Abstract

Emergency department (ED) and emergency medical services (EMS) volumes decreased during the COVID-19 pandemic, but the amount attributable to voluntary refusal vs effects of the pandemic and public health restrictions is unknown. To examine the factors associated with EMS refusal in relation to COVID-19 cases, public health interventions, EMS responses, and prehospital deaths. A retrospective cohort study was conducted in Detroit, Michigan, from March 1 to June 30, 2020. Emergency medical services responses geocoded to Census tracts were analyzed by individuals' age, sex, date, and community resilience using the Centers for Disease Control and Prevention Social Vulnerability Index. Response counts were adjusted with Poisson regression, and odds of refusals and deaths were adjusted by logistic regression. A COVID-19 outbreak characterized by a peak in local COVID-19 incidence and the strictest stay-at-home orders to date, followed by a nadir in incidence and broadly lifted restrictions. Multivariable-adjusted difference in 2020 vs 2019 responses by incidence rate and refusals or deaths by odds. The Social Vulnerability Index was used to capture community social determinants of health as a risk factor for death or refusal. The index contains 4 domain subscores; possible overall score is 0 to 15, with higher scores indicating greater vulnerability. A total of 80 487 EMS responses with intended ED transport, 2059 prehospital deaths, and 16 064 refusals (62 636 completed EMS to ED transports) from 334 Census tracts were noted during the study period. Of the cohort analyzed, 38 621 were women (48%); mean (SD) age was 49.0 (21.4) years, and mean (SD) Social Vulnerability Index score was 9.6 (1.6). Tracts with the highest per-population EMS transport refusal rates were characterized by higher unemployment, minority race/ethnicity, single-parent households, poverty, disability, lack of vehicle access, and overall Social Vulnerability Index score (9.6 vs 9.0, P = .002). At peak COVID-19 incidence and maximal stay-at-home orders, there were higher total responses (adjusted incident rate ratio [aIRR], 1.07; 1.03-1.12), odds of deaths (adjusted odds ratio [aOR], 1.60; 95% CI, 1.20-2.12), and refusals (aOR, 2.33; 95% CI, 2.09-2.60) but fewer completed ED transports (aIRR, 0.82; 95% CI, 0.78-0.86). With public health restrictions lifted and the nadir of COVID-19 cases, responses (aIRR, 1.01; 0.97-1.05) and deaths (aOR, 1.07; 95% CI, 0.81-1.41) returned to 2019 baselines, but differences in refusals (aOR, 1.27; 95% CI, 1.14-1.41) and completed transports (aIRR, 0.95; 95% CI, 0.90-0.99) remained. Multivariable-adjusted 2020 refusal was associated with female sex (aOR, 2.71; 95% CI, 2.43-3.03 in 2020 at the peak; aOR 1.47; 95% CI, 1.32-1.64 at the nadir). In this cohort study, EMS transport refusals increased with the COVID-19 outbreak's peak and remained elevated despite receding public health restrictions, COVID-19 incidence, total EMS responses, and prehospital deaths. Voluntary refusal was associated with decreased EMS transports to EDs, disproportionately so among women and vulnerable communities.

Highlights

  • Since the March 2020 declaration of a national emergency for the COVID-19 pandemic in the US, multiple reports have described reduced emergency health care use compared with previous years.[1,2,3,4,5] Emergency department (ED) visits decreased 42% nationwide by May 2020 and remained decreased by more than 20% in the fall of 2020,1,2,6 despite increased visits for mental health and substance abuse.[7]

  • At peak COVID-19 incidence and maximal stay-athome orders, there were higher total responses, odds of deaths, and refusals but fewer completed ED transports

  • With public health restrictions lifted and the nadir of COVID-19 cases, responses and deaths returned to 2019 baselines, but differences in refusals and completed transports remained

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Summary

Introduction

Since the March 2020 declaration of a national emergency for the COVID-19 pandemic in the US, multiple reports have described reduced emergency health care use compared with previous years.[1,2,3,4,5] Emergency department (ED) visits decreased 42% nationwide by May 2020 and remained decreased by more than 20% in the fall of 2020,1,2,6 despite increased visits for mental health and substance abuse.[7] Intensive care units in New York City saw decreasing volumes of patients with stroke, heart failure, and myocardial infarction[8] in the spring of 2020, and excess community deaths attributable to the pandemic simultaneously increased to more than 5000 in just 2 months.[9] Emergency department visits for myocardial infarctions and strokes[1,2] have decreased by more than 20%. The degrees to which care avoidance vs prehospital death contribute to pandemic-era EMS volume is obscured by multiple potentially confounding factors

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