Changes in Veterans Health Administration Emergency Department Visits During Two Years of COVID-19

To better understand the impact of the COVID-19 pandemic on emergency department (ED) utilization, we examined two years of Veterans Health Administration (VHA) ED visits. Emergent and non-emergent ED visits were examined separately to understand the impact of systems-level changes in healthcare delivery.

In this retrospective, observational cohort study we examined ED visits in 111 EDs within the VHA from March 2018-February 2022. Primary outcome was the count of emergent and non-emergent ED visits, using incident rate ratios (IRR) with 95% confidence intervals (CI) to examine ED visits during the first two years of the COVID-19 pandemic in eight separate quarters, compared to two years of seasonally equivalent quarters before COVID-19.

Over the four-year period, US veterans made 8,057,011 ED visits, with 54.7% in the eight pre-COVID-19 quarters, and 45.3% in the first eight quarters during the COVID-19 pandemic. Both emergent and non-emergent visit counts decreased in each of the first eight quarters during COVID-19 when compared to their respective pre-COVID-19 baseline. The change in emergent visits ranged between -26.9% (March-May 2020; IRR 0.73, 95% CI 0.72-0.74) and -7.0% (June-August 2021; IRR 0.93, 95% CI 0.92-0.94). The change in non-emergent visits ranged between -33.0% (March-May 2020; IRR 0.67, 95% CI 0.67-0.67) and -5.7% (June-August 2021; IRR 0.94, 95% CI 0.94-0.95). After the first six months of the pandemic, emergent ED visits had a sustained greater decrease compared to non-emergent visits.

As of 2022, ED visits had not returned to pre-pandemic baselines, and our results suggest that emergent visits have sustained a greater decrease even in the second year of the pandemic compared to their respective, seasonally equivalent pre-pandemic quarters from March 2018-February 2020. The finding that emergent visits decreased more than non-emergent is notable given that system-level changes in care delivery, particularly a shift toward use of telehealth, would be expected to have a greater impact on non-emergent care. More work is needed to understand whether acute care is being forgone altogether, as well as the subsequent impact.