Impact of a telemedicine program on avoidable and unavoidable emergency department visits during the COVID-19 pandemic

COVID-19 has had a profound impact on the healthcare system, with nearly 630 million cumulative cases to-date [1]. This has led to a significant strain on Emergency Department (ED) resources [2]. In order to reduce the burden on the ED and improve patient throughput, some have recommended using alternate care modalities, such as telemedicine, to care for patients with potentially avoidable ED visits (i.e., those who might not require ED-specific care) [3]. Our study sought to describe the difference in ED versus telemedicine visit types (emergent, avoidable, and COVID-19-related) over a two-year period since the beginning of the COVID-19 pandemic.

This was a retrospective, cross-sectional study assessing the distribution of in-person ED visits versus telemedicine visits across a major healthcare institution from January 1, 2020 to December 31, 2021, comparing visit categories. The study was conducted using data from two separate hospitals within a single healthcare system. Rush University Medical Center is a 664-bed urban tertiary care hospital in Chicago, Illinois with an annual Emergency Department volume of 70,000 patients per year. Rush Oak Park Hospital is a 87-bed urban community hospital in Oak Park, Illinois with an annual Emergency Department volume of 50,000 patients per year. The telemedicine program was established on August 19, 2019 through the same healthcare system and advertised to Rush patients as an alternate model for access to care. Patients of all ages were included. The urgency of a visit was categorized using the New York University Emergency Department Algorithm (NYU-EDA) modified to include a category for COVID-19-related visits [4]. The NYU-EDA uses ICD-10 diagnosis codes to assign ED visits to severity categories. For this study, we classified visits into either avoidable (i.e., non-emergent) or unavoidable (i.e., emergent) based on the approach of Ballard et al. [5], wherein the ED visit was assigned the category if the probability for either category was greater than 50%. If a specific visit did not map to a specific category with greater than 50% probability, it was categorized as “indeterminate/unclassified”. We also added an additional group for COVID-19, as this did not exist at the time when the NYU-EDA algorithm was created. These consisted of the following four ICD-10 codes: U07.1, Z11.52, Z20.822, and Z86.16. We conducted descriptive analysis as well as a chi-square test to study the relationship between NYU-EDA plus COVID-19 visit categorizations and type of visits (ED visits vs telemedicine visits) separately for each month during the study timeframe. In addition, charts/graphs were utilized to visualize ED vs telemedicine visit trends for each NYU-EDA + COVID-19 visit category. The Rush University Medical Center institutional review board evaluated this project and approved it with a waiver of informed consent.

During the two-year time period, there were 147,317 ED visits and 27,244 telemedicine visits. Of the ED visits, 38.5% were avoidable, 10.9% were emergent/unavoidable, 5.1% were COVID-19-related, and 45.5% were indeterminate/unclassified. Of the telemedicine visits, 44.0% were avoidable, 4.4% were emergent/unavoidable, 20.0% were COVID-19-related, and 31.6% were indeterminate/unclassified. The trends in visit distribution per month are demonstrated in Fig. 1 . The first two months primarily consisted of in-person ED visits. Beginning in March (coinciding with the first COVID-19 case in our healthcare system on March 4, 2020), there was a spike in telemedicine visits. Among those with COVID-19-related presentations, 42.0% sought care via telemedicine. Among avoidable visit diagnoses, there was a peak of 50% seeking telemedical care in the month following the first case at Rush, followed by a plateau at approximately 15% of all visits (total: 17.4% of all visits). Emergent/unavoidable visits comprised a small proportion of all telemedicine visits, with 93.1% of all emergent/unavoidable cases presenting directly to the ED.

Fig. 1.

A, Distribution of emergent visits by month from 2020 to 2021; B, Number of non-emergent visits by month from 2020 to 2021; C, Number of COVID-19 visits by month from 2020 to 2021.

When evaluating the total number of visits, COVID-19-related visits rose and declined in parallel for both the ED and telemedicine visits over the two-year period (Supplementary Fig. 1). In contrast, the trends in avoidable telemedicine visits appeared to mirror avoidable ED visits (e.g., avoidable ED visits declined as avoidable telemedicine visits increased). Though the trends between emergent ED and telemedicine visits were unchanged/flat, there was a spike in telemedicine emergent visits in March through May during the first three months after the first COVID-19 case. The distribution of telemedicine and ED visits across each month are included in the Supplementary Table 1.

Supplementary Fig. 1.

A, Number of emergent visits by month from 2020 to 2021.

When evaluating the total number of visits, COVID-19-related visits rose and declined in parallel for both the ED and telemedicine visits over the two-year period (Supplementary Fig. 1). In contrast, the trends in avoidable telemedicine visits appeared to mirror avoidable ED visits (e.g., avoidable ED visits declined as avoidable telemedicine visits increased). Though the trends between emergent ED and telemedicine visits were unchanged/flat, there was a spike in telemedicine emergent visits in March through May during the first three months after the first COVID-19 case. The distribution of telemedicine and ED visits across each month are included in the Supplementary Table 1.

This was a novel study analyzing the difference in ED versus telemedicine visit types over a two-year period since the beginning of the COVID-19 pandemic. Overall, we found that telemedical care accounted for 42% of COVID-19 visits, 17% of avoidable visits, and 7% of emergent/unavoidable visits during the first two years following the COVID-19 pandemic. This demonstrates a potential avenue to significantly reduce ED volume during times of increased boarding and reduced capacity, such as during the COVID-19 pandemic. Telemedicine is a promising alternative by providing direct access to a clinician directly from the patient's home, reducing potential exposures for communicable diseases and increasing comfort and convenience for patients [6,7]. Telemedicine can also reduce costs to patients and the healthcare system at-large [8].

Interestingly, while there was an initial spike after the first COVID-19 case was diagnosed locally, there remained a consistent volume which was elevated compared with the two months preceding this diagnosis. This mirrored declines in avoidable visits in the ED, while paralleling COVID-19 visit spikes, suggesting that the role for telemedicine to potentially offload ED volumes may be able to be sustained and can accommodate surges. This is particularly relevant for EDs that may be facing staffing shortages and boarding crises, as well as for offloading volumes during future pandemics and healthcare issues.

It is important to consider several limitations to the present study. This was a retrospective study of one healthcare system in a single region. While we intentionally included different hospital types (i.e., a large tertiary care and smaller community hospital), our results may not be generalizable to other healthcare systems or regions. Additionally, we were not able to determine whether patients had visited other healthcare systems or went untreated. The NYU-EDA algorithm uses dichotomous indicators and may not fully reflect all visits. COVID-19 was also not included in the original algorithm and was added for the purposes of this study. Finally, while we identified temporal trends in visit types, the data are only able to show trends and cannot demonstrate causality.

Overall, we identified temporal trends in emergent, non-emergent, and COVID-19 related visits in the ED versus telemedicine. COVID-19 visits rose in parallel for both the ED and telemedicine, while non-emergent visits appeared to offset each other between the ED and telemedicine.

The following are the supplementary data related to this article.

Supplementary Fig. 1.

B, Number of avoidable/non-emergent visits by month from 2020 to 2021.

Supplementary Fig. 1.

C, Number of COVID-19 visits by month from 2020 to 2021.

Supplementary Table 1

Distribution of visits by category.

Supplementary data to this article can be found online at https://doi.org/10.1016/j.ajem.2023.01.023.

Disclosures/Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. We have no disclosures to declare.

Meetings

None.

IRB

Approved.

CRediT authorship contribution statement

Michael Gottlieb: Writing – review & editing, Writing – original draft, Supervision, Project administration, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Shital Shah: Writing – review & editing, Writing – original draft, Visualization, Project administration, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Ryan Schipfer: Writing – review & editing, Writing – original draft, Project administration, Methodology, Investigation, Data curation, Conceptualization. Paul Casey: Writing – review & editing, Writing – original draft, Resources, Project administration, Methodology, Investigation, Conceptualization. Brian Stein: Writing – review & editing, Writing – original draft, Resources, Project administration, Methodology, Investigation, Conceptualization. Dennis McKinney: Writing – review & editing, Writing – original draft, Methodology, Conceptualization. Doug Thompson: Writing – review & editing, Writing – original draft, Supervision, Project administration, Methodology, Investigation, Formal analysis, Data curation, Conceptualization.

Declaration of Competing Interest

We have no conflicts of interest nor financial support to disclose.