Prospective Cohort Study of Emergency Department Visit Frequency and Diagnoses Before and During COVID-19 Pandemic in Urban, Low-Income, US- and Foreign-Born Mothers in Boston, MA.

Background: The coronavirus 2019 (COVID-19) pandemic fundamentally changed how populations interface with the healthcare system. Despite historical spikes in US mortality during the pandemic, emergency department (ED) visits were paradoxically low. This is a concerning phenomenon that raises a red flag regarding access to care, especially among vulnerable populations. In this study we sought to understand how ED utilization evolved during the COVID-19 pandemic among traditionally understudied, low-income, racially diverse US- and foreign-born mothers.
Methods: This is a secondary analysis of a pre-existing dataset of 3,073 participants enrolled in the Boston Birth Cohort at birth and followed prospectively. We obtained ED visit diagnoses from 2019 and 2020 via electronic health records, categorized according to the International Classification of Diseases, 10 ^th Revision, and compared them using graph plots, chi-square, and negative binomial regression.
Results: The number of ED visits decreased by 29.1% ( P  < 0.001) from 2019 (1,376) to 2020 (976). However, visits for infectious and parasitic diseases, including COVID-19, increased by 90.6% (32:61) with COVID-19 accounting for 77% of those visits in 2020 (47/61). Mental health-related visits increased by 40.9% (44:62), with diagnoses of alcohol use disorder increasing by 183% (6:17). Regression analysis showed 50% less ED utilization among foreign- vs US-born participants; however, the increase in infectious diseases visits was greater among foreign-born compared to US-born mothers (185% vs 26%, P  = 0.01), while the increase in mental health diagnoses was greater among US-born mothers (69% vs -33%, P  = 0.10).
Conclusion: Despite a decrease in total ED visits during the pandemic, there was an increase in COVID-19- (immigrant > US born) and mental health- (US-born only) related visits. Our findings demonstrate that EDs remain a critical access point for care for minority populations and have implications for preparedness, resources, and services of EDs in urban settings to better address the needs of communities. However, alternative avenues for healthcare services for these populations, particularly during health crises, warrant further investigation.
Competing Interests: Conflicts of Interest: By the WestJEM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. This work is supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) under grant numbers (UJ2MC31074, UT7MC45949), Autism Longitudinal Data Project. The Boston Birth Cohort (the parent study) is supported in part by the March of Dimes PERI grants (20-FY02-56 and 21-FY07-605); the National Institutes of Health (NIH) grants (2R01HD041702, R01HD086013, R01HD098232, R01ES031272, and R01ES031521; and the Hopkins Population Center Grant (P2CHD042854) from the National Institute of Child Health and Human Development. The information, content and/or conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred, by HRSA, HHS or the US government.