Public Perspectives on Decisions About Emergency Care Seeking for Care Unrelated to COVID-19 During the COVID-19 Pandemic | Emergency Medicine | JN Learning | AMA Ed Hub [Skip to Content]
[Skip to Content Landing]

Public Perspectives on Decisions About Emergency Care Seeking for Care Unrelated to COVID-19 During the COVID-19 Pandemic

Educational Objective
To identify the key insights or developments described in this article
1 Credit CME
Key Points

Question  What do people prioritize when deciding whether to present to the emergency department during the COVID-19 pandemic for care unrelated to COVID-19?

Findings  In this survey study of 933 US adults, we found that 16.9% and 25.5% of individuals confronted with scenarios consistent with myocardial infarction or appendicitis, respectively, prioritized avoidance of COVID-19 exposure in the emergency department over seeking appropriate care. Sociodemographics, political affiliations, and personal knowledge, attitudes, and beliefs regarding COVID-19 were not factors associated with decision-making regarding emergency care seeking.

Meaning  These findings suggest that health care systems and public health organizations should develop effective communications for patients and the community at large that reassure and encourage appropriate, timely health care for critical needs, not only during the ongoing COVID-19 pandemic, but also for future infectious outbreaks and other scenarios that could promote maladaptive pathogen-avoidance behaviors.


Importance  Delaying critical care for treatable conditions owing to fear of contracting COVID-19 in the emergency department (ED) is associated with avoidable morbidity and mortality.

Objective  To assess and quantify how people decided whether to present to the ED during the COVID-19 pandemic for care unrelated to COVID-19 using conjoint analysis, a form of trade-off analysis that examines how individuals make complex decisions.

Design, Setting, and Participants  This cross-sectional survey study was conducted using a nationwide sample from June 1, 2020, during the initial peak of the COVID-19 pandemic. Included participants were adults aged 18 years or older in the US who self-reported that they had not tested positive for COVID-19. Data were analyzed from July 2020 through May 2021.

Exposures  Participants completed a self-administered online survey.

Main Outcomes and Measures  Using a choice-based conjoint analysis survey, the relative importance was assessed for the following attributes for individuals in deciding whether to seek ED care for symptoms consistent with myocardial infarction or appendicitis: reduction in chance of dying because of ED treatment, crowdedness of ED with other patients, and chance of contracting COVID-19 in the ED. We also performed latent class analyses using conjoint data to identify distinct segments of the respondent population with similar choice patterns. Logistic regression was then used to explore whether patient sociodemographics and political affiliations were factors associated with decision-making.

Results  Among 1981 individuals invited to participate, 933 respondents (47.1%) completed the survey; participants’ mean (SD) age was 40.1 (13.0) years, and 491 (52.6%) were women. In latent class analyses, 158 individuals (16.9%) with symptoms of myocardial infarction and 238 individuals (25.5%) with symptoms of appendicitis prioritized avoidance of COVID-19 exposure in the ED (ie, chance of contracting COVID-19 in the ED or crowdedness of ED with other patients) over seeking appropriate care for symptoms. Having a usual source of care was a factor associated with lower odds of prioritizing avoidance of COVID-19 exposure (myocardial infarction scenario: adjusted odds ratio, 0.49 [95% CI, 0.32-0.76]; P = .001; appendicitis scenario: adjusted odds ratio, 0.57 [95% CI, 0.40-0.82]; P = .003), but most sociodemographic factors and political affiliations were not factors associated with decision-making.

Conclusions and Relevance  This study found that up to one-quarter of individuals were willing to forgo potentially life-saving ED care to avoid exposure to COVID-19. These findings suggest that health care systems and public health organizations should develop effective communications for patients and the community at large that reassure and encourage timely health care for critical needs during the ongoing COVID-19 pandemic and other scenarios.

Sign in to take quiz and track your certificates

Buy This Activity

JN Learning™ is the home for CME and MOC from the JAMA Network. Search by specialty or US state and earn AMA PRA Category 1 CME Credit™ from articles, audio, Clinical Challenges and more. Learn more about CME/MOC

CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

Accepted for Publication: June 8, 2021.

Published: August 19, 2021. doi:10.1001/jamanetworkopen.2021.20940

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Gale R et al. JAMA Network Open.

Corresponding Author: Brennan M. R. Spiegel, MD, MSHS, Department of Medicine, Cedars-Sinai Medical Center, 116 N Robertson Blvd, Pacific Theatres Building, 8th Floor, Los Angeles, CA 90048 (

Author Contributions: Mr. Fuller and Dr. Almario had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Ms Gale and Mr Eberlein share co–first authorship. Drs Almario and Spiegel share co–senior authorship.

Concept and design: Gale, Eberlein, Fuller, Almario, Spiegel.

Acquisition, analysis, or interpretation of data: Gale, Eberlein, Fuller, Khalil, Almario, Spiegel.

Drafting of the manuscript: All authors.

Critical revision of the manuscript for important intellectual content: Gale, Eberlein, Khalil, Almario, Spiegel.

Statistical analysis: Fuller, Almario.

Obtained funding: Not applicable.

Administrative, technical, or material support: Gale, Eberlein, Almario, Spiegel.

Supervision: Almario, Spiegel.

Conflict of Interest Disclosures: None reported.

Dong  E , Du  H , Gardner  L .  An interactive web-based dashboard to track COVID-19 in real time.   Lancet Infect Dis. 2020;20(5):533-534. doi:10.1016/S1473-3099(20)30120-1 PubMedGoogle ScholarCrossref
Kansagra  AP , Goyal  MS , Hamilton  S , Albers  GW .  Collateral effect of Covid-19 on stroke evaluation in the United States.   N Engl J Med. 2020;383(4):400-401. doi:10.1056/NEJMc2014816 PubMedGoogle ScholarCrossref
Siegler  JE , Heslin  ME , Thau  L , Smith  A , Jovin  TG .  Falling stroke rates during COVID-19 pandemic at a comprehensive stroke center.   J Stroke Cerebrovasc Dis. 2020;29(8):104953. doi:10.1016/j.jstrokecerebrovasdis.2020.104953 PubMedGoogle Scholar
Oseran  AS , Nash  D , Kim  C ,  et al.  Changes in hospital admissions for urgent conditions during COVID-19 pandemic.   Am J Manag Care. 2020;26(8):327-328. doi:10.37765/ajmc.2020.43837 PubMedGoogle Scholar
Birkmeyer  JD , Barnato  A , Birkmeyer  N , Bessler  R , Skinner  J .  The impact of the COVID-19 pandemic on hospital admissions in the United States.   Health Aff (Millwood). 2020;39(11):2010-2017. doi:10.1377/hlthaff.2020.00980 PubMedGoogle ScholarCrossref
Heist  T , Schwartz  K , Butler  S . Trends in overall and non-COVID-19 hospital admissions. Accessed Feb 1, 2021.
Lange  SJ , Ritchey  MD , Goodman  AB ,  et al.  Potential indirect effects of the COVID-19 pandemic on use of emergency departments for acute life-threatening conditions—United States, January-May 2020.   MMWR Morb Mortal Wkly Rep. 2020;69(25):795-800. doi:10.15585/mmwr.mm6925e2 PubMedGoogle ScholarCrossref
Pessoa-Amorim  G , Camm  CF , Gajendragadkar  P ,  et al.  Admission of patients with STEMI since the outbreak of the COVID-19 pandemic: a survey by the European Society of Cardiology.   Eur Heart J Qual Care Clin Outcomes. 2020;6(3):210-216. doi:10.1093/ehjqcco/qcaa046 PubMedGoogle ScholarCrossref
Baum  A , Schwartz  MD .  Admissions to Veterans Affairs hospitals for emergency conditions during the COVID-19 pandemic.   JAMA. 2020;324(1):96-99. doi:10.1001/jama.2020.9972 PubMedGoogle ScholarCrossref
Garcia  S , Albaghdadi  MS , Meraj  PM ,  et al.  Reduction in ST-segment elevation cardiac catheterization laboratory activations in the United States during COVID-19 pandemic.   J Am Coll Cardiol. 2020;75(22):2871-2872. doi:10.1016/j.jacc.2020.04.011 PubMedGoogle ScholarCrossref
Anderson  KE , McGinty  EE , Presskreischer  R , Barry  CL .  Reports of forgone medical care among US adults during the initial phase of the COVID-19 pandemic.   JAMA Netw Open. 2021;4(1):e2034882. doi:10.1001/jamanetworkopen.2020.34882 PubMedGoogle Scholar
Kluger  J. You may be surprised by the type of American who is postponing basic health care during the pandemic. Accessed May 26, 2021.
Marchese  G , Prochazka  B , Widimsky  P .  The importance of time: time delays in acute stroke.   Cor et Vasa. 2016;58(2):e225-e232. doi:10.1016/j.crvasa.2016.03.002 Google ScholarCrossref
Schaller  M , Park  JH .  The behavioral immune system (and why it matters).   Curr Dir Psychol Sci. 2011;20(2):99-103. doi:10.1177/0963721411402596 Google ScholarCrossref
Ackerman  JM , Tybur  JM , Blackwell  AD .  What role does pathogen-avoidance psychology play in pandemics?   Trends Cogn Sci. 2021;25(3):177-186. doi:10.1016/j.tics.2020.11.008 PubMedGoogle ScholarCrossref
Ridgway  JP , Robicsek  AA .  Risk of coronavirus disease 2019 (COVID-19) acquisition among emergency department patients: a retrospective case control study.   Infect Control Hosp Epidemiol. 2021;42(1):105-107. doi:10.1017/ice.2020.1224 PubMedGoogle ScholarCrossref
American Association for Public Opinion Research. Survey disclosure checklist. Accessed May 25, 2021.
Menees  SB , Almario  CV , Spiegel  BMR , Chey  WD .  Prevalence of and factors associated with fecal incontinence: results from a population-based survey.   Gastroenterology. 2018;154(6):1672-1681.e3. doi:10.1053/j.gastro.2018.01.062PubMedGoogle ScholarCrossref
Almario  CV , Ballal  ML , Chey  WD , Nordstrom  C , Khanna  D , Spiegel  BMR .  Burden of gastrointestinal symptoms in the United States: results of a nationally representative survey of over 71,000 Americans.   Am J Gastroenterol. 2018;113(11):1701-1710. doi:10.1038/s41395-018-0256-8 PubMedGoogle ScholarCrossref
Bridges  JF , Hauber  AB , Marshall  D ,  et al.  Conjoint analysis applications in health—a checklist: a report of the ISPOR Good Research Practices for Conjoint Analysis Task Force.   Value Health. 2011;14(4):403-413. doi:10.1016/j.jval.2010.11.013 PubMedGoogle ScholarCrossref
Law  MR , Watt  HC , Wald  NJ .  The underlying risk of death after myocardial infarction in the absence of treatment.   Arch Intern Med. 2002;162(21):2405-2410. doi:10.1001/archinte.162.21.2405 PubMedGoogle ScholarCrossref
Wysocki  AP , Allen  J , Rey-Conde  T , North  JB .  Mortality from acute appendicitis is associated with complex disease and co-morbidity.   ANZ J Surg. 2015;85(7-8):521-524. doi:10.1111/ans.12829 PubMedGoogle ScholarCrossref
McCutcheon  BA , Chang  DC , Marcus  LP ,  et al.  Long-term outcomes of patients with nonsurgically managed uncomplicated appendicitis.   J Am Coll Surg. 2014;218(5):905-913. doi:10.1016/j.jamcollsurg.2014.01.003 PubMedGoogle ScholarCrossref
UCLA Center for Health Policy Research. Race/ethnic health profiles. Accessed May 25, 2021.
Hoffman  RM , Koyama  T , Albertsen  PC ,  et al.  Self-reported health status predicts other-cause mortality in men with localized prostate cancer: results from the Prostate Cancer Outcomes Study.   J Gen Intern Med. 2015;30(7):924-934. doi:10.1007/s11606-014-3171-8 PubMedGoogle ScholarCrossref
Sangha  O , Stucki  G , Liang  MH , Fossel  AH , Katz  JN .  The Self-Administered Comorbidity Questionnaire: a new method to assess comorbidity for clinical and health services research.   Arthritis Rheum. 2003;49(2):156-163. doi:10.1002/art.10993 PubMedGoogle ScholarCrossref
Lee  SA .  Coronavirus Anxiety Scale: a brief mental health screener for COVID-19 related anxiety.   Death Stud. 2020;44(7):393-401. doi:10.1080/07481187.2020.1748481 PubMedGoogle ScholarCrossref
Orme  BK .  Getting started with conjoint analysis: strategies for product design and pricing research. Research Publishers; 2010.
Cunningham  CE , Deal  K , Chen  Y .  Adaptive choice-based conjoint analysis: a new patient-centered approach to the assessment of health service preferences.   Patient. 2010;3(4):257-273. doi:10.2165/11537870-000000000-00000 PubMedGoogle ScholarCrossref
Lichtenstein  GR , Waters  HC , Kelly  J ,  et al  Assessing drug treatment preferences of patients with Crohn’s disease.   Patient. 2010;3:113-123. doi:10.2165/11314880-000000000-00000 Google ScholarCrossref
Almario  CV , Keller  MS , Chen  M ,  et al.  Optimizing selection of biologics in inflammatory bowel disease: development of an online patient decision aid using conjoint analysis.   Am J Gastroenterol. 2018;113(1):58-71. doi:10.1038/ajg.2017.470 PubMedGoogle ScholarCrossref
Sawtooth Software. The latent class: technical paper V4.8. Accessed January 30, 2021.
Hsieh  HF , Shannon  SE .  Three approaches to qualitative content analysis.   Qual Health Res. 2005;15(9):1277-1288. doi:10.1177/1049732305276687 PubMedGoogle ScholarCrossref
Thrivable; American Diabetes Association. Effects of the COVID-19 pandemic on people with diabetes: December 2020 survey summary report. Accessed May 27, 2021.
Czeisler  MÉ , Marynak  K , Clarke  KEN ,  et al.  Delay or avoidance of medical care because of COVID-19-related concerns—United States, June 2020.   MMWR Morb Mortal Wkly Rep. 2020;69(36):1250-1257. doi:10.15585/mmwr.mm6936a4 PubMedGoogle ScholarCrossref
World Health Organization. COVID-19 continues to disrupt essential health services in 90% of countries. Accessed May 26, 2021.
Sharpless  NE .  COVID-19 and cancer.   Science. 2020;368(6497):1290. doi:10.1126/science.abd3377 PubMedGoogle ScholarCrossref
Blewett  LA , Johnson  PJ , Lee  B , Scal  PB .  When a usual source of care and usual provider matter: adult prevention and screening services.   J Gen Intern Med. 2008;23(9):1354-1360. doi:10.1007/s11606-008-0659-0 PubMedGoogle ScholarCrossref
Li  C , Dick  AW , Fiscella  K , Conwell  Y , Friedman  B .  Effect of usual source of care on depression among Medicare beneficiaries: an application of a simultaneous-equations model.   Health Serv Res. 2011;46(4):1059-1081. doi:10.1111/j.1475-6773.2011.01240.x PubMedGoogle ScholarCrossref
Tsai  J , Shi  L , Yu  WL , Lebrun  LA .  Usual source of care and the quality of medical care experiences: a cross-sectional survey of patients from a Taiwanese community.   Med Care. 2010;48(7):628-634. doi:10.1097/MLR.0b013e3181dbdf76 PubMedGoogle ScholarCrossref
Tolbert  J. What issues will uninsured people face with testing and treatment for COVID-19? Accessed May 27, 2021.
Xu  KT .  Usual source of care in preventive service use: a regular doctor versus a regular site.   Health Serv Res. 2002;37(6):1509-1529. doi:10.1111/1475-6773.10524 PubMedGoogle ScholarCrossref
Sung  NJ , Lee  JH .  Association between types of usual source of care and user perception of overall health care service quality in Korea.   Korean J Fam Med. 2019;40(3):143-150. doi:10.4082/kjfm.17.0093 PubMedGoogle ScholarCrossref
Sommers  AR , Wholey  DR .  The effect of HMO competition on gatekeeping, usual source of care, and evaluations of physician thoroughness.   Am J Manag Care. 2003;9(9):618-627.PubMedGoogle Scholar
DeVoe  JE , Wallace  LS , Pandhi  N , Solotaroff  R , Fryer  GE  Jr .  Comprehending care in a medical home: a usual source of care and patient perceptions about healthcare communication.   J Am Board Fam Med. 2008;21(5):441-450. doi:10.3122/jabfm.2008.05.080054 PubMedGoogle ScholarCrossref
Anguilm  C. Convincing patients not to delay necessary in-person care during COVID-19: top 5 tips. Updated December 7, 2020. Accessed May 26, 2021.
Wong  LE , Hawkins  JE , Langness  S , Murrell  KL , Iris  P , Sammann  A . Where are all the patients: addressing Covid-19 fear to encourage sick patients to seek emergency care. Accessed May 26, 2021.
PRNewswire. California Hospital Association launches “Care Can't Wait” public service campaign encouraging people to seek needed medical care. Accessed May 26, 2021.
Castellucci  M. Health systems leverage marketing to get patients back through the door. Accessed May 26, 2021.
Artiga  S , Orgera  K . Key facts on health and health care by race and ethnicity. Accessed May 28, 2021.
Hammond  WP , Mohottige  D , Chantala  K , Hastings  JF , Neighbors  HW , Snowden  L .  Determinants of usual source of care disparities among African American and Caribbean Black men: findings from the National Survey of American Life.   J Health Care Poor Underserved. 2011;22(1):157-175. doi:10.1353/hpu.2011.0016PubMedGoogle Scholar
Horenstein  A , Heimberg  RG .  Anxiety disorders and healthcare utilization: a systematic review.   Clin Psychol Rev. 2020;81:101894. doi:10.1016/j.cpr.2020.101894 PubMedGoogle Scholar
Nease  DE  Jr , Volk  RJ , Cass  AR .  Does the severity of mood and anxiety symptoms predict health care utilization?   J Fam Pract. 1999;48(10):769-777.PubMedGoogle Scholar
Wittchen  HU , Härtling  S , Dukes  E ,  et al.  Eine Analyse administrativ-epidemiologischer Daten zu Inanspruchnahme und Versorgungsmerkmalen. Generalized anxiety disorder in primary care: patterns of healthcare utilization in Germany.   MMW Fortschr Med. 2012;154(suppl 3):77-84.PubMedGoogle Scholar
Orlando Health Heart and Vascular Institute. Survey finds Americans may delay medical appointments, emergency care during pandemic. Accessed Feb 16, 2021.
Quaife  M , Terris-Prestholt  F , Di Tanna  GL , Vickerman  P .  How well do discrete choice experiments predict health choices: a systematic review and meta-analysis of external validity.   Eur J Health Econ. 2018;19(8):1053-1066. doi:10.1007/s10198-018-0954-6 PubMedGoogle ScholarCrossref
Want full access to the AMA Ed Hub?
After you sign up for AMA Membership, make sure you sign in or create a Physician account with the AMA in order to access all learning activities on the AMA Ed Hub
Buy this activity
Want full access to the AMA Ed Hub?
After you sign up for AMA Membership, make sure you sign in or create a Physician account with the AMA in order to access all learning activities on the AMA Ed Hub
Buy this activity
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right

Name Your Search

Save Search
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience

Lookup An Activity



My Saved Searches

You currently have no searches saved.


My Saved Courses

You currently have no courses saved.

With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right