Cleveland Clinic Data Bolster Trends of Plummeting Demand for Emergency Care in COVID-19 Pandemic

During the first two months after a state of emergency was declared in Ohio for the COVID-19 pandemic, Cleveland Clinic health system experienced substantial reductions in critical care transfers of patients for acute cardiac, neurological and vascular conditions. This finding, reported online in Circulation: Cardiovascular Quality and Outcomes, supplements growing evidence that people in the U.S. and other nations appear to be avoiding seeking essential medical care during the pandemic.

“Even hospitals with normal capability to handle non-COVID-19 emergency care are seeing that patients appear to be reluctant to come in, even for life-threatening conditions,” says the study’s lead author, Umesh Khot, MD, Head of Regional Cardiovascular Medicine at Cleveland Clinic.

Emergency transfers down by nearly 40%

The study analyzed daily emergency transfer volume to Cleveland Clinic for patients experiencing three categories of conditions:

• ST-elevation myocardial infarction (STEMI)
• Acute stroke
• Aortic emergencies (aortic dissection and acute abdominal aortic aneurysm)

Data from the earliest weeks of the pandemic (March 9, 2020, to May 6, 2020; “pandemic period”) were compared with data from three different baseline periods defined in relation to the declaration of Ohio’s state of emergency on March 9, 2020:

• January 1, 2019, to March 8, 2020 (first baseline)
• March 9, 2019, to May 6, 2019 (second baseline, which served as prior-year comparator)
• January 1, 2020, to March 8, 2020 (third baseline)

Analysis showed that mean daily transfer volume for the three emergency conditions significantly declined during the pandemic period relative to each of the baseline periods, as follows (all P < 0.001):

• 39% reduction from first baseline period
• 38% reduction from second baseline period
• 44% reduction from third baseline period

In absolute numbers, mean daily transfers fell from 4.2 ± 2.2 in the first baseline period to 2.5 ± 1.5 in the pandemic period.

Subgroup analysis was conducted to look at reductions in transfer volumes for each of the emergency conditions; declines from the first baseline period to the pandemic period were as follows:

• 48% for STEMI (P < 0.001)
• 39% for stroke (P < 0.001)
• 21% for aortic emergencies (P = 0.258)

What explains the findings?

The researchers note that these reductions came despite a lack of changes in the process for emergency transfers on behalf of either Cleveland Clinic or the originating emergency departments and hospitals. They add that the findings are especially notable because they come from a region — Northeast Ohio — that was not intensely impacted by COVID-19 during the early months of the pandemic.

“Why are we seeing these trends?” asks Dr. Khot. “People might be afraid of being exposed to the SARS-CoV-2 virus at the hospital, or they may not know that care is available for them.”

He adds that while it’s possible there was a true decline in the incidence of the conditions studied — perhaps due to decreased stress from people staying home from work, reduced air pollution or reduced infection with influenza due to social distancing — evidence of excess numbers of patients found dead at home in New York City and Italy during the pandemic makes it unlikely that the trends can fully be explained this way.

Additional stroke-specific insights

Study co-author Shazam Hussain, MD, Director of Cleveland Clinic’s Cerebrovascular Center, notes that a separate stroke-specific study conducted by his group, just published online in Stroke, may add insight on this question. The Cerebrovascular Center researchers observed a decrease of approximately 30% in the rate of acute stroke presentations at Cleveland Clinic emergency departments in Northeast Ohio during the first three and a half weeks after Ohio’s March 9 emergency declaration relative to the prior 10-week period. However, a number of key variables, including stroke severity and time from symptom onset to presentation, did not differ between the pandemic and pre-pandemic periods. This has led to speculation that there has been a decrease in stroke incidence.

“It is possible that a true decline in incidence might have occurred,” says Dr. Hussain, “but we have seen a number of patients coming in late after the start of their stroke, and we are dealing with the complications of that. Earlier treatment improves outcomes, so these delays in seeking care can be devastating.”

Cleveland Clinic Cardiovascular Medicine Chair Samir Kapadia, MD, a co-author of the Circulation: Cardiovascular Quality and Outcomes study, concurs. “While it’s too soon to draw absolute conclusions about the specific reasons behind the declines in emergency transfers,” says Dr. Kapadia, “these findings highlight the importance of getting the word out to the public that people still need to promptly seek care during the pandemic for an emergency, such as for chest pain or stroke symptoms.”