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What do people prioritize when deciding whether to present to the emergency department during the COVID-19 pandemic for care unrelated to COVID-19?
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.
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.
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.
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.
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.
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.
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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.
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 (Brennan.Spiegel@cshs.org).
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.
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