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. 2022 Oct 3;5(10):e2239076.
doi: 10.1001/jamanetworkopen.2022.39076.

Analysis of Emergency Department Encounters Among High Users of Health Care and Social Service Systems Before and During the COVID-19 Pandemic

Affiliations

Analysis of Emergency Department Encounters Among High Users of Health Care and Social Service Systems Before and During the COVID-19 Pandemic

Melanie Molina et al. JAMA Netw Open. .

Abstract

Importance: Although the general US population had fewer emergency department (ED) visits during the COVID-19 pandemic, patterns of use among high users are unknown.

Objectives: To examine natural trends in ED visits among high users of health and social services during an extended period and assess whether these trends differed during COVID-19.

Design, setting, and participants: This retrospective cohort study combined data from 9 unique cohorts, 1 for each fiscal year (July 1 to June 30) from 2012 to 2021, and used mixed-effects, negative binomial regression to model ED visits over time and assess ED use among the top 5% of high users of multiple systems during COVID-19. Data were obtained from the Coordinated Care Management System, a San Francisco Department of Public Health platform that integrates medical and social information with service use.

Exposures: Fiscal year 2020 was defined as the COVID-19 year.

Main outcomes and measures: Measured variables were age, gender, language, race and ethnicity, homelessness, insurance status, jail health encounters, mental health and substance use diagnoses, and mortality. The main outcome was annual mean ED visit counts. Incidence rate ratios (IRRs) were used to describe changes in ED visit rates both over time and in COVID-19 vs non-COVID-19 years.

Results: Of the 8967 participants, 3289 (36.7%) identified as White, 3005 (33.5%) as Black, and 1513 (16.9%) as Latinx; and 7932 (88.5%) preferred English. The mean (SD) age was 46.7 (14.2) years, 6071 (67.7%) identified as men, and 7042 (78.5%) had experienced homelessness. A statistically significant decrease was found in annual mean ED visits among high users for every year of follow-up until year 8, with the largest decrease occurring in the first year of follow-up (IRR, 0.41; 95% CI, 0.40-0.43). However, during the pandemic, ED visits decreased 25% beyond the mean reduction seen in prepandemic years (IRR, 0.75; 95% CI, 0.72-0.79).

Conclusions and relevance: In this study, multiple cohorts of the top 5% of high users of multiple health care systems in San Francisco had sustained annual decreases in ED visits from 2012 to 2021, with significantly greater decreases during COVID-19. Further research is needed to elucidate pandemic-specific factors associated with these findings and understand how this change in use was associated with health outcomes.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Kanzaria reported receiving personal fees and working as a consultant for Amae Health Inc outside the submitted work. Dr Raven’s and Dr Kanzaria’s salaries were supported by a grant from the Benioff Homelessness and Housing Initiative at the University of California, San Francisco. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Nine Cohorts of the Top 5% of Higher Users of Medical Services (HUMS) Combined by Year of Follow-up
Nine cohorts of top 5% of HUMS were defined. The prepandemic cohorts were followed up until fiscal year (FY) 2020, which was defined as the COVID-19 year (red). To account for the natural decay in ED visits among HUMS, the cohorts’ data were combined by year of follow-up rather than by temporal year. This allowed assessment of how ED visits during the COVID-19 year compared with the overall expected decay in ED visits among HUMS over time.
Figure 2.
Figure 2.. Heatmap of Mean Number of Annual Emergency Department (ED) Visits by Follow-up Year, Stratified by Cohort
Yellow indicates greater mean number of ED visits; blue, fewer mean number of ED visits; boldface numbers, number of ED visits during the COVID-19 year. aIndex year.

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