Deaths From Ambulatory Care-Sensitive Conditions Increased During the COVID-19 Pandemic

The COVID-19 pandemic undeniably altered whether patients sought hospital care. In the early days of the pandemic, patients were actively dissuaded from seeking health care due to fears that they would contract COVID-19 or unnecessarily occupy personnel.

However, regular primary care visits are vital to ensure preventable conditions don’t develop into something more serious. A new original investigation, published in JAMA Network Open, sought to determine whether patients with ambulatory care-sensitive conditions (ACSCs) experienced worse hospital outcomes during the COVID-19 pandemic.

Ambulatory care-sensitive conditions are defined as preventable conditions in primary care, such as dehydration, gastroenteritis, asthma, congestive heart failure, and pneumococcal pneumonia. Prior research has suggested the number of hospitalizations and emergency department (ED) visits due to ACSC decreased early in the pandemic, while intensive care unit (ICU) admissions and length of stay were unchanged.

It is unclear whether the decrease in ACSCs during the COVID-19 was a good thing, as it could indicate some patients who needed care not gaining admission into hospitals. This cohort study analyzed whether the in-hospital ACSC mortality rate increased after the declaration of the COVID-19 national state of emergency in Japan.

The investigators compared the mean outcomes of in-hospital ACSC mortality in the months before and after the state of emergency was declared (January 1, 2020–December 31, 2020) and the corresponding months before the pandemic (January 1, 2015–December 31, 2019). When the Japanese government declared a state of emergency in April 2020, the public was encouraged to refrain from going out and gathering and to practice masking and handwashing to stop the spread of COVID-19.

Study data were collected between January 1, 2015–December 31, 2020 from a deidentified hospital claims database of 242 acute care hospitals Analyzed data comprised 11% of all hospital admissions in Japan, and the study authors noted that patient age, sex, and principal diagnoses were similar to nationwide estimates.

The primary study outcomes were the number of in-hospital deaths, the number of hospitalizations, and the in-hospital mortality rate associated with ACSC. Secondary outcomes included the mean length of stay and ambulance transport ratio.

A total of 28,321 ACSC-related hospitalizations were observed during the study period, averaging 54.1% male and 76 years of age. Of them, 24,261 occurred during the prepandemic period and 4060 during the pandemic. Overall, 7.5% were fatal (n = 2117). Predictably, the number of hospitalizations decreased overall, for chronic conditions, and for vaccine-preventable conditions.

However, in-hospital deaths and in-hospital deaths within 24 hours of admission increased for acute conditions. The in-hospital mortality rate also increased for acute conditions, while the 24-hour in-hospital mortality rates increased overall, for acute conditions, and for vaccine-preventable conditions. During the pandemic, patients hospitalized with ACSC were on average older, had a higher Elixhauser comorbidity index, shorter length of stay, and a higher rate of ambulance transport.

The study authors concluded that the number of in-hospital deaths increased after COVID-19 was declared an emergency in Japan. In-hospital mortality rates within 24 hours of hospital arrival increased overall by 87%, as well as for acute and vaccine-preventable conditions.

A key study finding was that despite the decreased hospitalizations, the number of deaths and in-hospital mortality rates actually increased during the COVID-19 pandemic, particularly for patients with acute ACSC. The study authors noted this could be due to a decreased quality of in-hospital care.