COVID-19 pandemic drove significant rise in patients choosing to leave ERs before medically recommended

Researchers have long known that patients who leave emergency departments before medically advised use more emergency care services, are more likely to be readmitted to the hospital and face higher costs of care—as well as increased mortality rates.

Until now, however, little has been known about national, multi-year trends, including the impact of the COVID-19 pandemic on this phenomenon.

“In addition, most studies have focused on specific subgroups of patients, such as those with stroke or those with appendicitis who leave after surgery,” said Elena Andreyeva, PhD, a faculty member with the Texas A&M University School of Public Health. “We wanted to determine the factors related to the patient, hospital or encounter that led the patient to leave early, as well as to identify any national, multi-year trends.”

Andreyeva said the patient factors known to be associated with leaving before medically advised were being male, having Medicaid or no health insurance coverage, having substance abuse disorders, arriving by ambulance and being economically disadvantaged.

“Patients leave early because they don’t trust health care providers or institutions, don’t think they can afford care and, in the case of substance abuse disorders, are afraid of being judged,” Andreyeva said. “Other reasons are long wait times and dissatisfaction with the care they received while waiting. This is especially true for patients in urban areas, where emergency departments serve a larger proportion of minority and Medicaid patients and often function at or above capacity.”

For their study, published in the American Journal of Emergency Medicine, Andreyeva and two colleagues from the University of Alabama at Birmingham conducted a statistical analysis of medical record abstractions, patient interviews and hospital electronic health records from the Centers for Disease Control and Prevention’s National Hospital Ambulatory Medical Care Survey for 2016 to 2021.

“Our study affirms previous research on the characteristics associated with higher rates of leaving emergency departments before medically advised,” Andreyeva said. “Unlike other studies, however, ours did not find a significant association between patient’s race/ethnicity and incidences of leaving before medically advised, which perhaps could be because the factors previously documented could be attributed to underlying socioeconomic disparities.”

The study also affirmed previous research findings that patients who left before medically advised were significantly more likely to have arrived by ambulance and to have alcohol or substance use disorders.

In addition, the study found that the rates of patients leaving before medically advised increased during the COVID-19 pandemic. There were 721 million emergency department visits from 2016 to 2021, of which 194 million (26.9  percent) occurred after March 2020. Patients left before medically advised in 5.9 million emergency department visits during the study period—especially in the second, third and fourth quarters of 2020 and fourth quarter of 2021—for a 53.6 percent increase over pre-pandemic levels.

The researchers noted that the increase could be the result of concern about COVID-19 infection and dissatisfaction with longer waiting times and other factors triggered by the surge in pandemic-related demands on hospitals.

“The increase during the COVID-19 pandemic underscores the need to improve strategies related to quality of care and communication between patients and providers and during initial triage, especially when resources are constrained,” Andreyeva said. “Improving patient satisfaction and outcomes would help reduce the number of return visits and health care costs.”