates than commercial insurance,” Moody’s said.


  • 19 Jun 2020 8:42 AM | AIMHI Admin (Administrator)

    Niagara EMS is recruiting for the position of Deputy Chief! This is an exciting opportunity to join the leadership team of a progressive organization that is advancing the modernization of EMS to a Mobile Integrated Health service model. If this sounds interesting to you, read more and consider submitting your application today! 
    https://bit.ly/3d9KU4z

  • 18 Jun 2020 10:21 AM | AIMHI Admin (Administrator)

    Modern Healthcare source article | Comments courtesy of Matt Zavadsky

    Way to go Michigan! Model for other states?

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    Michigan Legislature approves $220M for frontline pandemic healthcare workers

    6/17/20

     

    https://www.modernhealthcare.com/safety-quality/coronavirus-outbreak-live-updates-covid-19

     

    (AP) The Michigan Legislature on Wednesday unanimously approved spending $880 million in federal relief aid in response to the coronavirus pandemic, setting aside funding for frontline workers, municipalities and child care providers.

     

    Democratic Gov. Gretchen Whitmer, whose administration was involved in negotiations, will sign it.

     

    The legislation includes $220 million to give pay raises to certain health workers ($2 an hour) and first responders (up to $1,000), $200 million to reimburse local governments for virus-related spending and $125 million to reduce child care costs.


  • 18 Jun 2020 10:01 AM | AIMHI Admin (Administrator)

    Modern Healthcare source article | Comments courtesy of Matt Zavadsky

    Interesting potential developments – the telemedicine waivers have helped a lot of EMS agencies bring innovation to their communities… May be a good opportunity for EMS to weigh in on EMS-specific interventions when the white paper is open for comment.

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    Senate health chair lays out two COVID-19 telehealth changes he wants permanent

    RACHEL COHRS  

    June 17, 2020

     

     

    Senate health committee Chair Lamar Alexander (R-Tenn.) said on Wednesday that he wants to make permanent two telehealth changes brought about by the COVID-19 pandemic: nixing the so-called originating site rule and expanding the scope of reimbursable services.

     

    Alexander laid out his wish list at a hearing on the issue scheduled weeks before lawmakers are expected to begin negotiations on another COVID-19 relief package.

     

    Pre-coronavirus policy dictated that patients had to live in a rural area and access telehealth services at a doctor's office or clinic. But because of temporary changes in response to the COVID-19 pandemic, patients can receive care anywhere in the country, and can be seen remotely from their homes.

     

    Alexander also indicated support for Medicare and Medicaid's expansion to cover nearly twice as many telehealth services. The temporary changes also allowed Federally Qualified Health Centers and Rural Health Clinics to use telehealth services.

     

    Many of the telehealth changes made on a temporary basis extend throughout the COVID-19 public health emergency. The current designation is scheduled to end in July, but it could be renewed.

     

    But Alexander said he doesn't support extending waivers for requirements under the Health Insurance Portability and Accountability Act, and didn't highlight pay parity as an issue of interest.

    Continue Reading►


  • 18 Jun 2020 9:48 AM | AIMHI Admin (Administrator)

    HealthAffairs Source Article | Comments Courtesy of Matt Zavadsky

    Interesting ‘Fast Track’ study released yesterday in Health Affairs as communities consider mandating face masks. 

    Enforcement can be a little ‘thorny’.  The Center for Public Safety Management recently published an article for ICMA on that topic.

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    Community Use Of Face Masks And COVID-19: Evidence From A Natural Experiment Of State Mandates In The US

    Wei Lyu and George L. Wehby

    JUNE 16, 2020

     

    https://www.healthaffairs.org/doi/10.1377/

     

    CONCLUSION

    The study provides evidence that states in the US mandating use of face masks in public had a greater decline in daily COVID-19 growth rates after issuing these mandates compared to states that did not issue mandates. These effects are observed conditional on other existing social distancing measures and are independent of the CDC recommendation to wear facial covers issued on April 3. As countries worldwide and states begin to relax social distancing restrictions and considering the high likelihood of a second COVID-19 wave in the fall/winter,30 requiring use of face masks in public might help in reducing COVID-19 spread.

     

    ABSTRACT

    State policies mandating public or community use of face masks or covers in mitigating novel coronavirus disease (COVID-19) spread are hotly contested. This study provides evidence from a natural experiment on effects of state government mandates in the US for face mask use in public issued by 15 states plus DC between April 8 and May 15. The research design is an event study examining changes in the daily county-level COVID-19 growth rates between March 31, 2020 and May 22, 2020. Mandating face mask use in public is associated with a decline in the daily COVID-19 growth rate by 0.9, 1.1, 1.4, 1.7, and 2.0 percentage-points in 1–5, 6–10, 11–15, 16–20, and 21+ days after signing, respectively. Estimates suggest as many as 230,000–450,000 COVID-19 cases possibly averted By May 22, 2020 by these mandates. The findings suggest that requiring face mask use in public might help in mitigating COVID-19 spread. [Editor’s Note: This Fast Track Ahead Of Print article is the accepted version of the peer-reviewed manuscript. The final edited version will appear in an upcoming issue of Health Affairs.]

     Continue Reading►


  • 15 Jun 2020 10:13 AM | AIMHI Admin (Administrator)

    CNN Health / Kaiser Health News Source Article | Comments Courtesy of Matt Zavadsky

    Hats off to everyone helping to keep our communities safe on the front lines!

    An added challenge for local EMS agencies is that often, ‘sponsoring’ organizations use freelance EMS personnel without coordinating with the local EMS agency.  This may cause confusion on-scene.

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    No 'rule book' for EMTs responding to protests amid a pandemic

    By Carmen Heredia Rodriguez, Kaiser Health News

    Mon June 15, 2020

     

     

    (Kaiser Health News)  Emergency medical services across the country, already burdened by the high demands of Covid-19, have faced added pressure in the past week as they responded to protests ignited by the death of George Floyd in the custody of Minneapolis police.

    The need to protect themselves against the coronavirus adds another complication to emergency crews' efforts in these dangerous conditions. Their personal protective equipment (PPE) can be difficult to wear in a crowd, said emergency medical services officials. Plus, switching from that gear to equipment needed to shield medics from bullets, rocks or tear gas can be challenging.

    Brent Stevenson, assistant chief of the Denver Health Paramedic Division, said facing a protest and a pandemic at once is uncharted territory.

    "I don't think there was a rule book for me really to figure out what we're gonna do," he said.

    In addition, many crews must overcome the fatigue caused by months of fighting Covid-19. In Dallas, some senior-level EMS officers have worked every day for the past several weeks, said EMS deputy chief Tami Kayea.

    First responders are trained to handle emergencies in large events. And even though many protesters have assembled peacefully, the size and mobility of last week's protests surprised EMS officials in some cities.

    "Any large gathering of people is unpredictable in nature, because it's just people," said Sean Larkins, superintendent of emergency medical services in Detroit. "You just never know what could happen."

    An added consideration is how to distinguish themselves from the police and deflect any crowd hostility, several EMS officials said. In Oakland, California, the word "medic" is printed on the vests, said the private ambulance shift commander.

    Continue reading►

  • 12 Jun 2020 9:52 AM | AIMHI Admin (Administrator)

    Study by Northwell Health | Comments Courtesy of Matt Zavadsky

    Very nice pre-publication copy of a study from the team at Northwell about the impact of video vs. audio consultations for ED alternatives during Community Paramedic visits.

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    Video or Telephone? A Natural Experiment on the Added Value of Video Communication in Community Paramedic Responses

    Karen A. Abrashkin, MD*; Jonathan D. Washko, MBA; Timmy Li, PhD; Jonathan Berkowitz, MD; Asantewaa Poku, MPH; Jenny Zhang, BS; Kristofer L. Smith, MD, MPP; Karin V. Rhodes, MD, MS

     

    Study objective: The objective of this study was to determine the effect of video versus telephonic communication between community paramedics and online medical control physicians on odds of patient transport to a hospital emergency department (ED).

     

    Methods: This was a retrospective analysis of data from a telemedicine-capable community paramedicine program operating within an advanced illness management program that provides home-based primary care to approximately 2,000 housebound patients per year who have advanced medical illness, multiple chronic conditions, activities of daily living dependencies, and past year hospitalizations. Primary outcome was difference in odds of ED transport between community paramedicine responses with video communication versus those with telephonic communication. Secondary outcomes were physicians’ perception of whether video enhanced clinical evaluation and whether perceived enhancement affected ED transport.

     

    Results: Of 1,707 community paramedicine responses between 2015 and 2017, 899 (53%) successfully used video; 808 (47%) used telephonic communication. Overall, 290 patients (17%) were transported to a hospital ED. In the adjusted regression model, video availability was not associated with a significant difference in the odds of ED transport (odds ratio 0.80; 95% confidence interval 0.62 to 1.03). Online medical control physicians reported that video enhanced clinical evaluation 85% of the time, but this perception was not associated with odds of ED transport.

     

    ConclusionWe found support that video is considered an enhancement by physicians overseeing a community Paramedicine response, but is not associated with a statistically significant difference in transport to the ED compared with telephonic communication in this nonrandom sample. These results have implications for new models of out-of-hospital care that allow patients to be evaluated and treated in the home. [Ann Emerg Med. 2020;-:1-7.]

    Download Pre-Print Study►

  • 8 Jun 2020 3:31 PM | AIMHI Admin (Administrator)

    CDC Source Article | Comments Courtesy of Matt Zavadsky

    Sounds a lot like the EMS 9-1-1 response volume decrease?!

    Interesting recommendations at the end.

    Full report, with charts and graphs, attached.

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    Impact of the COVID-19 Pandemic on Emergency Department Visits — United States, January 1, 2019–May 30, 2020

    Early Release / June 3, 2020 / 69

     

    https://www.cdc.gov/mmwr/volumes/69/wr/mm6923e1.htm?s_cid=mm6923e1_w

     

    Summary

    What is already known about this topic?

    The National Syndromic Surveillance Program (NSSP) collects electronic health data in real time.

     

    What is added by this report?

    NSSP found that emergency department (ED) visits declined 42% during the early COVID-19 pandemic, from a mean of 2.1 million per week (March 31–April 27, 2019) to 1.2 million (March 29–April 25, 2020), with the steepest decreases in persons aged ≤14 years, females, and the Northeast. The proportion of infectious disease–related visits was four times higher during the early pandemic period.

     

    What are the implications for public health practice?

    To minimize SARS-CoV-2 transmission risk and address public concerns about visiting the ED during the pandemic, CDC recommends continued use of virtual visits and triage help lines and adherence to CDC infection control guidance.

     

    On March 13, 2020, the United States declared a national emergency to combat coronavirus disease 2019 (COVID-19). As the number of persons hospitalized with COVID-19 increased, early reports from Austria (1), Hong Kong (2), Italy (3), and California (4) suggested sharp drops in the numbers of persons seeking emergency medical care for other reasons. To quantify the effect of COVID-19 on U.S. emergency department (ED) visits, CDC compared the volume of ED visits during four weeks early in the pandemic March 29–April 25, 2020 (weeks 14 to 17; the early pandemic period) to that during March 31–April 27, 2019 (the comparison period). During the early pandemic period, the total number of U.S. ED visits was 42% lower than during the same period a year earlier, with the largest declines in visits in persons aged ≤14 years, females, and the Northeast region. Health messages that reinforce the importance of immediately seeking care for symptoms of serious conditions, such as myocardial infarction, are needed. To minimize SARS-CoV-2, the virus that causes COVID-19, transmission risk and address public concerns about visiting the ED during the pandemic, CDC recommends continued use of virtual visits and triage help lines and adherence to CDC infection control guidance.

     

    To assess trends in ED visits during the pandemic, CDC analyzed data from the National Syndromic Surveillance Program (NSSP), a collaborative network developed and maintained by CDC, state and local health departments, and academic and private sector health partners to collect electronic health data in real time. The national data in NSSP includes ED visits from a subset of hospitals in 47 states (all but Hawaii, South Dakota, and Wyoming), capturing approximately 73% of ED visits in the United States able to be analyzed at the national level. During the most recent week, 3,552 EDs reported data. Total ED visit volume, as well as patient age, sex, region, and reason for visit were analyzed.

     

    Weekly number of ED visits were examined during January 1, 2019–May 30, 2020. In addition, ED visits during two 4-week periods were compared using mean differences and ratios. The change in mean visits per week during the early pandemic period and the comparison period was calculated as the mean difference in total visits in a diagnostic category between the two periods, divided by 4 weeks ([visits in diagnostic category {early pandemic period} – visits in diagnostic category {comparison period}]/4). The visit prevalence ratio (PR) was calculated for each diagnostic category as the proportion of ED visits during the early pandemic period divided by the proportion of visits during the comparison period ([visits in category {early pandemic period}/all visits {early pandemic period}]/[visits in category {comparison period}/all visits {comparison period}]). All analyses were conducted using R software (version 3.6.0; R Foundation).

     

    Reason for visit was analyzed using a subset of records that had at least one specific, billable International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) code. In addition to Hawaii, South Dakota, and Wyoming, four states (Florida, Louisiana, New York outside New York City, and Oklahoma), two California counties reporting to the NSSP (Santa Cruz and Solano), and the District of Columbia were also excluded from the diagnostic code analysis because they did not report diagnostic codes during both periods or had differences in completeness of codes between 2019 and 2020. Among eligible visits for the diagnostic code analysis, 20.3% without a valid ICD-10-CM code were excluded. ED visits were categorized using the Clinical Classifications Software Refined tool (version 2020.2; Healthcare Cost and Utilization Project), which combines ICD-10-CM codes into clinically meaningful groups (5). A visit with multiple ICD-10-CM codes could be included in multiple categories; for example, a visit by a patient with diabetes and hypertension would be included in the category for diabetes and the category for hypertension. Because COVID-19 is not yet classified in this tool, a custom category, defined as any visit with the ICD-10-CM code for confirmed COVID-19 diagnosis (U07.1), was created (6). The analysis was limited to the top 200 diagnostic categories during each period.

     

    The lowest number of visits reported to NSSP occurred during April 12–18, 2020 (week 16). Although visits have increased since the nadir, the most recent complete week (May 24–30, week 22) remained 26% below the corresponding week in 2019 (Figure 1). The number of ED visits decreased 42%, from a mean of 2,099,734 per week during March 31–April 27, 2019, to a mean of 1,220,211 per week during the early pandemic period of March 29–April 25, 2020. Visits declined for every age group (Figure 2), with the largest proportional declines in visits by children aged ≤10 years (72%) and 11–14 years (71%). Declines in ED visits varied by U.S. Department of Health and Human Services region,* with the largest declines in the Northeast (Region 1, 49%) and in the region that includes New Jersey and New York (Region 2, 48%) (Figure 2). Visits declined 37% among males and 45% among females across all NSSP EDs between the comparison and early pandemic periods.

     

    Among all ages, an increase of >100 mean visits per week from the comparison period to the early pandemic period occurred in eight of the top 200 diagnostic categories (Table). These included 1) exposure, encounters, screening, or contact with infectious disease (mean increase 18,834 visits per week); 2) COVID-19 (17,774); 3) other general signs and symptoms (4,532); 4) pneumonia not caused by tuberculosis (3,911); 5) other specified and unspecified lower respiratory disease (1,506); 6) respiratory failure, insufficiency, or arrest (776); 7) cardiac arrest and ventricular fibrillation (472); and 8) socioeconomic or psychosocial factors (354). The largest declines were in visits for abdominal pain and other digestive or abdomen signs and symptoms (–66,456), musculoskeletal pain excluding low back pain (–52,150), essential hypertension (–45,184), nausea and vomiting (–38,536), other specified upper respiratory infections (–36,189), sprains and strains (–33,709), and superficial injuries (–30,918). Visits for nonspecific chest pain were also among the top 20 diagnostic categories for which visits decreased (–24,258). Although not in the top 20 declining diagnoses, visits for acute myocardial infarction also declined (–1,156).

     

    During the early pandemic period, the proportion of ED visits for exposure, encounters, screening, or contact with infectious disease compared with total visits was nearly four times as large as during the comparison period (Table) (prevalence ratio [PR] = 3.79, 95% confidence interval [CI] = 3.76–3.83). The other diagnostic categories with the highest proportions of visits during the early pandemic compared with the comparison period were other specified and unspecified lower respiratory disease, which did not include influenza, pneumonia, asthma, or bronchitis (PR = 1.99; 95% CI = 1.96–2.02), cardiac arrest and ventricular fibrillation (PR = 1.98; 95% CI = 1.93–2.03), and pneumonia not caused by tuberculosis (PR = 1.91; 95% CI = 1.90–1.93). Diagnostic categories that were recorded less commonly during the early pandemic period included influenza (PR = 0.16; 95% CI = 0.15–0.16), no immunization or underimmunization (PR = 0.28; 95% CI = 0.27–0.30), otitis media (PR = 0.35; 95% CI = 0.34–0.36), and neoplasm-related encounters (PR = 0.40; 95% CI = 0.39–0.42).

     

    In the 2019 comparison period, 12% of all ED visits were in children aged ≤10 years old, compared with 6% during the early pandemic period. Among children aged ≤10 years, the largest declines were in visits for influenza (97% decrease), otitis media (85%), other specified upper respiratory conditions (84%), nausea and vomiting (84%), asthma (84%), viral infection (79%), respiratory signs and symptoms (78%), abdominal pain and other digestive or abdomen symptoms (78%), and fever (72%). Mean weekly visits with confirmed COVID-19 diagnoses and screening for infectious disease during the early pandemic period were lower among children than among adults. Among all ages, the diagnostic categories with the largest changes (abdominal pain and other digestive or abdomen signs and symptoms, musculoskeletal pain, and essential hypertension) were the same in males and females, but declines in those categories were larger in females than males. Females also had large declines in visits for urinary tract infections (–19,833 mean weekly visits).

     

    Discussion

    During an early 4-week interval in the COVID-19 pandemic, ED visits were substantially lower than during the same 4-week period during the previous year; these decreases were especially pronounced for children and females and in the Northeast. In addition to diagnoses associated with lower respiratory disease, pneumonia, and difficulty breathing, the number and ratio of visits (early pandemic period versus comparison period) for cardiac arrest and ventricular fibrillation increased. The number of visits for conditions including nonspecific chest pain and acute myocardial infarction decreased, suggesting that some persons could be delaying care for conditions that might result in additional mortality if left untreated. Some declines were in categories including otitis media, superficial injuries, and sprains and strains that can often be managed through primary or urgent care. Future analyses will help clarify the proportion of the decline in ED visits that were not preventable or avoidable such as those for life-threatening conditions, those that were manageable through primary care, and those that represented actual reductions in injuries or illness attributable to changing activity patterns during the pandemic (such as lower risks for occupational and motor vehicle injuries or other infectious diseases).

     

    The striking decline in ED visits nationwide, with the highest declines in regions where the pandemic was most severe in April 2020, suggests that the pandemic has altered the use of the ED by the public. Persons who use the ED as a safety net because they lack access to primary care and telemedicine might be disproportionately affected if they avoid seeking care because of concerns about the infection risk in the ED.

     

    Syndromic surveillance has important strengths, including automated electronic reporting and the ability to track outbreaks in real time (7). Among all visits, 74% are reported within 24 hours, with 75% of discharge diagnoses typically added to the record within 1 week.

     

    The findings in this report are subject to at least four limitations. First, hospitals reporting to NSSP change over time as facilities are added, and more rarely, as they close (8). An average of 3,173 hospitals reported to NSSP nationally in April 2019, representing an estimated 66% of U.S. ED visits, and an average of 3,467 reported in April 2020, representing 73% of ED visits. Second, diagnostic categories rely on the use of specific codes, which were missing in 20% of visits and might be used inconsistently across hospitals and providers, which could result in misclassification. The COVID-19 diagnosis code was introduced recently (April 1, 2020) and timing of uptake might have differed across hospitals (6). Third, NSSP coverage is not uniform across or within all states; in some states nearly all hospitals report, whereas in others, a lower proportion statewide or only those in certain counties report. Finally, because this analysis is limited to ED visit data, the proportion of persons who did not visit EDs but received treatment elsewhere is not captured.

     

    Health care systems should continue to address public concern about exposure to SARS-CoV-2 in the ED through adherence to CDC infection control recommendations, such as immediately screening every person for fever and symptoms of COVID-19, and maintaining separate, well-ventilated triage areas for patients with and without signs and symptoms of COVID-19 (9). Wider access is needed to health messages that reinforce the importance of immediately seeking care for serious conditions for which ED visits cannot be avoided, such as symptoms of myocardial infarction. Expanded access to triage telephone lines that help persons rapidly decide whether they need to go to an ED for symptoms of possible COVID-19 infection and other urgent conditions is also needed. For conditions that do not require immediate care or in-person treatment, health care systems should continue to expand the use of virtual visits during the pandemic (10).

     


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