Decreased Emergency Department Utilization by Lower Socioeconomic Status Population as a Result of the COVID-19 Pandemic




Plumber, Arifa

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BACKGROUND: The SARS-CoV-2 (virus which causes COVID-19) pandemic has resulted in lower emergency department (ED) volumes. It precipitated business and school closures along with the implementation of physical distancing measures, which culminated in a Shelter-in-Place Order (SIPO) issued for a major urban area county in March 2020. OBJECTIVE: The objective of this study was to determine the effect of the COVID-19 pandemic on access to health care by patients of different socioeconomic status by examining differences in ED volume by zip code stratified by the SocioNeeds Index, a measure of socioeconomic need correlated with poor health outcomes. Our hypothesis was that decrease in patient visits due to the SIPO was not uniform across Dallas County but was based on socioeconomic need and proximity to Parkland's ED. METHODS: This retrospective chart review examines whether there was a quantitative change in patient visits to an urban, tertiary county hospital (Parkland or PMH) ED from 2019-2020 by zip code. The inclusion criterion was any ED visit from a patient with a zip code within Dallas County, and the exclusion criterion was any blank, alphanumeric, or PO box zip codes including zip codes located outside of Dallas County. The SocioNeeds Index, which rates each zip code by demographic factors relative to others in the county, was used as a proxy for the socioeconomic status of residents of each zip code. We mapped daily patient visits by zip code for four phases: Phase 1 was the three months preceding the first COVID-19 case's announcement in Dallas, Phase 2 began with the first COVID case, Phase 3 encompassed when the SIPO was in effect for Dallas County, and Phase 4 comprised the three months following the expiration of the SIPO. We compared this data to records over the same time period from the previous year to control for seasonal variation in the absence of a pandemic. RESULTS: There were 275,756 ED patient visits included in this study. We identified a statistically significant decrease in ED visits among patients from all zip codes during the pandemic: 24% between Phase 1 and 4 (p<0.0001) in 2020. Additionally, there was a decrease in visits after the first case in Dallas: Phase 2 (-14%, p<0.0001), Phase 3 (-41%, p<0.0001) and Phase 4 (-25%, p<0.0001) when compared to 2019 but an increase in visits (36%, p< 0.0001) in 2020 once the SIPO expired. Zip codes with highest SNI ranks (highest needs communities) were found to have greater reductions in visits during the SIPO and more sluggish recoveries after the expiration of the SIPO in comparison to those zip codes with the lowest needs. An examination of the geographic distribution of self-reported zip codes indicated that most communities in Dallas County saw a reduction in patient visits over Phases 2 and 3 (especially zip codes further from the ED) and an increase in visits during Phase 4 although not to pre-pandemic values. These changes, however, were not uniform across the county and were tied to socioeconomic factors and proximity of residence to PMH. CONCLUSION: Our hypothesis was supported by the results obtained: a significant decrease in ED visits was observed during the pandemic relative to a non-pandemic year among patients in most zip codes except those with the highest socioeconomic status, suggesting that the threat of the virus and SIPO deterred patients disproportionately from the higher socioeconomic needs communities from accessing healthcare. These results could have implications for future pandemic public health messaging and targeted outreach to communities with barriers to healthcare access.

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