Emergency Medicine

Patterns of Emergency Department visits for acute and chronic diseases during the two pandemic waves in Italy

a b s t r a c t

Background: Evidence is lacking about the impact of subsequent COVID-19 pandemic waves on Emergency De- partments (ED). We analyzed the differences in patterns of ED visits in Italy during the two pandemic waves, fo- cusing on changes in accesses for acute and chronic diseases.

Methods: We conducted a retrospective study using data from a metropolitan area in northern Italy that includes twelve ED. We analyzed weekly trends in non-COVID-19 ED visits during the first (FW) and second wave (SW) of the pandemic. Incidence rate ratios (IRRs) of triage codes, patient destination, and cause-specific ED visits in the FW and SW of the year 2020 vs. 2019 were estimated using Poisson regression models.

Main findings: We found a significant decrease of ED visits by triage code, which was more marked for low prior- ity codes and during the FW. We found an increased share of hospitalizations compared to home discharges both in the FW and in the SW. ED visits for acute and chronic conditions decreased during the FW, ranging, from -70% for injuries (IRR = 0.2862, p < 0.001) to -50% and – 60% for ischemic heart disease and heart failure.

Conclusions: The two pandemic waves led to a selection of patients with higher and more urgent needs of acute hospital care. These findings should lead to investigate how to improve systems’ capacity to manage changes in population needs.

(C) 2021

  1. Introduction

Few weeks after the first case of COVID-19 was identified in Italy on February 21st, 2020, the Italian government enforced a national lock- down from March to May 2020 [1,2]. After the easing of several impor- tant restrictions on May 4, 2020, a total lockdown was never put back in place in Italy. By late October 2020, when Italy experienced a second wave of COVID-19, the Italian authorities adopted a different approach: the Government enforced differentiated response measures organized in progressively restrictive tiers (imposed on a regional basis) that were strictly related to epidemiological criteria. Between spring and au- tumn 2020 national and regional governments had plenty of time to get

Abbreviations: COVID-19, Coronavirus Disease 2019; ED, Emergency Departments; FW, first wave; SW, Second Wave.

* Corresponding author at: Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum – University of Bologna, Via San Giacomo 12, 40126 Bologna, Italy.

E-mail addresses: [email protected] (D. Golinelli), [email protected] (F. Campinoti), [email protected]

(F. Sanmarchi), [email protected] (S. Rosa), [email protected] (G. Farina), [email protected] (A. Tampieri), [email protected] (M.P. Fantini), [email protected] (F. Giostra), [email protected] (L. Santi).

prepared for a possible resurgence of COVID-19 contagions, and citizens and patients had time to get used to the new habits enforced by the pan- demic. In response to the extended state of emergency and the novel re- strictive measures, healthcare utilization patterns changed among the general population [3,4].

Even before the pandemic, plenty of literature [5,6] described the profile of the population accessing Emergency Departments (ED), attempting to investigate the appropriateness of the conditions that prompted patients to seek urgent medical assistance. The COVID-19 pandemic represents a natural experiment to identify the truly inalien- able patients’ health needs and to verify to what extent these needs push patients to seek medical assistance despite the fear of contagion and the reorganization of services due to the health crisis.

However, while the effects of the first wave of the pandemic on ED have been studied worldwide [7-10], evidence is lacking about the im- pact of subsequent pandemic waves on cause-specific ED visits. For this reason, we retrospectively analyzed numbers and types of ED visits during year 2020 in the metropolitan area of Bologna (BMA), which is the principal town of one of the most affected areas of Italy and Europe, Emilia Romagna, a region that reported 172,007 COVID-19 cases (3795.1 standardized incidence rate per 100,000 population)

https://doi.org/10.1016/j.ajem.2021.07.010

0735-6757/(C) 2021

and 7825 COVID-19 deaths (135.0 mortality rate per 100,000 popula- tion) from February 01 to December 31, 2020 [11].

This study aims to analyze the differences in patterns of ED visits in BMA (Italy) during the two pandemic waves of 2020, focusing on changes in ED accesses for acute time-dependent diseases and exacer- bation of chronic diseases.

  1. Methods

We conducted a retrospective cross-sectional observational study, using anonymized data from the healthcare services‘ information sys- tems of BMA, a wide metropolitan area in Emilia-Romagna (northern Italy) that encompasses the city of Bologna and the neighboring munic- ipalities (1,019,875 citizens) and includes twelve ED. The study popula- tion consisted of patients of all ages that visited the ED (i.e., with an ED diagnosis code) in 2019 and 2020. The diagnosis code is given by the physician to each patient undergoing clinical evaluation at the ED.

We then classified ED visits as COVID-19 and non-COVID-19, based on the primary International Classification of Diseases Manual 9th Edi- tion – Clinical Modification (ICD-9-CM) diagnostic code [9], and ex- cluded the COVID-19 ED visits from the analysis. The classification algorithm for COVID-19 cases is reported in the section a) of the Supple- mentary material.

We analyzed weekly trends in non-COVID-19 cause-specific ED visits during the two time periods of COVID-19 case peak (i.e., daily in- cidence higher than 100 cases in BMA): from March 9 to May 3 (first wave, FW), when a strict nation-wide lockdown was enforced, and from October 18 to December 31 (second wave, SW), when a set of more lenient and region-based social distancing measures was enforced.

We analyzed the distribution of ED visits overall, by gender and by age group in the FW and SW, compared with the same periods of the previous year.

We classified ED visits according to the patients’ triage code (red- yellow vs. green-white). ED visits in BMA have been categorized by se- verity codes according to the Triage protocols in four levels of urgency [12,13]: white code (not-urgent condition), green code (postponable conditions); yellow code (medical condition requiring urgent care with no vital signs impairment but at-risk for deterioration); red code (medical condition with acute impairment of vital signs requiring emer- gency care).

We also classified ED visits according to patients’ discharge destina- tion (admitted to hospital vs. discharged at home).

We then identified 5 acute time-dependent conditions (ischemic heart disease, conduction disorders of the heart, and dysrhythmias, is- chemic cerebral disorders, gastrointestinal hemorrhages, injury) that need Timely intervention and are usually diagnosed and treated in the emergency department, as identified by the Italian Government Decree

DM 70/2015 [14], and 5 conditions that reflect exacerbation of chronic diseases (neoplasm, diabetes, heart failure, COPD, anemia), whose care is normally shared between the ED and out-patient services. These conditions have been chosen among those with higher impact on BMA’s ED in terms of yearly number of cause-specific ED visits during the study period [9,15]. The categorization into acute and chronic dis- eases was made according to the main diagnosis of ED visits, which we identified through the ICD-9-CM manual codes reported in section

b) (see Supplementary material).

The weekly number of visits and the incidence rate per 10,000 in- habitants were compared with the same period of the previous year. In- cidence rate ratios (IRRs) of triage codes, patient destination, and cause- specific ED visits in the FW and SW of the year 2020 vs. 2019 were esti- mated using Poisson regression models.

This study has been approved by the Emilia Romagna AVEC research ethics committee board with identifier n? 726/2020/Oss/AOUBo on 08.03.2020 and carried out in conformity with the regulations on data management with the Italian law on privacy (Legislation Decree 196/ 2003 amended by Legislation Decree 101/2018).

  1. Results

The study population consisted of 219,151 patients accessing BMA’s ED, of which 29,917 during the FW of year 2020 and 43,232 during the SW of 2020 (Table 1).

The number of ED visits was stable until week 82,020, then it dropped abruptly (Fig. 1). The reduction was -58.8% in the FW (Table 1). Afterward, the number of ED visits started to slowly rise again during the FW until it reached levels closer to those of 2019. From week 43 to week 50, 2020 we registered a second decline of ED visits. The reduction was -38.7% in the SW (Table 1).

The distribution by gender and age group showed no differences be- tween each wave and the corresponding period of the previous year (Table 1). However, we found a more marked reduction of ED visits for patients aged 0-14 years during the FW (IRR = 0.1955, p < 0.0001, 95% CI: 0.1923-0.1986) than during the SW (IRR = 0.4528,

p < 0.0001, 95% CI: 0.4474-0.4582).

We found a clear and statistically significant decrease of ED visits by triage code (Table 2). The decrease was more marked for low priority (white-green) codes than for high priority (red-yellow) ones and in the FW than in the SW (IRR = 0.3817, p < 0.0001, 95% CI: 0.3760-0.3874, vs IRR = 0.5405, p < 0.0001, 95% CI: 0.5249-0.5565,

and IRR = 0.5709, p < 0.0001, 95% CI: 0.5634-0.5786, vs IRR =

0.7826, p < 0.0001, 95% CI: 0.7626-0.8032, for white-green vs yellow- red codes in the FW vs SW, respectively). Also, we found an increased share of hospitalizations compared to home discharges both in the FW and in the SW.

Table 1

Change in total ED visits, ED visits by gender and age group. Change in ED visits by gender and age group for the two study periods compared to the same period of the previous year.a First wave Second wave

2019

2020

IRR

95% CI

2019

2020

IRR

95% CI

n

IR

n

IR

n

IR

n

IR

ED visits

Total

74,443

493.9

29,917

197.9

0.4122b

0.4056-0.4190

71,559

474.8

43,232

286.0

0.6132b

0.6045-0.6221

Gender

Male

36,278

240.7

14,401

95.2

0.4127b

0.4072-0.4182

34,808

230.9

21,204

140.2

0.6231b

0.6159-0.6304

Female

38,165

253.2

15,516

102.6

0.4113b

0.4037-0.4190

36,751

243.8

22,028

145.7

0.6032b

0.5933-0.6133

Age group

0-14

12,244

81.2

2199

14.5

0.1955b

0.1923-0.1986

11,235

74.6

4801

31.8

0.4528b

0.4474-0.4582

15-49

28,878

191.6

11,856

78.4

0.4278b

0.4220-0.4336

28,051

186.1

16,712

110.5

0.6127b

0.6053-0.6201

50-64

11,807

78.3

5852

38.7

0.4989b

0.4917-0.5062

11,448

76.0

7720

51.1

0.6723b

0.6634-0.6813

65-74

7263

48.2

3219

21.3

0.4548b

0.4486-0.4611

6978

46.3

4517

29.9

0.6554b

0.6474-0.6635

>75

14,229

94.4

6772

44.8

0.5003b

0.4952-0.5055

13,794

91.5

9390

62.1

0.7006b

0.6941-0.7071

n/a

22

19

53

92

a ED visits are reported as absolute numbers (n), incidence rate per 10.000 population (IR), incidence rate ratio (IRR) and 95% confidence interval (95% CI).

b p < 0.0001.

Fig. 1. Weekly trend of ED visits. Number of weekly all-cause ED visits during the study periods for the years 2019 and 2020.

As to ED visits for specific conditions (Table 2), we found a statisti- cally significant decrease of ED visits for all acute time-dependent con- ditions and exacerbations of chronic diseases during the FW as compared to 2019, ranging, from approximately -70% for injuries (IRR = 0.2862, p < 0.001, 95% CI: 0.2772-0.2954) to -50% and -60%

for ischemic heart disease and heart failure (IRR = 0.5202, p < 0.0001, 95% CI: 0.4284-0.6317, and IRR = 0.4024, p < 0.01, 95% CI:

0.3494-0.4635). We found a similar, albeit lower, decrease of ED visits during the SW (e.g.-40% for injury, IRR = 0.6101, p < 0.0001, 95% CI: 0.5949-0.6256), except for ischemic heart disease and heart failure, which failed to reach statistical significance.

  1. Discussion

In this study, we registered a significant reduction of ED visits during the two pandemic waves in Italy compared to the same periods of the previous year. The decrease of ED visits for medical conditions requiring urgent care with no vital signs’ impairment but at-risk for deterioration (yellow codes) and medical condition with acute impairment of vital signs requiring emergency care (red codes) is more marked during the first pandemic wave. The same applies to not-urgent (white codes) and postponable conditions (green codes). However, the de- crease is steeper for white-green codes than for red-yellow codes.

Table 2 Change in ED triage codes, patient destination and cause specific ED visits. Change in ED visits by triage code, patient destination, and primary diagnosis for the two study periods compared to the same period of the previous year.a

First wave Second wave

2019

2020

IRR

95% CI

2019

2020

IRR

95% CI

n

IR

n

IR

n

IR

n

IR

Triage code

White-Green

61,744

409.7

23,058

152.5

0.3817b

0.3760-0.3874

58,745

389.8

33,095

218.9

0.5709b

0.5634-0.5786

Yellow-Red

12,699

84.3

6859

45.4

0.5405b

0.5249-0.5565

12,814

85.0

10,042

66.4

0.7826b

0.7626-0.8032

Patient destination

Home discharge

54,717

363.1

19,123

126.5

0.3565b

0.3507-0.3624

52,456

348.1

30,615

202.5

0.5900b

0.5819-0.5983

Hospital admission

10,828

71.8

8509

56.3

0.7845b

0.7626-0.8070

10,855

72.0

10,102

66.8

0.9281b

0.9034-0.9535

Other

8898

59.0

2285

15.1

0.2571b

0.2456-0.2692

8248

54.7

2515

16.6

0.3051b

0.2918-0.3190

Acute

Ischemic heart disease

297

2.0

155

1.0

0.5202b

0.4284-0.6317

282

1.9

250

1.7

0.8837

0.7453-1.0477

time-dependent

Conduction disorders of the

867

5.8

360

2.4

0.4140b

0.3661-0.4681

806

5.3

537

3.6

0.6642b

0.5955-0.7408

diseases

heart and dysrhythmias

Ischemic cerebral disorders

411

2.7

232

1.5

0.5627b

0.4791-0.6610

411

2.7

309

2.0

0.7494b

0.6466-0.8686

Gastrointestinal hemorrhagies

225

1.5

145

1.0

0.6424b

0.5214-0.7915

254

1.7

169

1.1

0.6632b

0.5460-0.8057

Injury

17,022

112.9

4848

32.1

0.2862b

0.2772-0.2954

15,869

105.3

9673

64.0

0.6101b

0.5949-0.6256

Exacerbation of

Neoplasm

254

1.7

151

1.0

0.5926b

0.4845-0.7248

245

1.6

188

1.2

0.7649c

0.6325-0.9250

chronic diseases

Diabetes

207

1.4

86

0.6

0.4141b

0.3221-0.5325

167

1.1

112

0.7

0.6685b

0.5262-0.8493

Heart failure

669

4.4

270

1.8

0.4024b

0.3494-0.4635

564

3.7

520

3.4

0.9190

0.8158-1.0353

COPD and allied conditions

469

3.1

121

0.8

0.2572b

0.2106-0.3141

464

3.1

227

1.5

0.4877b

0.4161-0.5716

Anemia

253

1.7

114

0.8

0.4492b

0.3601-0.5603

274

1.8

195

1.3

0.7094b

0.5904-0.8524

a Cause-specific ED visits are reported as absolute numbers (n), incidence rate per 10.000 population (IR), incidence rate ratio (IRR) and 95% confidence interval (95% CI).

b p < 0.0001.

c p < 0.01.

These findings can be explained by the different containment measures adopted during the two waves of the pandemic. By confining people at home, interrupting work activities, and reducing road traffic, the fre- quency of travel-, work- and stress-related conditions dropped [7]; this is especially true during the first wave, due to the stricter confine- ment measures. The fear of contagion and the “stay at home” message delivered by the authorities during the first weeks since the pandemic outbreak seems to have discouraged the general population from seek- ing medical attention. However, the significantly increased hospitaliza- tion rate, observed during both the FW and the SW, shows that the different attitude towards healthcare utilization has led to a – at least partial – selection of more severe patients accessing the ED with unpostponable medical needs.

Notably, the share of patients in need of hospitalization after accessing ED is lower during the SW compared to the FW. A possible ex- planation might be the enforcement of milder social distancing mea- sures, reduced fear of contagion, and the people adaptation to the pandemic life, during the SW.

The current health crisis represents a natural experiment, and our findings reinforce the concept that many pre-pandemic ED visits were inappropriate, unnecessary or avoidable, as reported by several authors [7-10]. This is supported by the steeper reduction of low priority codes compared to the less marked reduction of high priority ones, together with the variation of the share of patients in need of hospitalization after accessing ED. As pointed out by Mantica and colleagues [10], dur- ing the SW the non-COVID-19 admissions to ED showed a progressive slow reduction rather than a collapse. This is confirmed by our findings and may be explained by the health systems’ enhancED capacity and preparedness in maintaining different healthCare pathways for both COVID-19 and non-COVID-19 patients, and by the reduced fear of COVID-19 in the general population [10].

The decline of cause-specific ED visits, both overall and for acute time-dependent and chronic diseases, was lower in the SW than in the FW, and even absent for ischemic heart disease and exacerbation of heart failure. We assume that these findings may be attributable to a delay in seeking hospital care and to the system’s inability to provide the same standards of care, particularly during the unpredictable health crisis of the first pandemic wave in Italy.

The lack of a statistically significant reduction in the number of ED

visits for ischemic heart disease and heart failure is noteworthy. For in- stance, ED visits for ischemic heart disease reduced by 48% during the FW, while they showed no significant reduction during the SW.

This finding might be linked to numerous factors: the slow resump-

tions of normal activities, a greater awareness of the disease, and the re- bound effect caused by an exacerbation of the neglected pathological conditions.

Our analysis nevertheless provides an incomplete comparison of the two pandemic waves, since the available data could be affected by misclassification or misreporting of COVID-19 cases. Given that seasonality is an issue that might affect the number and type of ED visits, we were only able to compare the two pandemic waves with the same periods of the previous year. We classified acute and chronic diseases relying on the definitions provided by the ICD-9- CM manual and including those with higher impact on BMA’s ED in terms of yearly number of ED visits [9,15]. This classification may not be completely exhaustive, and this should be considered as a lim- itation of the study. Furthermore, we had access only to aggregated data for ED visits diagnosis, which prevented us from conducting more detailed analyses (e.g. specific causes of injury). Moreover, the SW of the pandemic lasted more than the FW and our data did not cover the period beyond December 31, 2020. However, this study reinforces the growing body of literature that shows the dis- ruption caused by the pandemic on emergency departments during the year 2020. Furthermore, our findings support the pre-pandemic literature which indicates that one of the most important criticalities of EDs is avoidable or inappropriate access.

  1. Conclusions

In this study, we noticed a clear pattern of reduced ED visits in both waves of the COVID-19 pandemic in Italy, with a steeper reduction dur- ing the first wave. Our results show that that the two pandemic waves led to a selection of patients with higher and more urgent needs of acute hospital care.

Given the recurrence of the crisis, the scenario described by our study should lead to further investigate how to improve systems’ capac- ity and capability to manage changes in population healthcare needs.

Source(s) of support

There are no conflicts of interests, financial or otherwise, and no funding from any source.

Author contributions

DG and FC had the idea, contributed to study design and data inter- pretation, and drafted the manuscript; LS and FS contributed to design, data acquisition and interpretation, and drafted the manuscript; AT con- tributed to design and data acquisition, and drafted the manuscript; GF contributed to design and Data interpretation; SR contributed to data ac- quisition and analysis; MB contributed to data acquisition and interpre- tation; BB contributed to study design and data interpretation; MPF contributed to conception and data interpretation, and critically revised the manuscript; FG contributed to design, data interpretation, and crit- ically revised the manuscript.

LS and SR have verified the underlying data.

All authors gave their final approval and agreed to be accountable for all aspects of the work.

Data sharing statement

The data used in the study are controlled by a third party, two public health authorities (Local Health Authority of Bologna and Local Health Authority of Imola) and cannot be shared publicly. However, aggregated and anonymized data are available upon specific request to the corre- sponding authors. Interested researchers can replicate our study find- ings by contacting the authors or the Local Health Authorities of Bologna Metropolitan Area (AUSL Bologna and AUSL Imola).

Appendix A. Supplementary data

Supplementary data to this article can be found online at https://doi. org/10.1016/j.ajem.2021.07.010.

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