Emergency Department Use for Sickle Cell Declined at Onset of COVID-19

Brandon K. Attell, PhD

Credit: LinkedIn

Emergency department (ED) utilization patterns were impacted by the COVID-19 pandemic among individuals with sickle cell disease (SCD), with a notable decline in use at the onset of the public emergency, according to a new retrospective cohort study.¹

Across population-based SCD surveillance systems in California, Georgia, Michigan, and Tennessee, the pandemic onset in 2020 led to a decline in utilization at the person- and visit level, particularly for those ≤10 years old. By the end of the year, rates had increased, but not to pre-COVID-19 levels.

“Because SCD is a condition marked by chronic complications and pain which often requires frequent medical care, those living with SCD are in an especially vulnerable position, as disruptions caused by COVID-19 have high potential to impact their quality of life,” wrote the investigative team, led by Brandon K. Attell, PhD, Georgia Health Policy Center, Georgia State University.

A rare disease, approximately 100,000 people in the US are impacted by SCD, with close to 223,000 yearly ED visits occurring on average.²

Exacerbations of SCD, including vaso-occlusive crises (VOCs), become acute pain episodes that require management typically administered in the ED, leading to frequent utilization in this population.³ Those living in areas with access issues or a lack of SCD specialists may rely on the ED as a source of regular treatment for SCD.⁴

Importantly, individuals with SCD may be at higher risk of adverse outcomes, including hospitalization and death, when they acquire a COVID-19 infection.⁵ Owing to the fear of COVID-19 infection, many individuals with SCD may avoid the ED or delay a visit with self-management of pain symptoms.

Without a comprehensive understanding of ED utilization, this retrospective cohort study sought to assess the volume and patterns of ED use for SCD using population-based surveillance systems across 4 US states.

Attell and colleagues described the trends in the rate of monthly ED use from January 2019 to December 2020, focusing on immediate changes in utilization driven by the onset of the pandemic. The team then evaluated the changes in utilization volume by comparing total ED visits between March and December 2020 with the same period in 2019, with further stratification by demographic characteristics.

Most individuals with SCD in the analysis were from Georgia (n = 4524), followed by California (n = 2176), Michigan (n = 2168), and Tennessee (n = 1454). Individuals were typically younger, with more than half ≤30 years of age at the start of the study, and there was a greater percentage of women than men. Race and ethnicity analyses showed approximately 80% of individuals in each state were non-Hispanic Black.

At the start of the pandemic, in March 2020, ED utilization slightly increased (+4%) in California and Michigan and decreased in Georgia and Tennessee (–10% and –9%, respectively). By April 2020, ED utilization significantly dropped in all 4 states: –26% in California, –29% in Georgia, –37% in Tennessee, and –38% in Michigan.

Monthly ED utilization trended toward pre-COVID-19 utilization rates, after the lowest level observed in April 2020, but did not fully return to pre-pandemic levels by December 2020.

Changes in the volume of total ED visits also decreased during the COVID-19 pandemic, ranging between –15% in California and –25% in Tennessee. Infants and young children aged 0–9 years experienced the greatest decrease in total visit volume, with a utilization drop between –54% in Michigan and –61% in California.

Attell and colleagues noted the change in the number of individuals with any ED utilization (≥1 visit) demonstrated a notable decline, of approximately 25% across the 3 of the 4 states, with the greatest decrease in infants and young children aged 0–9 years.

“This study confirms and extends the existing literature related to the impact of the COVID-19 emergency on healthcare utilization patterns in the US, in a unique population with increased healthcare needs, compared to the general public,” Attell and colleagues wrote.

References

1. _{Attell BK, Plaxco AP, Zhou M, et al. Emergency department utilization before and during the COVID-19 pandemic among individuals with sickle cell disease. BMC Emerg Med. 2024;24(1):134. Published 2024 Jul 29. doi:10.1186/s12873-024-01043-5}
2. _{Attell BK, Barrett PM, Pace BS, et al. Characteristics of Emergency Department Visits Made by Individuals With Sickle Cell Disease in the U.S., 1999-2020. AJPM Focus. 2023;3(1):100158. Published 2023 Oct 30. doi:10.1016/j.focus.2023.100158}
3. _{Blinder MA, Duh MS, Sasane M, Trahey A, Paley C, Vekeman F. Age-Related Emergency Department Reliance in Patients with Sickle Cell Disease. J Emerg Med. 2015;49(4):513-522.e1. doi:10.1016/j.jemermed.2014.12.080}
4. _{Hemker BG, Brousseau DC, Yan K, Hoffmann RG, Panepinto JA. When children with sickle-cell disease become adults: lack of outpatient care leads to increased use of the emergency department. Am J Hematol. 2011;86(10):863-865. doi:10.1002/ajh.22106}
5. _{Hoogenboom WS, Alamuri TT, McMahon DM, et al. Clinical outcomes of COVID-19 in patients with sickle cell disease and sickle cell trait: A critical appraisal of the literature. Blood Rev. 2022;53:100911. doi:10.1016/j.blre.2021.100911}