BACKGROUND AND OBJECTIVES:

The impact of the coronavirus disease 2019 (COVID-19) pandemic on pediatric emergency department (ED) visits is not well characterized. We aimed to describe the epidemiology of pediatric ED visits and resource use during the pandemic.

METHODS:

We conducted a cross-sectional study using the Pediatric Health Information System for ED visits to 27 US children’s hospitals during the COVID-19 pandemic period (March 15, 2020, to August 31, 2020) and a 3-year comparator period (March 15 to August 31, 2017–2019). ED visit rates, patient and visit characteristics, resource use, and ED charges were compared between the time periods. We specifically evaluated changes in low–resource-intensity visits, defined as ED visits that did not result in hospitalization or medication administration and for which no laboratory tests, diagnostic imaging, or procedures were performed.

RESULTS:

ED visit rates decreased by 45.7% (average 911 026 ED visits over 2017–2019 vs 495 052 visits in 2020) during the pandemic. The largest decrease occurred among visits for respiratory disorders (70.0%). The pandemic was associated with a relative increase in the proportion of visits for children with a chronic condition from 23.7% to 27.8% (P < .001). The proportion of low–resource-intensity visits decreased by 7.0 percentage points, and total charges decreased by 20.0% during the pandemic period.

CONCLUSIONS:

The COVID-19 pandemic was associated with a marked decrease in pediatric ED visits across a broad range of conditions; however, the proportional decline of poisoning and mental health visits was less pronounced. The impact of decreased visits on patient outcomes warrants further research.

What’s Known on This Subject:

Health care systems were affected by the coronavirus disease 2019 pandemic; however, the impact on pediatric emergency department visits and resource use is unknown.

What This Study Adds:

Emergency department visits declined in US children’s hospitals across a broad range of conditions during the coronavirus disease 2019 pandemic. Vulnerable children were disproportionately affected. The proportion of low–resource-intensity visits decreased, whereas resource use increased during the pandemic period.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerged in China late in 2019, and the World Health Organization declared the outbreak a pandemic on March 11, 2020.1,2  The devastating global impact of the coronavirus disease 2019 (COVID-19) pandemic continues to date, but the United States accounts for the highest disease burden and overall number of deaths globally.3  Although mortality among children is low, >600 000 children in the United States have been affected with a broad spectrum of disease.46 

SARS-CoV-2, and efforts to curb disease transmission, have negatively affected the US health care system.7  After declaration of a national emergency on March 13,8  public schools closed,9  shelter-in-place orders were imposed,10  and nonemergency, elective, and preventive medical care was deferred.11  The collective impact of these directives on emergency department (ED) use in the United States was profound: by April 25th, ED visits across a range of practice settings had decreased by 42%.12  Although respiratory disorders, including viral illnesses, are among the most common reasons children seek ED care,13  data from the Centers for Disease Control and Prevention revealed that ED visits in the United States for children <14 years of age fell by 70% during the early weeks of the pandemic.12  Whether this substantial decline in ED visits has persisted over time is unclear. Furthermore, pediatric EDs serve as regional referral centers providing specialized care, but data characterizing the clinical and financial impact of the COVID-19 pandemic on this practice setting are limited.1416  Finally, in current studies, researchers do not explore whether the decline in ED visits differentially impacted certain pediatric conditions or whether resource use differed for patients seeking ED care during the pandemic.14,15  As SARS-CoV-2 cases continue to rise among children,46  an improved understanding of the clinical and financial impact of the COVID-19 pandemic specifically on pediatric ED care is needed.1417  Thus, we describe the epidemiology of pediatric ED visits and resource use at tertiary care children’s hospitals in the United States during the first 5 months of the COVID-19 pandemic.

We conducted a cross-sectional study using data from the Pediatric Health Information System (PHIS), an administrative database including 50 tertiary care children’s hospitals in the United States.18  The PHIS database contains International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) diagnosis and procedure codes, billed services (eg, laboratory studies), and hospital charges. Data integrity is jointly monitored by participating institutions and the Children’s Hospital Association.19  We included all ED visits during the COVID-19 pandemic (March 15, 2020, to August 31, 2020) and a 3-year comparator period (March 15–August 31, 2017–2019) for 27 hospitals with complete administrative and billing data for the study periods. The Wayne State University Institutional Review Board deemed that this study did not qualify as human subject research.

Consistent with authors of a previous report, we defined the start of the pandemic period as the first Sunday (March 15, 2020) after the national emergency declaration on March 13, 2020.20  To account for yearly variation in ED volume and case mix, we averaged visit numbers for the 3-year comparator period across the same calendar dates as the pandemic period. We also examined ED visits from January 1, 2020, to March 14, 2020, to characterize ED visit volumes before the defined pandemic period. To contextualize ED visits from January to August 2020, we obtained daily national SARS-CoV-2 case counts for pediatric and adult patients from the Centers for Disease Control and Prevention.4,21 

Demographic characteristics for each ED visit included age (<1, 1–4, 5–9, 10–14, 15–18, and ≥19 years), sex, race and ethnicity (non-Hispanic white, non-Hispanic Black, Hispanic, or other), insurance coverage (government, private, or other), geographic region (Midwest, Northeast, South, West), distance from the hospital (calculated as the number of miles between the centroids of the patient’s and hospital’s zip codes), day of the week (weekend versus weekday), and time of arrival to the ED (8 am–3:59 pm, 4 pm–11:59 pm, and midnight to 7:59 am). We did not restrict the cohort by age to capture potential epidemiological changes in adult visits to pediatric EDs during the pandemic period. Race and ethnicity were included in the analyses as a social construct that has previously been associated with differences in ED care–seeking behavior.22,23 

We described patient complexity for each visit using a previously developed 3-tiered categorical variable: (1) no chronic condition, (2) noncomplex chronic condition, or (3) complex chronic condition (CCC).2427  First, we characterized patients as having a CCC, defined as any medical condition expected to last at least 12 months with multiorgan or severe single-organ involvement necessitating pediatric subspecialty care and hospitalization, using a previously validated approach.24,25  For those without a CCC, we used the Agency for Healthcare Research and Quality’s (AHRQ) Chronic Condition Indicator to categorize patients using ICD-10-CM diagnosis codes into 2 groups: with or without a chronic condition.26 

We examined primary discharge diagnoses, ED management, disposition, and select quality metrics for each visit.27  Principal ICD-10-CM discharge diagnosis codes were classified by AHRQ’s Clinical Classifications Software Refined.28  ED management included (1) performing laboratory testing or diagnostic imaging; (2) administering medications (other than ibuprofen or acetaminophen); and (3) performing procedures.27,29  Laboratory testing, diagnostic imaging, and medications administered for each visit were identified through billed transactions. Any charge within each category was categorized as resource utilization within the ED if the charge occurred on day 0 or before 6 pm on day 1 of hospitalization.30  Procedures were identified by current procedural terminology codes, with any assigned current procedural terminology code in the range 10 000 to 69 990 considered a procedure.30  Disposition was categorized as discharged from the hospital, transferred, hospitalized (with “observation” admissions categorized as a hospitalization), or died.31  Consistent with previous work, ED visits that did not result in hospitalization and in which no laboratory tests, diagnostic imaging, or procedures were performed were defined as a “low–resource-intensity visit.”29  ED visit charges billed to the patient were inflated to the 2020 US dollar (USD) on the basis of the Consumer Price Index for Hospital and Related Services.32 

Patient demographic and clinical characteristics were summarized by using frequencies for categorical variables and medians with interquartile ranges (IQRs) for numerical variables. Categorical variables were compared with Rao-Scott χ2 tests, adjusting for clustering at the hospital level. Numerical variables were compared with Wilcoxon rank tests. Year-over-year comparisons of daily volumes were shifted to compare similar days of the week to account for the variation in volume by day of the week. For instance, the daily volume change of January 25, 2020, was compared relative to the most proximal Saturday in previous years: January 26, 2019; January 27, 2018; and January 28, 2017. Total charges and charges stratified by discharge status in 2020 were compared with those in each of 2019, 2018, and 2017 with paired signed rank tests. SAS 9.4 (SAS Institute, Inc, Cary, NC) was used for all analyses.

ED visits across 27 pediatric hospitals revealed a sharp decline starting March 12, 2020, ∼1 month before SARS-CoV-2 cases started accelerating (Fig 1). By April 13, 2020, ED visits had declined to a low of 70.5% of previous average years’ volume and remained at 27.2% below prepandemic volumes into July 2020. In total, during the pandemic period, ED volume decreased from 911 026 ED visits averaged over 2017–2019 to 495 052 visits in 2020 (45.7% decline). The decline in volume across sites ranged from 36.1% to 69.9%, with average decreases across institutions by geographic region as follows: the Midwest decreased by 49.3%, West by 46.2%, Northeast by 46.0%, and South by 42.8%.

FIGURE 1

Overall change in pediatric ED visits during the COVID-19 pandemic. The primary y-axis displays the number of ED visits at each individual hospital (gray) and aggregate number (black) in 2020 relative to average ED volume in 2017–2019. The secondary y-axis displays the incidence of SARS-CoV-2 cases and the average daily pediatric SARS-CoV-2 cases in the United States.4,20 

FIGURE 1

Overall change in pediatric ED visits during the COVID-19 pandemic. The primary y-axis displays the number of ED visits at each individual hospital (gray) and aggregate number (black) in 2020 relative to average ED volume in 2017–2019. The secondary y-axis displays the incidence of SARS-CoV-2 cases and the average daily pediatric SARS-CoV-2 cases in the United States.4,20 

Compared with previous years, the demographic characteristics of children visiting the ED differed during the 2020 pandemic (Table 1). The proportion of children 15 to 18 years of age increased from 10.3% to 12.9%, and the proportion of adults aged ≥19 years increased from 4.1% to 6.3% during the pandemic (P < .001 for both). The proportion of children with a chronic condition increased from 23.7% to 27.8%, and there was an increase in the proportion of visits among non-Hispanic white children (32.3%–35.9%), those with private insurance (29.8%–32.0%), and patients residing >10 miles from the hospital (43.7%–47.3%) (P < .001 for all).

TABLE 1

Demographic Characteristics

CharacteristicComparator PeriodPandemic PeriodP
March 15 to August 31, 2017–2019 (N = 2 733 078)March 15 to August 31, 2020 (N = 495 052)
3-y Average (n = 911 026)
Age, y   <.001 
 <1 130 196 (14.3) 71 054 (14.4) — 
 1–4 296 436 (32.5) 144 968 (29.3) — 
 5–9 198 732 (21.8) 97 703 (19.7) — 
 10–14 154 662 (17.0) 86 319 (17.4) — 
 15–18 93 410 (10.3) 63 901 (12.9) — 
 19+ 37 591 (4.1) 31 107 (6.3) — 
Age, median (IQR), y 5 (1–11) 6 (1–13) <.001 
Sex   <.001 
 Male 475 396 (52.2) 253 052 (51.1) — 
 Female 435 514 (47.8) 241 902 (48.9) — 
Chronic conditiona   <.001 
 None 694 988 (76.3) 357 416 (72.2) — 
 Noncomplex chronic conditionb 144 052 (15.8) 86 624 (17.5) — 
 CCCc 71 986 (7.9) 51 012 (10.3) — 
Race and/or ethnicity   <.001 
 Non-Hispanic white 293 966 (32.3) 177 617 (35.9) — 
 Non-Hispanic Black 203 039 (22.3) 105 830 (21.4) — 
 Hispanic 304 273 (33.4) 148 274 (30.0) — 
 Other 109 748 (12.0) 63 331 (12.8) — 
Payer   <.001 
 Government 570 523 (65.2) 295 464 (62.0) — 
 Private 260 865 (29.8) 152 602 (32.0) — 
 Other 43 596 (5.0) 28 182 (5.9) — 
Geographic region   <.001 
 Midwest 208 038 (22.8) 105 445 (21.3) — 
 Northeast 68 185 (7.5) 36 823 (7.4) — 
 South 332 011 (36.4) 189 820 (38.3) — 
 West 302 791 (33.2) 162 964 (32.9) — 
 Distance from hospital, median (IQR), miles 8.7 (4.6–17.6) 9.4 (4.9, 19.1) <.001 
Distance from hospital   <.001 
 <5 miles 252 208 (27.7) 126 856 (25.6) — 
 5–10 miles 258 314 (28.4) 133 079 (26.9) — 
 10–20 miles 208 501 (22.9) 117 958 (23.8) — 
 20+ miles 189 737 (20.8) 116 571 (23.5) — 
 Missing 2267 (0.2) 588 (0.1) — 
Time of day   <.001 
 8 am to 3:59 pm 325 576 (35.7) 181 923 (36.8) — 
 4 pm to 11:59 pm 458 097 (50.3) 246 248 (49.8) — 
 Midnight to 7:59 am 127 117 (14.0) 66 613 (13.5) — 
Day of week   .257 
 Weekday 646 921 (71.0) 351 144 (70.9) — 
 Weekend 264 105 (29.0) 143 908 (29.1) — 
CharacteristicComparator PeriodPandemic PeriodP
March 15 to August 31, 2017–2019 (N = 2 733 078)March 15 to August 31, 2020 (N = 495 052)
3-y Average (n = 911 026)
Age, y   <.001 
 <1 130 196 (14.3) 71 054 (14.4) — 
 1–4 296 436 (32.5) 144 968 (29.3) — 
 5–9 198 732 (21.8) 97 703 (19.7) — 
 10–14 154 662 (17.0) 86 319 (17.4) — 
 15–18 93 410 (10.3) 63 901 (12.9) — 
 19+ 37 591 (4.1) 31 107 (6.3) — 
Age, median (IQR), y 5 (1–11) 6 (1–13) <.001 
Sex   <.001 
 Male 475 396 (52.2) 253 052 (51.1) — 
 Female 435 514 (47.8) 241 902 (48.9) — 
Chronic conditiona   <.001 
 None 694 988 (76.3) 357 416 (72.2) — 
 Noncomplex chronic conditionb 144 052 (15.8) 86 624 (17.5) — 
 CCCc 71 986 (7.9) 51 012 (10.3) — 
Race and/or ethnicity   <.001 
 Non-Hispanic white 293 966 (32.3) 177 617 (35.9) — 
 Non-Hispanic Black 203 039 (22.3) 105 830 (21.4) — 
 Hispanic 304 273 (33.4) 148 274 (30.0) — 
 Other 109 748 (12.0) 63 331 (12.8) — 
Payer   <.001 
 Government 570 523 (65.2) 295 464 (62.0) — 
 Private 260 865 (29.8) 152 602 (32.0) — 
 Other 43 596 (5.0) 28 182 (5.9) — 
Geographic region   <.001 
 Midwest 208 038 (22.8) 105 445 (21.3) — 
 Northeast 68 185 (7.5) 36 823 (7.4) — 
 South 332 011 (36.4) 189 820 (38.3) — 
 West 302 791 (33.2) 162 964 (32.9) — 
 Distance from hospital, median (IQR), miles 8.7 (4.6–17.6) 9.4 (4.9, 19.1) <.001 
Distance from hospital   <.001 
 <5 miles 252 208 (27.7) 126 856 (25.6) — 
 5–10 miles 258 314 (28.4) 133 079 (26.9) — 
 10–20 miles 208 501 (22.9) 117 958 (23.8) — 
 20+ miles 189 737 (20.8) 116 571 (23.5) — 
 Missing 2267 (0.2) 588 (0.1) — 
Time of day   <.001 
 8 am to 3:59 pm 325 576 (35.7) 181 923 (36.8) — 
 4 pm to 11:59 pm 458 097 (50.3) 246 248 (49.8) — 
 Midnight to 7:59 am 127 117 (14.0) 66 613 (13.5) — 
Day of week   .257 
 Weekday 646 921 (71.0) 351 144 (70.9) — 
 Weekend 264 105 (29.0) 143 908 (29.1) — 

—, not applicable.

a

Diagnoses reported during all ED encounters were used to categorize patients by chronic condition.

b

These children had a chronic condition, identified with the AHRQ’s Chronic Condition Indicator system but did not have a CCC, identified with Feudtner's diagnosis list.2426 

c

These children had a CCC identified with the diagnosis list from Feudtner et al.24,25 

There were changes in the distribution of the types of encounters during the pandemic, as shown in Table 2 (Supplemental Table 5). The most notable were decreases in the overall number of visits among children with respiratory illnesses (70.0%), including respiratory infections and asthma (69.6% and 73.9%, respectively). Sharp declines in ED visits were observed for less urgent conditions, such as otitis media and upper respiratory infection (75.1% and 69.6% decreases, respectively). Less pronounced decreases were observed for ED visits resulting from injuries and/or poisoning (33.1%) and mental health disorders (29.0%) and among pregnant patients (23.0%). Within the injuries and/or poisoning diagnostic chapter, the weighted average decrease in diagnostic codes related to poisoning (20.2%) was less pronounced than the decline in diagnostic codes related to injury (34.6%) (Supplemental Table 5). The most frequent poisoning-related diagnosis (poisoning by drugs, initial encounter) in the comparator period (n = 2414) declined 8.1% in the pandemic period (Supplemental Table 5). Among the mental health disorders, visits for depressive disorders decreased 38.8%, whereas visits for suicidal ideation or attempt declined 4.0% and stimulant-related disorders were unchanged (2.0%) (Supplemental Table 5).

TABLE 2

Three Most Frequent Diagnoses in the Comparator Period for Each ICD-10-CM Diagnosis Chapters With Visit Frequency and Percent Change During the Pandemic Period

DiagnosisComparator PeriodPandemic PeriodPercent ChangeAbsolute Change
March 15 to August 31, 2017–2019March 15 to August 31, 2020
nn
Injury, poisoning, and certain other consequences of external causes 205 098 137 217 −33.1% −67 881 
 Superficial injury; contusion, initial encounter 37 005 19 403 −47.6% −17 602 
 Other unspecified injury 27 929 14 667 −47.5% −13 262 
 Open wounds of head and neck, initial encounter 26 738 22 026 −17.6% −4712 
Symptoms, signs, and abnormal clinical and laboratory findings, not elsewhere classified 158 123 86 746 −45.0% −71 377 
 Abdominal pain and other digestive or abdomen signs and symptoms 37 384 19 246 −48.5% −18 138 
 Fever 36 087 23 745 −34.2% −12 342 
 Nausea and vomiting 25 743 8781 −65.9% −16 962 
Diseases of the respiratory system 157 649 47 079 −70.0% −110 570 
 Other specified upper respiratory infections 92 103 28 015 −69.6% −64 088 
 Asthma 23 950 6245 −73.9% −17 705 
 Acute bronchitis 11 565 2571 −77.8% −8994 
Diseases of the digestive system 76 613 38 782 −49.0% −37 831 
 Other specified and unspecified gastrointestinal disorders 16 636 9548 −42.6% −7088 
 Noninfectious gastroenteritis 12 844 3357 −73.9% −9487 
 Diseases of mouth, excluding dental 11 144 3039 −72.7% −8105 
Diseases of the ear and mastoid process 43 286 13 747 −68.0% −29 539 
 Otitis media 33 551 8342 −75.1% −25 209 
 Other specified and unspecified disorders of the ear 8716 5008 −42.5% −3708 
 Diseases of middle ear and mastoid (except otitis media) 865 300 −65.3% −565 
Diseases of the skin and subcutaneous tissue 41 084 21 584 −47.0% −19 500 
 Skin and subcutaneous tissue infections 19 621 11 446 −41.7% −8175 
 Other specified inflammatory condition of skin 10 404 4894 −53.0% −5510 
 Other specified and unspecified skin disorders 5998 2796 −53.4% −3202 
Certain infectious and parasitic diseases 33 024 23 720 −28.0% −9304 
 Viral infection 26 361 12 658 −52.0% −13 703 
 Fungal infections 1897 798 −57.9% −1099 
 Parasitic, other specified and unspecified infections 1877 765 −59.2% −1112 
Diseases of the nervous system 32 976 18 989 −42.0% −13 987 
 Headache, including migraine 14 451 6840 −52.7% −7611 
 Epilepsy, convulsions 13 546 9071 −33.0% −4475 
 Nervous system pain and pain syndromes 1069 484 −54.7% −585 
Diseases of the genitourinary system 27 503 20 489 −26.0% −7014 
 Urinary tract infections 12 548 9158 −27.0% −3390 
 Other specified male genital disorders 3669 3057 −16.7% −612 
 Inflammatory conditions of male genital organs 2192 1655 −24.5% −537 
Diseases of the musculoskeletal system and connective tissue 27 389 14 794 −46.0% −12 595 
 Musculoskeletal pain, not low back pain 14 287 7377 −48.4% −6910 
 Spondylopathies or spondyloarthropathy (including infective) 3083 1660 −46.2% −1423 
 Other specified bone disease and musculoskeletal deformities 2181 1226 −43.8% −955 
Mental, behavioral and neurodevelopmental disorders 22 668 16 107 −29.0% −6561 
 Depressive disorders 5684 3476 −38.8% −2208 
 Suicidal ideation or attempt or intentional self-harm 3918 3760 −4.0% −158 
 Anxiety and fear-related disorders 2626 2124 −19.1% −502 
Factors influencing health status and contact with health services 19 999 16 159 −19.0% −3840 
 Encounter for observation and examination for conditions ruled out (excludes infectious disease, neoplasm, mental disorders) 6086 3477 −42.9% −2609 
 Other specified status 5770 1917 −66.8% −3853 
 Other aftercare encounter 3462 2306 −33.4% −1156 
Diseases of the eye and adnexa 16 893 5687 −66.0% −11 206 
 Cornea and external disease 12 749 3481 −72.7% −9268 
 Other specified eye disorders 2187 1043 −52.3% −1144 
 Oculofacial plastics and orbital conditions 1101 555 −49.6% −546 
Diseases of the circulatory system 13 077 9085 −31.0% −3992 
 Nonspecific chest pain 8382 5846 −30.3% −2536 
 Other specified diseases of veins and lymphatics 1813 1057 −41.7% −756 
 Cardiac dysrhythmias 654 455 −30.5% −199 
Endocrine, nutritional and metabolic diseases 11 347 7451 −34.0% −3896 
 Fluid and electrolyte disorders 5552 2740 −50.6% −2812 
 Diabetes mellitus with complication 3681 3274 −11.1% −407 
 Other specified and unspecified endocrine disorders 577 381 −34.0% −196 
Certain conditions originating in the perinatal period 9404 6956 −26.0% −2448 
 Other specified and unspecified perinatal conditions 2667 1950 −26.9% −717 
 Neonatal digestive and feeding disorders 2030 1508 −25.7% −522 
 Hemolytic jaundice and perinatal jaundice 1928 1640 −14.9% −288 
Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism 7413 4779 −36.0% −2634 
 Sickle cell trait or anemia 3975 2515 −36.7% −1460 
 Coagulation and hemorrhagic disorders 1108 563 −49.2% −545 
 Diseases of white blood cells 1052 808 −23.2% −244 
Congenital malformations, deformations and chromosomal abnormalities 2515 1810 −28.0% −705 
 Digestive congenital anomalies 772 651 −15.7% −121 
 Cardiac and circulatory congenital anomalies 413 292 −29.3% −121 
 Musculoskeletal congenital conditions 305 180 −41.0% −125 
Neoplasms 2466 1947 −21.0% −519 
 Leukemia: acute lymphoblastic leukemia 502 368 −26.7% −134 
 Conditions due to neoplasm or the treatment of neoplasm 496 389 −21.6% −107 
 Benign neoplasms 496 365 −26.4% −131 
Pregnancy, childbirth, and the puerperium 2079 1599 −23.0% −480 
 Other specified complications in pregnancy 1044 756 −27.6% −288 
 Early, first, or unspecified trimester hemorrhage 492 400 −18.6% −92 
 Spontaneous abortion and complications of spontaneous abortion 152 114 −24.8% −38 
DiagnosisComparator PeriodPandemic PeriodPercent ChangeAbsolute Change
March 15 to August 31, 2017–2019March 15 to August 31, 2020
nn
Injury, poisoning, and certain other consequences of external causes 205 098 137 217 −33.1% −67 881 
 Superficial injury; contusion, initial encounter 37 005 19 403 −47.6% −17 602 
 Other unspecified injury 27 929 14 667 −47.5% −13 262 
 Open wounds of head and neck, initial encounter 26 738 22 026 −17.6% −4712 
Symptoms, signs, and abnormal clinical and laboratory findings, not elsewhere classified 158 123 86 746 −45.0% −71 377 
 Abdominal pain and other digestive or abdomen signs and symptoms 37 384 19 246 −48.5% −18 138 
 Fever 36 087 23 745 −34.2% −12 342 
 Nausea and vomiting 25 743 8781 −65.9% −16 962 
Diseases of the respiratory system 157 649 47 079 −70.0% −110 570 
 Other specified upper respiratory infections 92 103 28 015 −69.6% −64 088 
 Asthma 23 950 6245 −73.9% −17 705 
 Acute bronchitis 11 565 2571 −77.8% −8994 
Diseases of the digestive system 76 613 38 782 −49.0% −37 831 
 Other specified and unspecified gastrointestinal disorders 16 636 9548 −42.6% −7088 
 Noninfectious gastroenteritis 12 844 3357 −73.9% −9487 
 Diseases of mouth, excluding dental 11 144 3039 −72.7% −8105 
Diseases of the ear and mastoid process 43 286 13 747 −68.0% −29 539 
 Otitis media 33 551 8342 −75.1% −25 209 
 Other specified and unspecified disorders of the ear 8716 5008 −42.5% −3708 
 Diseases of middle ear and mastoid (except otitis media) 865 300 −65.3% −565 
Diseases of the skin and subcutaneous tissue 41 084 21 584 −47.0% −19 500 
 Skin and subcutaneous tissue infections 19 621 11 446 −41.7% −8175 
 Other specified inflammatory condition of skin 10 404 4894 −53.0% −5510 
 Other specified and unspecified skin disorders 5998 2796 −53.4% −3202 
Certain infectious and parasitic diseases 33 024 23 720 −28.0% −9304 
 Viral infection 26 361 12 658 −52.0% −13 703 
 Fungal infections 1897 798 −57.9% −1099 
 Parasitic, other specified and unspecified infections 1877 765 −59.2% −1112 
Diseases of the nervous system 32 976 18 989 −42.0% −13 987 
 Headache, including migraine 14 451 6840 −52.7% −7611 
 Epilepsy, convulsions 13 546 9071 −33.0% −4475 
 Nervous system pain and pain syndromes 1069 484 −54.7% −585 
Diseases of the genitourinary system 27 503 20 489 −26.0% −7014 
 Urinary tract infections 12 548 9158 −27.0% −3390 
 Other specified male genital disorders 3669 3057 −16.7% −612 
 Inflammatory conditions of male genital organs 2192 1655 −24.5% −537 
Diseases of the musculoskeletal system and connective tissue 27 389 14 794 −46.0% −12 595 
 Musculoskeletal pain, not low back pain 14 287 7377 −48.4% −6910 
 Spondylopathies or spondyloarthropathy (including infective) 3083 1660 −46.2% −1423 
 Other specified bone disease and musculoskeletal deformities 2181 1226 −43.8% −955 
Mental, behavioral and neurodevelopmental disorders 22 668 16 107 −29.0% −6561 
 Depressive disorders 5684 3476 −38.8% −2208 
 Suicidal ideation or attempt or intentional self-harm 3918 3760 −4.0% −158 
 Anxiety and fear-related disorders 2626 2124 −19.1% −502 
Factors influencing health status and contact with health services 19 999 16 159 −19.0% −3840 
 Encounter for observation and examination for conditions ruled out (excludes infectious disease, neoplasm, mental disorders) 6086 3477 −42.9% −2609 
 Other specified status 5770 1917 −66.8% −3853 
 Other aftercare encounter 3462 2306 −33.4% −1156 
Diseases of the eye and adnexa 16 893 5687 −66.0% −11 206 
 Cornea and external disease 12 749 3481 −72.7% −9268 
 Other specified eye disorders 2187 1043 −52.3% −1144 
 Oculofacial plastics and orbital conditions 1101 555 −49.6% −546 
Diseases of the circulatory system 13 077 9085 −31.0% −3992 
 Nonspecific chest pain 8382 5846 −30.3% −2536 
 Other specified diseases of veins and lymphatics 1813 1057 −41.7% −756 
 Cardiac dysrhythmias 654 455 −30.5% −199 
Endocrine, nutritional and metabolic diseases 11 347 7451 −34.0% −3896 
 Fluid and electrolyte disorders 5552 2740 −50.6% −2812 
 Diabetes mellitus with complication 3681 3274 −11.1% −407 
 Other specified and unspecified endocrine disorders 577 381 −34.0% −196 
Certain conditions originating in the perinatal period 9404 6956 −26.0% −2448 
 Other specified and unspecified perinatal conditions 2667 1950 −26.9% −717 
 Neonatal digestive and feeding disorders 2030 1508 −25.7% −522 
 Hemolytic jaundice and perinatal jaundice 1928 1640 −14.9% −288 
Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism 7413 4779 −36.0% −2634 
 Sickle cell trait or anemia 3975 2515 −36.7% −1460 
 Coagulation and hemorrhagic disorders 1108 563 −49.2% −545 
 Diseases of white blood cells 1052 808 −23.2% −244 
Congenital malformations, deformations and chromosomal abnormalities 2515 1810 −28.0% −705 
 Digestive congenital anomalies 772 651 −15.7% −121 
 Cardiac and circulatory congenital anomalies 413 292 −29.3% −121 
 Musculoskeletal congenital conditions 305 180 −41.0% −125 
Neoplasms 2466 1947 −21.0% −519 
 Leukemia: acute lymphoblastic leukemia 502 368 −26.7% −134 
 Conditions due to neoplasm or the treatment of neoplasm 496 389 −21.6% −107 
 Benign neoplasms 496 365 −26.4% −131 
Pregnancy, childbirth, and the puerperium 2079 1599 −23.0% −480 
 Other specified complications in pregnancy 1044 756 −27.6% −288 
 Early, first, or unspecified trimester hemorrhage 492 400 −18.6% −92 
 Spontaneous abortion and complications of spontaneous abortion 152 114 −24.8% −38 

Diagnosis chapters are listed in descending order of visit frequency during the comparator period.

ED visits during the COVID-19 pandemic were associated with increased resource use, revealed by relative increases in laboratory testing (11.1% [95% confidence interval (CI): 10.9 to 11.2]), diagnostic imaging (5.5% [95% CI: 5.3 to 5.6]), medication administration (2.2% [95% CI: 2.0 to 2.3]), and performance of procedures (3.2% [95% CI: 3.1 to 3.3]). Among the laboratory tests performed, testing for SARS-CoV-2 accounted for 5.2% (26 809 of 490 052) of tests during the pandemic period. Compared with previous years, hospitalizations increased 3.3 and intensive care admissions increased 0.4 percentage points between the comparator and pandemic periods (Table 3). Low–resource-intensity visits decreased from 30.7% of all ED visits in the prepandemic period to 23.7% during the pandemic period (−7.0% [95% CI: −7.1 to −6.9]).

TABLE 3

Resource Use for Pediatric ED Visits in the Study Periods

Comparator PeriodPandemic PeriodPercent Change (95% CI)
March 15 to August 31, 2017–2019March 15 to August 31, 2020
n (%)n (%)
ED management    
 Laboratory test performed 312 886 (34.3) 224 861 (45.4) 11.1% (10.9 to 11.2) 
 Imaging study performed 285 558 (31.3) 182 315 (36.8) 5.5% (5.3 to 5.6) 
 Medication administered 395 535 (43.4) 225 796 (45.6) 2.2% (2.0 to 2.3) 
 Procedure performed 85 614 (9.4) 62 404 (12.6) 3.2% (3.1 to 3.3) 
Disposition from the ED    
 Discharged 795 723 (87.3) 414 588 (83.7) −3.6% (−3.7 to −3.5) 
 Hospitalized 103 881 (11.4) 72 947 (14.7) 3.3% (3.2 to 3.4) 
 ICU 11 271 (1.2) 8115 (1.6) 0.4% (0.4 to 0.4) 
 Died in ED or during hospitalization 524 (0.1) 504 (0.1) 0% (0 to 0.1) 
 Transfer out of the ED 10 897 (1.2) 7013 (1.4) 0.2% (0.2 to 0.3) 
Other metrics    
 ED length of stay, median (IQR), ha 2 (1–3) 2 (1–4) — 
 Hospital length of stay, median (IQR), da 2 (1–3) 2 (1–4) — 
    Low–resource-intensity visitb 279 455 (30.7) 117 259 (23.7) −7.0% (−7.1 to −6.9) 
Charges for discharged ED patients, median (IQR), USDa 1296 (666–2261) 1647 (950–3004) — 
 Charges for hospitalized ED patients, median (IQR), USDa 20 524 (12 137–37 098) 24 531 (14 480–43 995) — 
Comparator PeriodPandemic PeriodPercent Change (95% CI)
March 15 to August 31, 2017–2019March 15 to August 31, 2020
n (%)n (%)
ED management    
 Laboratory test performed 312 886 (34.3) 224 861 (45.4) 11.1% (10.9 to 11.2) 
 Imaging study performed 285 558 (31.3) 182 315 (36.8) 5.5% (5.3 to 5.6) 
 Medication administered 395 535 (43.4) 225 796 (45.6) 2.2% (2.0 to 2.3) 
 Procedure performed 85 614 (9.4) 62 404 (12.6) 3.2% (3.1 to 3.3) 
Disposition from the ED    
 Discharged 795 723 (87.3) 414 588 (83.7) −3.6% (−3.7 to −3.5) 
 Hospitalized 103 881 (11.4) 72 947 (14.7) 3.3% (3.2 to 3.4) 
 ICU 11 271 (1.2) 8115 (1.6) 0.4% (0.4 to 0.4) 
 Died in ED or during hospitalization 524 (0.1) 504 (0.1) 0% (0 to 0.1) 
 Transfer out of the ED 10 897 (1.2) 7013 (1.4) 0.2% (0.2 to 0.3) 
Other metrics    
 ED length of stay, median (IQR), ha 2 (1–3) 2 (1–4) — 
 Hospital length of stay, median (IQR), da 2 (1–3) 2 (1–4) — 
    Low–resource-intensity visitb 279 455 (30.7) 117 259 (23.7) −7.0% (−7.1 to −6.9) 
Charges for discharged ED patients, median (IQR), USDa 1296 (666–2261) 1647 (950–3004) — 
 Charges for hospitalized ED patients, median (IQR), USDa 20 524 (12 137–37 098) 24 531 (14 480–43 995) — 

—, not applicable.

a

Comparisons were statistically significant to <.001 by using Wilcoxon rank tests.

b

Low–resource-intensity visit was defined as a visit in which the patient was not hospitalized and in which no laboratory tests, diagnostic imaging, or procedures were performed.29 

Overall, total charges from cases originating in the ED decreased from an average of $5.7 billion in 2017–2019 to $4.6 billion in 2020. This represents a 20.0% decrease in total charges during the pandemic period. Hospitals experienced a median (IQR) change in charges from 2017–2019 to 2020 of −$35.1 million (−17.8 to −63.8) (P < .001; Table 4). In terms of percentage decreases, the hospitals saw charges decrease by a median (IQR) percent of −33.7% (−26.7 to −38.2) from patients who were discharged from the ED and −16.0% (−6.5 to −23.2) from patients who were admitted (both P < .001).

TABLE 4

Median Charges for Pediatric ED Visits During the Study Periods

Comparator PeriodPandemic Period
2017201820192020
March 15 to June 30March 15 to June 30March 15 to June 30March 15 to June 30
Total charges, median (IQR)a 169.3 (112.3–275.8) 192.8 (111.8–294) 201.3 (122.2–330.6) 142.9 (87.8–238.1)b 
ED discharges, median (IQR) 48.5 (31.6–69) 47.2 (29.4–78.1) 47.2 (32.6–90.7) 32.8 (17.2–48.9)b 
ED admissions, median (IQR) 134.8 (73.4–207.9) 129.6 (78.8–221.2) 134.4 (78.2–264.6) 116.9 (60.3–197.1)b 
Comparator PeriodPandemic Period
2017201820192020
March 15 to June 30March 15 to June 30March 15 to June 30March 15 to June 30
Total charges, median (IQR)a 169.3 (112.3–275.8) 192.8 (111.8–294) 201.3 (122.2–330.6) 142.9 (87.8–238.1)b 
ED discharges, median (IQR) 48.5 (31.6–69) 47.2 (29.4–78.1) 47.2 (32.6–90.7) 32.8 (17.2–48.9)b 
ED admissions, median (IQR) 134.8 (73.4–207.9) 129.6 (78.8–221.2) 134.4 (78.2–264.6) 116.9 (60.3–197.1)b 
a

Millions, adjusted to 2020 USD.

b

Comparisons were significant to P < .001 by using paired signed rank tests, except for 2017 vs 2020 ED admissions, which is significant to P = .001.

In this large multicenter study of 495 000 visits across 27 US EDs, we found that the COVID-19 pandemic profoundly impacted pediatric EDs. The overall number of ED visits declined rapidly and consistently across 27 pediatric hospitals, even before SARS-CoV-2 infections began to rise in the United States. It is suggested in our data that although this widespread decline impacted a broad range of pediatric conditions, pediatric EDs continued to care for higher-acuity patients during the pandemic period.

Notably, pediatric ED visits began to decrease steadily before the surge of SARS-CoV-2 cases, suggesting that public health measures, including emergency declarations to control the spread of disease, likely influenced health care–seeking behaviors.17  SARS-CoV-2 circulated with marked regional differences across the United States,3,21  but the timing of the impact on pediatric ED volumes was uniform, with all 27 sites experiencing an immediate decrease in the overall number of visits. These declines are consistent with smaller international studies of pediatric hospitals, which revealed rapid declines in ED visits and hospitalizations around the time of each country’s emergency declarations, well before peaks in SARS-CoV-2 cases.3335  Yet, it is unclear from our data analysis and the current literature whether visits for SARS-CoV-2 or other common acute and nonacute pediatric conditions contributed most substantially to ED volume recovery.14,15,3335 

Although our results highlight that ED volumes are revealing slow recovery, our analysis underscores that the marked decline in pediatric ED visits and subsequent hospitalizations had a notable financial impact for children’s hospitals in the United States. Although numerous factors contribute, cancelled nonurgent and elective care visits coupled with the rising costs associated with disrupted medical and equipment supply chains led to a financial crisis for many US health care systems.36  By the end of 2020, the Children’s Hospital Association projects that losses for pediatric hospitals will reach $10 billion,16  but with our data, we are the first to quantify the true financial impact of the COVID-19 pandemic on pediatric EDs.

Our data reveal the impact of public health initiatives to curb disease spread and directives to avoid nonessential care11 : low–resource-intensity visits dropped significantly during the COVID-19 pandemic. As the low–resource-intensity visits declined during the COVID-19 pandemic, our data suggest a disproportionate decline in pediatric ED visits for potentially vulnerable children, characterized by race and ethnicity, insurance status, and proximity to the hospital. Although initiatives exist to encourage nonurgent visits in the primary care setting,37  the decline in these visits in the context of the pandemic is concerning because pediatric practices also saw marked decreases in routine patient visits, caring for only 30% of their typical clinic volume.38  Health care–seeking behavior is multifactorial, influenced both positively and negatively by public health strategies to contain SARS-CoV-2, but our results draw attention to the fact that health care avoidance may be mediated by various sociodemographic factors.

With our results, we also provide initial insight into care delivery for pediatric patients coming to the ED during the COVID-19 pandemic. As expected, ED care for nonurgent conditions such as acute otitis media and upper respiratory infection declined; however, conditions commonly requiring ED care also had a steep decline in visits, including asthma, injuries, mental health conditions, and child abuse. Stay-at-home orders and school closures may have altered the epidemiology of other viral infections that commonly lead to asthma exacerbations requiring acute care.33  These same directives contributed to a decline in motor vehicle travel, playground closure, and cancellation of sporting events, partly explaining a decrease in acute injuries and fractures.3941  Public health measures to control SARS-CoV-2 may have had unintended benefits for children by mitigating the need for medical care for common childhood conditions.

On the other hand, our findings also support that there may be negative unintended consequences arising from mitigating public health measures that disrupt normal social interactions. First, our data reveal that ED visits related to poisoning and substance use disorders were not as profoundly impacted by the pandemic. Our findings align with reports that calls to poison control centers rose during the COVID-19 pandemic, driven by accidental exposures to various household substances including disinfectants.42  Substance use disorders are more common among adolescents,43  who increasingly sought ED care during the pandemic period. Second, social isolation and familial socioeconomic struggles resulting from public health measures may have negatively affected children’s mental health, particularly for adolescents.44  Yet, while 40% of adults reported declining mental health by June 2020,45  pediatric ED visits for depression, anxiety, and suicide declined. The longer-term impact of decreased mental health visits to pediatric EDs remains unclear. Finally, we note a decrease in visits during the pandemic for child maltreatment and abuse, aligning with documented decreases in child protection reports. Experts are concerned that child abuse is occurring without intervention from medical and legal authorities46 ; thus, it is possible that in the context of the COVID-19 pandemic, the pediatric ED as a safety net may have inadvertently failed.

This study has several important limitations. First, our data reflect the experience of 27 US children’s hospitals, which limits national and international generalizability. However, our results align with previous US and international studies suggesting that similar trends regarding ED volumes and visit intensity exist for general EDs.14,15,3335  Second, children transferred to the PHIS hospital were not excluded, and reported charges may not reflect overall health care expenditures because diagnostic testing that may have been performed before the ED visit is not included. Third, ED visit acuity cannot be characterized in PHIS by using measures such as the emergency severity index. Thus, proxy measures were used, including hospitalization and intensive care admission, which may not accurately reflect ED visit acuity. Our results, however, note an increase in acuity, which aligns with a single-center US report in which emergency severity index was included in the analysis.15  Fourth, PHIS is an administrative data set and does not contain detailed clinical data. As such, we are unable to characterize the reason for the ED visit or the clinical course, limiting our ability to examine potential escalations in ED clinical care or increased morbidity for visits occurring during the pandemic period. Given the large number of children included in PHIS, many comparisons were statistically significant but may not be clinically meaningful. Finally, our data do not account for alternative care availability, such as visits occurring in the primary care setting. Thus, we are unable to comment on the exact impact of the decline in ED visits on children’s overall access to health care, but outpatient visits also declined.38 

Pediatric EDs in the United States saw a dramatic decline in visits for both acute and nonacute conditions during the COVID-19 pandemic. Although visits declined across a broad range of pediatric conditions, the proportional decline for poisoning and mental health visits was less pronounced. Because low–resource-intensity visits decreased and resource use increased, further study is needed to determine if patient outcomes were influenced by care-seeking behaviors during the COVID-19 pandemic.

Drs DeLaroche and Neuman conceptualized and designed the study and drafted the initial manuscript; Drs Aronson, Fleegler, Florin, Goyal, Hirsch, Jain, Kornblith, Sills, and Wells conceptualized and designed the study; Mr Rodean conceptualized and designed the study and conducted data analyses; and all authors analyzed and interpreted the data, revised the manuscript critically for important intellectual content, approved the final manuscript as submitted, and agree to be accountable for all aspects of the work.

FUNDING: No external funding.

     
  • AHRQ

    Agency for Healthcare Research and Quality

  •  
  • CCC

    complex chronic condition

  •  
  • CI

    confidence interval

  •  
  • COVID-19

    coronavirus disease 2019

  •  
  • ED

    emergency department

  •  
  • ICD-10-CM

    International Classification of Diseases, 10th Revision, Clinical Modification

  •  
  • IQR

    interquartile range

  •  
  • PHIS

    Pediatric Health Information System

  •  
  • SARS-CoV-2

    severe acute respiratory syndrome coronavirus 2

  •  
  • USD

    US dollar

1
Zhou
P
,
Yang
XL
,
Wang
XG
, et al
.
A pneumonia outbreak associated with a new coronavirus of probable bat origin
.
Nature
.
2020
;
579
(
7798
):
270
273
2
World Health Organization
.
Archived: WHO timeline - COVID-19. Available at: https://www.who.int/news-room/detail/27-04-2020-who-timeline---covid-19. Accessed September 24, 2020
3
Center for Systems Science and Engineering at Johns Hopkins University
.
COVID-19 dashboard. Available at: https://coronavirus.jhu.edu/map.html. Accessed October 20, 2020
4
American Academy of Pediatrics
.
Children and COVID-19: state-level data report. Version: 11/12/20. Available at: https://downloads.aap.org/AAP/PDF/AAP%20and%20CHA%20-%20Children%20and%20COVID-19%20State%20Data%20Report%2011.12.20%20FINAL.pdf. Accessed November 21, 2020
5
CDC COVID-19 Response Team
.
Coronavirus disease 2019 in children — United States, February 12–April 2, 2020
.
MMWR Morb Mortal Wkly Rep
.
2020
;
69
(
14
):
422
426
6
Sisk
B
,
Cull
W
,
Harris
JM
,
Rothenburger
A
,
Olson
L
.
National trends of cases of COVID-19 in children based on US state health department data
.
Pediatrics
.
2020
;
146
(
6
):
e2020027425
7
Bartsch
SM
,
Ferguson
MC
,
McKinnell
JA
, et al
.
The potential health care costs and resource use associated with COVID-19 in the United States
.
Health Aff (Millwood)
.
2020
;
39
(
6
):
927
935
8
Taylor
DB
.
A timeline of the coronavirus pandemic. New York Times. December 28, 2020. Available at: https://www.nytimes.com/article/coronavirus-timeline.html. Accessed September 23, 2020
9
Auger
KA
,
Shah
SS
,
Richardson
T
, et al
.
Association between statewide school closure and COVID-19 incidence and mortality in the US
.
JAMA
.
2020
;
324
(
9
):
859
870
10
Wu
J
,
Smith
S
,
Khurana
M
,
Siemaszko
C
,
DeJesus-Banos
B
.
Stay-at-home orders across the country. NBC News. March 25, 2020. Available at: https://www.nbcnews.com/health/health-news/here-are-stay-home-orders-across-country-n1168736. Accessed June 12, 2020
11
Centers for Medicare & Medicaid Services
.
Non-emergent, elective medical services, and treatment recommendations. Available at: https://www.cms.gov/files/document/cms-non-emergent-elective-medical-recommendations.pdf. Accessed September 23, 2020
12
Hartnett
KP
,
Kite-Powell
A
,
DeVies
J
, et al.;
National Syndromic Surveillance Program Community of Practice
.
Impact of the COVID-19 pandemic on emergency department visits - United States, January 1, 2019-May 30, 2020
.
MMWR Morb Mortal Wkly Rep
.
2020
;
69
(
23
):
699
704
13
Agency for Healthcare Research and Quality
.
Overview of Pediatric Emergency Department Visits, 2015. HCUP Statistic Brief #242
.
Rockville, MD
:
Agency for Healthcare Research and Quality
.
14
Dean
P
,
Zhang
Y
,
Frey
M
, et al
.
The impact of public health interventions on critical illness in the pediatric emergency department during the SARS-CoV-2 pandemic
.
J Am Coll Emerg Physicians Open
.
2020
;
1
(
6
):
1542
151
15
Chaiyachati
BH
,
Agawu
A
,
Zorc
JJ
,
Balamuth
F
.
Trends in pediatric emergency department utilization after institution of coronavirus disease-19 mandatory social distancing
.
J Pediatr
.
2020
;
226
:
274
277.e1
16
Ray
G
.
Children’s hospitals’ statement on essential COVID-19 relief. Available at: https://www.childrenshospitals.org/Newsroom/Press-Releases/2020/Childrens-Hospitals-Statement-on-Essential-COVID19-Relief. Accessed September 30, 2020
17
Kocher
KE
,
Macy
ML
.
Emergency department patients in the early months of the coronavirus disease 2019 (COVID-19) pandemic – what have we learned? [published online ahead of print June 9, 2020]
.
JAMA Health Forum
.
doi:10.1001/jamahealthforum.2020.0705
18
Mongelluzzo
J
,
Mohamad
Z
,
Ten Have
TR
,
Shah
SS
.
Corticosteroids and mortality in children with bacterial meningitis
.
JAMA
.
2008
;
299
(
17
):
2048
2055
19
Fletcher
DM
.
Achieving data quality. How data from a pediatric health information system earns the trust of its users
.
J AHIMA
.
2004
;
75
(
10
):
22
26
20
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
21
Centers for Disease Control and Prevention
.
CDC COVID data tracker. Available at: https://covid.cdc.gov/covid-data-tracker/index.html#cases_casesinlast7days. Accessed September 22, 2020
22
Uscher-Pines
L
,
Pines
J
,
Kellermann
A
,
Gillen
E
,
Mehrotra
A
.
Emergency department visits for nonurgent conditions: systematic literature review
.
Am J Manag Care
.
2013
;
19
:
47
59
23
Nicholson
E
,
McDonnell
T
,
De Brún
A
, et al
.
Factors that influence family and parental preferences and decision making for unscheduled paediatric healthcare - systematic review
.
BMC Health Serv Res
.
2020
;
20
(
1
):
663
24
Feudtner
C
,
Christakis
DA
,
Connell
FA
.
Pediatric deaths attributable to complex chronic conditions: a population-based study of Washington State, 1980-1997
.
Pediatrics
.
2000
;
106
(
1 pt 2
):
205
209
25
Feudtner
C
,
Feinstein
JA
,
Zhong
W
,
Hall
M
,
Dai
D
.
Pediatric complex chronic conditions classification system version 2: updated for ICD-10 and complex medical technology dependence and transplantation
.
BMC Pediatr
.
2014
;
14
:
199
26
Healthcare Cost and Utilization Project
.
Chronic Condition Indicator (CCI) for ICD-10-CM (beta version). Available at: https://www.hcup-us.ahrq.gov/toolssoftware/chronic_icd10/chronic_icd10.jsp. Accessed September 22, 2020
27
Neuman
MI
,
Alpern
ER
,
Hall
M
, et al
.
Characteristics of recurrent utilization in pediatric emergency departments
.
Pediatrics
.
2014
;
134
(
4
).
28
Agency for Healthcare Research and Quality
.
Clinical Classifications Software Refined (CCSR) for ICD-10-CM diagnoses. Available at: https://www.hcup-us.ahrq.gov/toolssoftware/ccsr/ccs_refined.jsp. Accessed September 23, 2020
29
Samuels-Kalow
M
,
Peltz
A
,
Rodean
J
, et al
.
Predicting low-resource-intensity emergency department visits in children
.
Acad Pediatr
.
2018
;
18
(
3
):
297
304
30
Centers for Medicare & Medicaid Services
.
Medicare claims processing manual. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c03.pdf. Accessed October 2, 2020
31
Macy
ML
,
Hall
M
,
Shah
SS
, et al
.
Differences in designations of observation care in US freestanding children’s hospitals: are they virtual or real?
J Hosp Med
.
2012
;
7
(
4
):
287
293
32
Federal Reserve Back of St. Louis
.
Consumer price index for all urban consumers: hospital and related services in U.S. city average. Available at: https://fred.stlouisfed.org/series/CUUR0000SEMD. Accessed September 9, 2020
33
Angoulvant
F
,
Ouldali
N
,
Yang
DD
, et al
.
COVID-19 pandemic: impact caused by school closure and national lockdown on pediatric visits and admissions for viral and non-viral infections, a time series analysis
.
Clin Infect Dis
.
2020
;
ciaa710
34
Dopfer
C
,
Wetzke
M
,
Zychlinsky Scharff
A
, et al
.
COVID-19 related reduction in pediatric emergency healthcare utilization - a concerning trend
.
BMC Pediatr
.
2020
;
20
(
1
):
427
35
Ciofi Degli Atti
ML
,
Campana
A
,
Muda
AO
, et al
.
Facing SARS-CoV-2 pandemic at a COVID-19 regional children’s hospital in Italy
.
Pediatr Infect Dis J
.
2020
;
39
(
9
):
e221
e225
36
American Hospital Association
.
Hospitals and health systems face unprecedented financial pressures due to COVID-19. Available at: https://www.aha.org/system/files/media/file/2020/05/aha-covid19-financial-impact-0520-FINAL.pdf. Accessed September 30, 2020
37
Morgan
SR
,
Chang
AM
,
Alqatari
M
,
Pines
JM
.
Non-emergency department interventions to reduce ED utilization: a systematic review
.
Acad Emerg Med
.
2013
;
20
(
10
):
969
985
38
Goza
SH
,
Wietecha
M
. American Academy of Pediatrics and Children’s Hospital Association letter to the US Department of Health and Human Services regarding federal emergency funding from the Coronavirus Aid, Relief and Economic Security (CARES) Act. Available at: https://downloads.aap.org/DOFA/AAP-CHA_Letter_to_HHS--CARES_Emergency_Funding.pdf. Accessed September 30, 2020
39
De Vos
J
.
The effect of COVID-19 and subsequent social distancing on travel behavior
.
Transportation Research Interdisciplinary Perspectives
.
2020
;
5
:
1
3
.
40
KABOOM!
.
Playground closures in America. Available at: https://kaboom.org/covid-19/playground-closures-america. Accessed September 30, 2020
41
Sheinin
D
.
The week the coronavirus ground the sports world to a halt. Available at: https://www.washingtonpost.com/sports/2020/03/14/sports-cancellations-timeline-coronavirus/?arc404=true. Accessed September 30, 2020
42
Kuehn
BM
.
Spike in poison control calls related to disinfectant exposures
.
JAMA
.
2020
;
323
(
22
):
2240
43
Kann
L
,
Kinchen
S
,
Shanklin
SL
, et al.;
Centers for Disease Control and Prevention (CDC)
.
Youth risk behavior surveillance–United States, 2013
.
MMWR Suppl
.
2014
;
63
(
4
):
1
168
44
Guessoum
SB
,
Lachal
J
,
Radjack
R
, et al
.
Adolescent psychiatric disorders during the COVID-19 pandemic and lockdown
.
Psychiatry Res
.
2020
;
291
:
113264
45
Czeisler
,
Lane
RI
,
Petrosky
E
, et al
.
Mental health, substance use, and suicidal ideation during the COVID-19 pandemic — United States, June 24–30, 2020
.
MMWR Morb Mortal Wkly Rep
.
2020
;
69
(
32
):
1049
1057
46
Thomas
EY
,
Anurudran
A
,
Robb
K
,
Burke
TF
.
Spotlight on child abuse and neglect response in the time of COVID-19
.
Lancet Public Health
.
2020
;
5
(
7
):
e371

Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

Supplementary data