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Non-COVID Hospital Admissions Plunged, Still Down in Pandemic

Marcia Frellick
September 30, 2020

Acute medical hospital admissions for non-COVID-19 patients fell sharply with the spread of COVID-19 in March and April 2020, according to an analysis of more than 1 million admissions in a nationally representative hospitalist group.

Specifically, non-COVID admissions were down 42.8% at the height of the pandemic (95% CI, -43.2 to -42.4), report John Birkmeyer, MD, chief clinical officer for Sound Physicians in Tacoma, Washington, and colleagues. Admissions increased in June and July, but were still down by 15.9% (95% CI, -16.5 to -15.4) relative to baseline.

As of a few weeks ago, non-COVID admissions remained down by 14%, Birkmeyer said in an interview with Medscape Medical News.

When extrapolated to all hospital admissions, the decline represents "about 2.5 million fewer Americans being admitted to the hospital for acute medical illness every year in the US," Birkmeyer said.

Birkmeyer and colleagues published their findings online September 24 in Health Affairs.

Declines Vary by Region, Population

Non-COVID-19 admissions were greatest among patients residing in Hispanic neighborhoods, with a 32% drop from baseline for all conditions.

When stratified by medical condition, the authors found that admissions remain well below normal levels for patients with pneumonia (-44.1%), chronic obstructive pulmonary disease/asthma (-40.1%), sepsis (-25.1%), urinary tract infection (-24.3%), and acute ST-elevation myocardial infarction, (-22.2%). By contrast, non-COVID admissions for alcohol-related conditions, pancreatitis, and diabetes had returned to baseline levels by June and July.

Admissions declined in all patient groups defined by age, race and ethnicity, Medicaid and self-pay status, and income, according to the study.

The authors suggest three plausible explanations for the declines. First, people are too afraid to come in for care. While Birkmeyer acknowledged that certainly was the case at the beginning of the pandemic, he said that wouldn't completely explain the persistence of the low numbers now.

A second possibility is that hospitals have found much of the care can be done outside the hospital with telemedicine, for example.

But Birkmeyer says he believes the main driver is fewer people are getting sick.

He explains that air quality is better with fewer people traveling, which may reduce non-COVID admissions, especially respiratory admissions; social distancing, stay-at home directives, and mask wearing may be containing spread of many diseases beyond COVID-19; and a slower pace of life may be reducing inflammation from stress that has been associated with cardiovascular events.

Birkmeyer said their study is consistent with data coming from the southern hemisphere, where hospitals have already experienced a pandemic winter.

"For the first time ever, there was essentially no flu season," Birkmeyer said, "which basically is consistent with the idea that measures put in place to battle COVID are having a salutary effect in preventing patients from getting flu and other illnesses."

However, Birkmeyer said, "There's no doubt there are pockets of patients who likely need to be in the hospital but aren't."

Andrew Oseran, MD, a cardiology fellow at Massachusetts General Hospital in Boston who published a study in July on trends of urgent hospital admissions in the COVID-19 era, told Medscape Medical News he's not convinced the main driver of reduced admissions is that people are less sick, but thinks it is part of the equation.

He points out the study also shows a decline in admissions for urinary tract infections and heart attacks and stroke, conditions for which care would not be less necessary during the pandemic.

Oseran also said he believes the fear of coming into a hospital remains substantial.

"This pandemic is surging in different parts of the country at different times, so we may see behaviors changing depending on where the pandemic is taking place," he said.

Particularly concerning, Oseran said, are the differences in how the decrease affected people in several demographics, primarily Black and Hispanic populations.

"The folks most at risk for getting COVID-19 and getting sick are also the ones who suffer the collateral effects," such as not coming to the hospital for non-COVID care, he said.

For his part, Birkmeyer said an interesting aspect of their findings is what was not found. For example, the drop in admissions did not seem to be dependent on whether specific hospitals had heavy COVID-19 caseloads.

Even hospitals minimally affected by COVID-19 saw a drop of 39.5% in non-COVID admissions. Those most affected by COVID-19 saw a decrease of 50% in non-COVID admissions.

Inpatient Mortality Rates Largely Unchanged

In addition, Birkmeyer notes that the findings did not uphold the researchers' hypothesis on how the non-COVID inpatients fared in the hospital.

The team had originally hypothesized that mortality would be increased for non-COVID patients for two reasons: that hospitals' attention would be taken up with COVID-19 patients and thus care would suffer elsewhere, and that it would be the sicker patients who came in, thus raising odds of mortality.

Neither scenario proved true, with a couple of exceptions, he said. Higher mortality rates were seen among non-COVID Hispanic patients and the poor at the height of the pandemic.

Birkmeyer said, "Public health authorities should continue to monitor for subgroups that are being undertreated, but we shouldn't assume that all of the 'missing' hospitalized patients are patients who need to be there."

This study was supported by a grant from the National Institute on Aging. Birkmeyer has an equity interest as an officer for Sound Physicians. Oseran has disclosed no relevant financial relationships.

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Reviewed on 10/1/2020
References
SOURCE: Medscape, September 30, 2020. Health Aff. Published online September 24, 2020.

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