Researchers: Lowered Inpatient Admission Rates Might Reflect Patient Fears, Could Pose Public Health Concerns

Researchers are still attempting to understand the precise impact of the COVID-19 pandemic on hospital admissions in the U.S. healthcare system. Now, published as an “ahead-of-print” article online in Health Affairs on Sep. 24, a team of healthcare researchers has looked at a variety of issues involved in non-COVID admissions, in the wake of the COVID-19 pandemic. The article, entitled “The Impact Of The COVID-19 Pandemic on Hospital Admissions In The United States,” was authored by John D. Birkmeyer, Amber Barnato, Nancy Birkmeyer, Robert Bessler, and Jonathan Skinner. It appears that patients may be avoiding even needed hospital-based care at this time, probably out of fear of infection; and the article’s authors express concern that public health may suffer as a result.

In their article, Birkmeyer et al write that “Hospital admissions fell precipitously with the declaration of the coronavirus disease 2019 (COVID-19) pandemic, with several reports of hospitals operating at less than 50 percent capacity. Volumes fell in part because hospitals purposefully curtailed elective surgery and other non-critical medical services. But hospitals have also reported puzzling declines in admissions for acute medical illness, including stroke and acute myocardial infarction. In addition to their implications for hospital solvency,” the researchers write “falling hospitalization rates could portend substantial harm to public health if patients defer care for life-threatening conditions. Early evidence on how the first wave of the COVID-19 pandemic has affected US hospital admissions has thus far been limited to individual hospital systems, Veterans Affairs patients, or elderly patients participating in bundled payment programs. Much less is known about variations in admissions by age, insurance coverage, and sociodemographic group in this initial period of decline and during the first ‘rebound’ in health care utilization in June/July 2020. Given the widespread uncertainty, public anxiety, stay-at-home orders and other restrictions imposed during the initial phase of the pandemic, patients  with acute medical illness, life threatening or not, stayed home out of fear of contagion or concerns about access at COVID-19-overrun hospitals.13 We also sought to gain insights on the extent to which patients continued to avoid hospital care as the first phase of the pandemic receded after April, restrictions eased, and businesses opened in many states.”

The researchers looked at data on a nationwide basis and also extrapolated from data obtained from the database of Sound Physicians in Tacoma, Washington, where two of the researchers work. Looking at the decline in inpatient admissions so far during the pandemic, they write that “The most plausible explanation for the broad-based declines in medical admissions is that patients avoided seeking hospital care, perhaps in response to fear of contagion arising from media reports, or as a result of state stay-at-home orders. Conversely,” they state, “our results do not suggest access challenges at hospitals overrun with COVID19 patients as a major reason for admission declines. Even among hospitals experiencing a minimal impact from COVID-19 admissions, non-COVID-19 medical admissions fell by 39.5 percent; for hospitals with the greatest COVID19 impact, non-COVID-19 admissions fell by 50.0 percent.”

Meanwhile, the researchers write, “ A second, more surprising finding of this analysis is that during the Nadir period, admission declines varied only modestly by patient demographic factors, including insurance status and minority and income characteristics of the areas in which patients live. The relatively uniform April 2020 declines in admissions across patient demographic groups may reflect offsetting factors. For example, relatively advantaged populations may have greater access to ambulatory care resources for safely deferring hospital-based care, including telemedicine services, which increased dramatically during the pandemic. Alternatively, our largely null findings in this regard may simply reflect that the pandemic affected patient decision-making in a powerful, universal way that trumped the usual determinants of health care utilization. During the April Nadir, non-COVID-19 admissions declined less for patients with some acute medical conditions than others. In our analysis,

the three medical conditions for which nonCOVID-19 admissions declined the least were stroke, altered mental status, and pancreatitis—conditions generally associated with new or severe symptoms not easily ignored or effectively managed at home. Our findings in this regard are consistent with a study during the SARS epidemic which reported that admission rates in Canadian hospitals fell less for acute, life-threatening illnesses than for less urgent conditions. By the rebound, non-COVID-19 medical admission volumes had returned to within 16 percent of baseline overall, although admissions for non-COVID-19 pneumonia, COPD/asthma, and sepsis remained well below pre-pandemic baselines.”

Importantly, the researchers find that “These findings are consistent with broader studies that suggest the discretionary nature and elasticity of admission decisions in patients with certain medical conditions. Less consistent with the elasticity view is the continued lower admissions for STEMI and stroke, generally considered to be acute non-discretionary admissions.”

Meanwhile, the researchers write, “Although we expected illness severity in non-COVID-19 medical admissions to increase as less sick patients avoided the hospital, in-hospital mortality in patients without COVID-19 increased only modestly during the nadir of medical admissions in April, before returning to pre-COVID-19 levels in June. Largely flat mortality rates imply that the total number of in-hospital deaths for non-COVID-19 medical conditions declined by nearly the same degree as admissions.”

Their conclusion? “Our results provide empirical support for concerns about the broad public health impact of the pandemic on non-COVID-19 populations. Some medical conditions (e.g., stroke, STEMI) require effective hospital treatment to avoid adverse outcomes; therefore fewer hospitalizations for such medical conditions are almost certainly associated with patient harm. Health system leaders and public health authorities should be focusing on how best to ensure that patients with conditions that require hospital care obtain it during the pandemic. Where the impact of hospital-based care is less clear, however, longer-term studies will be needed to determine the extent to which avoiding hospitalization during the pandemic may affect patient mortality, morbidity, and quality of life.”

John D. Birkmeyer is chief clinical officer of Sound Physicians, Tacoma, Wash.; Amber Barnato is a professor at the Dartmouth Institute for Health Policy and Clinical Practice in the Geisel School of Medicine, Lebanon, N.H.; Nancy Birkmeyer is principal research scientist at the Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, N.H.; Robert Bessler is CEO and founder of Sound Physicians; Jonathan Skinner is a professor at the Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine.