Abstract
BACKGROUND AND OBJECTIVES

Recent studies have reported increasing eating disorder incidence and severity following the coronavirus disease 2019 (COVID-19) pandemic. In a diverse cohort of pediatric hospitals, we examined trends in the volume of emergency visits and inpatient admissions for eating disorders before and during the pandemic.

METHODS

We examined monthly trends in volume of patients with eating disorders (identified by principal International Classification of Diseases, 10th Revision, diagnosis codes) across 38 hospitals in the Pediatric Health Information System pre– (January 2018–March 2020) and post–COVID-19 onset (April 2020–June 2022). Using interrupted time series analysis, we examined the pre- and post monthly trends in eating disorder emergency and inpatient volume.

RESULTS

Before the pandemic, eating disorder emergency visit volume was increasing by 1.50 visits per month (P = .006), whereas in the first year postonset, visits increased by 12.9 per month (P < .001), followed by a 6.3 per month decrease in the second year postonset (P < .001). Pre–COVID-19, eating disorder inpatient volume was increasing by 1.70 admissions per month (P = .01). In the first year postonset, inpatient volume increased by 11.9 per month (P < .001), followed by a 7.6 per month decrease in the second year postonset (P < .001).

CONCLUSIONS

The volume of patients seeking emergency and inpatient eating disorder care at pediatric hospitals has increased dramatically since the pandemic onset and has not returned to prepandemic levels despite a decline in the second year postonset, with important implications for hospital capacity.

What’s Known on the Subject:

Recent studies have indicated increasing incidence and severity of eating disorders after the onset of the coronavirus disease 2019 (COVID-19) pandemic. Studies examining post–COVID-19 changes in volume of emergency visits or inpatient admissions in geographically diverse settings are limited.

Using a large, diverse cohort of 38 pediatric hospitals, we found emergency department visits and inpatient admissions approximately doubled in the first year since the onset of the COVID-19 pandemic, which has important implications for hospital capacity and staffing.

Soon after the first confirmed case of the novel coronavirus disease 2019 (COVID-19) in January 2020,1  daily life changed dramatically for people of all ages in the United States, but particularly for children and adolescents.2  Stay-at-home advisories and social distancing efforts led to school disruptions, removing nearly 60 million children from their normal school lives.2  School closings left students without daily contact with teachers and peers, as well as the daily structure and services provided by schools.2  Not surprisingly, early studies demonstrated psychological consequences of the COVID-19 pandemic, including rising rates of depression, anxiety, and eating disorders.28

Eating disorder incidence and severity have both increased since the onset of the COVID-19 pandemic because of a variety of factors (eg, disruptions to daily routines, uncertainty about the future, and limited access to care).914  Single-site studies have shown increases in inpatient admission volume for patients with eating disorders, whereas a multisite study found increases in the requests for outpatient care.1517  In addition to new cases, those with preexisting eating disorders have been negatively affected by the pandemic10 ; in a recent meta-analysis, 65% reported a deterioration in their eating disorder-related condition.18  The pandemic has been cited as a direct trigger for onset of an eating disorder, and those with onset during the pandemic experienced more acute onset and accelerated deterioration compared with those with onset before the pandemic.1921  The increasing incidence and worsening severity are of particular concern because eating disorders are already known to have high morbidity and mortality.22

Unsurprisingly, emergency departments (EDs) across the country have been overwhelmed by the rise in pediatric patients in need of mental health care, including those with eating disorders.14,23  The number of ED visits for patients ages 12 to 17 years with eating disorders doubled from 2019 to 2022.14  Patients with mental health needs, particularly those with eating disorders, required more resources (eg, care coordination and specialized medical and psychiatric care) than other emergency patient populations, even before the pandemic.17,24,25  However, during the pandemic, patients with eating disorders required even more resources given higher rates of psychiatric comorbidities, more severe dehydration, greater weight loss and more profound bradycardia, and higher inpatient admission rates than those seen before the pandemic.20,26  The increase in both frequency and severity of eating disorder visits has combined to stress EDs and their staff as they provide care for this challenging population; understanding patterns of volume changes is imperative for future planning.27

Although studies have documented the increased need for eating disorder care during the pandemic, studies to date have been largely limited to single sites and primarily focused on outpatient care or inpatient admissions as opposed to ED visits.13,15,16,28  Additionally, little is known about changes in demographic characteristics of populations presenting pre- and postpandemic.7,22  To document the change in volume of patients seeking eating disorder-related care before and during the COVID-19 pandemic in a geographically diverse sample of pediatric hospitals and emergency rooms, we used data from the Pediatric Health Information System (PHIS), an administrative cohort from tertiary care pediatric hospitals. Our aim was to examine trends in the volume of ED visits and inpatient admissions for patients with eating disorders, and describe sociodemographic characteristics before and after the onset of the COVID-19 pandemic.

We extracted billing data for ED visits and inpatient admissions from PHIS for patients aged ≥10 years diagnosed with eating disorders. We included 38 PHIS participating hospitals that submitted complete data from January 2018 to June 2022. Patients with eating disorders were identified by principal discharge diagnosis code (International Classification of Diseases, 10th Revision; Supplemental Table 2). We also extracted aggregate total ED visit and inpatient admission volume for all patients over the study period for comparison.

Variables collected for ED visits and inpatient admissions included age at admission, sex, race, ethnicity, insurance payer, median household income by zip code, and principal diagnosis code. Inpatient admissions that originated in the ED or had any charges for psychiatric treatment unit during admission were identified by flags in PHIS. Median household income was divided into 3 groups on the basis of 2016 tertiles of income in the United States.29  Principal diagnosis codes were used to group the primary eating disorder diagnoses (Supplemental Table 2).

Our primary dependent variable was aggregate monthly volume of eating disorder ED visits and inpatient admissions across all included hospitals. We also calculated eating disorder volume indexed to total patient volume (per 100 000 ED visits; per 10 000 inpatient admissions). Patients admitted via the ED were included in both ED visit and inpatient volumes, whereas inpatient volumes included all admitted patients, regardless of source of admission (eg, ED, transfer from another facility, or direct admission). We defined the pre–COVID-19 period as the 27 months from January 2018 to March 2020, and post–COVID-19 onset as the 27 months from April 2020 to June 2022. We include a reference line in figures corresponding to March 15, 2020, as the approximate onset date of the COVID-19 pandemic and the start of COVID-19–related restrictions (eg, school closures, stay-at-home orders) in the United States.

We compared patient sociodemographic characteristics and eating disorder diagnosis by visit type between pre– and post–COVID-19 onset periods using t tests (continuous age) and χ2 tests for all other categorical variables. We reported frequency (percentage) for categorical variables and mean (SD) for age. We also examined length of stay (LOS) pre– and post–COVID-19 onset for inpatient admissions. Because of the skewed distribution of LOS, we reported median (interquartile range [IQR]) and tested for differences by period using the Wilcoxon rank-sum test. We also reported cumulative bed-days and tested for a pre- and postdifference using unadjusted Poisson regression analysis.

Our primary analysis used interrupted time series regression examining the pre– and post–COVID-19 onset monthly trends in aggregate eating disorder discharge volume overall and indexed to total volume for (1) ED visits, and (2) inpatient admissions across all hospitals. Visual inspection of the data indicated the potential for volumes leveling off or declining beginning in ∼1 year after the onset of the pandemic. We therefore divided the postonset period into 2 periods representing the first year since onset (12 months; April 2020–March 2021) and second year since onset and beyond (15 months; April 2021–June 2022) in our regression models. Models tested for a change over time before COVID-19 (preslope), an immediate shift postonset (postintercept), and a change over time in the first year postonset (first year postslope), as well as an immediate shift and a change over time in the second year postonset and beyond. For models examining eating disorder volume indexed to total volume, estimates were exponentiated and interpreted as a percentage change. Models did not adjust for additional covariates, such as individual demographic or clinical factors. As a balancing measure, we also examined the pre- and postmonthly trends in aggregate total volume of ED visits and inpatient admissions using interrupted time series regression. All analyses were performed in SAS (v9.4; Cary, NC) at an α-level of .05.

In the 27 months before the onset of the COVID-19 pandemic, there were a total of 2793 eating disorder ED visits versus 5217 in the 27 months postonset of the pandemic across 38 hospitals. Pre–COVID-19, the mean number of eating disorder-related ED visits per hospital was 73.5 (SD = 89.1; range 6–436) compared with 137.3 (SD = 178.5; range 0–975) post–COVID-19 onset. A total of 95% of hospitals had higher aggregate raw volumes and higher average monthly visit volumes in the postonset period. Sociodemographic factors and eating disorder diagnoses among ED visits pre- and post–COVID-19 are presented in Table 1. After the onset of the pandemic, a higher proportion of ED visits for patients with eating disorders were among patients of adolescent age (14–17 years), female sex, white race, privately insured, and from higher-median income zip codes. In addition, a slightly higher proportion of visits were among patients diagnosed with anorexia nervosa. There was no significant difference in percentage of eating disorder ED visits that resulted in inpatient admission pre– versus post–COVID-19 onset (n = 2057, 73.7% versus n = 3773, 72.3%, respectively; P = .20).

TABLE 1

Sociodemographic Characteristics and Eating Disorder Diagnosis for Emergency Visits and Inpatient Admissions Among Patients 10 Years and Older With Eating Disorders Discharged From 38 PHIS Hospitals Pre- and Postonset of the COVID-19 Pandemic (N = 8010 ED visits, N = 9302 inpatient admissions)

ED Visits (N = 8010)Inpatient Admissions (N = 9302)
Pre–COVID-19 (n = 2793)Post–COVID-19 Onset (n = 5217)P aPre–COVID-19 (n = 3570)Post–COVID Onset (n = 5732)P a
Age at admission (y), mean (SD) 15.5 (2.5) 15.5 (2.2) .34 15.4 (2.3) 15.5 (2.2) .018
Age category   <.001   <.001
10–11 y 185 (6.6%) 243 (4.6%)  268 (7.5%) 294 (5.1%)
12–13 y 587 (21.0%) 1039 (19.9%)  755 (21.2%) 1147 (20.0%)
14–15 y 881 (31.5%) 1791 (34.3%)  1153 (32.3%) 1990 (34.7%)
16–17 y 776 (27.8%) 1566 (30.0%)  986 (27.6%) 1722 (30.0%)
18+ y 364 (13.0%) 578 (11.1%)  408 (11.4%) 579 (10.1%)
Female sex 2445 (87.5%) 4679 (89.7%) .003 3077 (86.2%) 5089 (88.8%) <.001
Race   <.001   <.001
White 2129 (76.2%) 4167 (79.9%)  2738 (76.7%) 4639 (80.9%)
Black/African-American 123 (4.4%) 203 (3.9%)  141 (4.0%) 211 (3.7%)
Asian American 92 (3.3%) 189 (3.6%)  116 (3.3%) 180 (3.1%)
Another race 225 (8.0%) 373 (7.2%)  297 (8.3%) 384 (6.7%)
Multiple races 30 (1.1%) 90 (1.7%)  31 (0.9%) 93 (1.6%)
Unknown 194 (7.0%) 195 (3.7%)  247 (6.9%) 225 (3.9%)
Ethnicity   .22   <.001
Non-Hispanic/Latinx 2286 (81.9%) 4299 (82.4%)  2897 (81.2%) 4732 (82.5%)
Hispanic/Latinx 395 (14.1%) 748 (14.3%)  462 (12.9%) 772 (13.5%)
Unknown 112 (4.0%) 170 (3.3%)  211 (5.9%) 228 (4.0%)
Insurance payer   <.001   <.001
Private 1841 (65.9%) 3603 (69.1%)  2458 (68.9%) 4058 (70.8%)
Public 858 (30.7%) 1464 (28.1%)  997 (27.9%) 1533 (26.7%)
Other 72 (2.6%) 141 (2.7%)  87 (2.4%) 127 (2.2%)
Unknown 22 (0.8%) 9 (0.2%)  28 (0.8%) 14 (0.2%)
Median household income ($, USD)b .22 .036 <$40 000 603 (21.6%) 1063 (20.4%)  801 (22.4%) 1190 (20.8%)
$40 000–$89 999 1942 (69.5%) 3633 (69.6%)  2463 (69.0%) 3961 (69.1%)
$90 000 or more 197 (7.1%) 428 (8.2%) 248 (7.0%) 468 (8.2%) Unknown 51 (1.8%) 93 (1.8%) 58 (1.6%) 113 (2.0%) Eating disorder diagnosisc .007 .002 Anorexia nervosa 1734 (62.1%) 3348 (64.2%) 2356 (71.0%) 4231 (73.8%) ARFID 298 (10.7%) 590 (11.3%) 450 (12.6%) 686 (12.0%) Bulimia nervosa or BED 117 (4.2%) 150 (2.9%) 106 (3.0%) 114 (2.0%) Other specified eating disorder 116 (4.2%) 182 (3.5%) 123 (3.5%) 151 (2.6%) Eating disorder unspecified 528 (18.9%) 947 (18.2%) 355 (9.9%) 550 (9.6%) ED Visits (N = 8010)Inpatient Admissions (N = 9302) Pre–COVID-19 (n = 2793)Post–COVID-19 Onset (n = 5217)P aPre–COVID-19 (n = 3570)Post–COVID Onset (n = 5732)P a Age at admission (y), mean (SD) 15.5 (2.5) 15.5 (2.2) .34 15.4 (2.3) 15.5 (2.2) .018 Age category <.001 <.001 10–11 y 185 (6.6%) 243 (4.6%) 268 (7.5%) 294 (5.1%) 12–13 y 587 (21.0%) 1039 (19.9%) 755 (21.2%) 1147 (20.0%) 14–15 y 881 (31.5%) 1791 (34.3%) 1153 (32.3%) 1990 (34.7%) 16–17 y 776 (27.8%) 1566 (30.0%) 986 (27.6%) 1722 (30.0%) 18+ y 364 (13.0%) 578 (11.1%) 408 (11.4%) 579 (10.1%) Female sex 2445 (87.5%) 4679 (89.7%) .003 3077 (86.2%) 5089 (88.8%) <.001 Race <.001 <.001 White 2129 (76.2%) 4167 (79.9%) 2738 (76.7%) 4639 (80.9%) Black/African-American 123 (4.4%) 203 (3.9%) 141 (4.0%) 211 (3.7%) Asian American 92 (3.3%) 189 (3.6%) 116 (3.3%) 180 (3.1%) Another race 225 (8.0%) 373 (7.2%) 297 (8.3%) 384 (6.7%) Multiple races 30 (1.1%) 90 (1.7%) 31 (0.9%) 93 (1.6%) Unknown 194 (7.0%) 195 (3.7%) 247 (6.9%) 225 (3.9%) Ethnicity .22 <.001 Non-Hispanic/Latinx 2286 (81.9%) 4299 (82.4%) 2897 (81.2%) 4732 (82.5%) Hispanic/Latinx 395 (14.1%) 748 (14.3%) 462 (12.9%) 772 (13.5%) Unknown 112 (4.0%) 170 (3.3%) 211 (5.9%) 228 (4.0%) Insurance payer <.001 <.001 Private 1841 (65.9%) 3603 (69.1%) 2458 (68.9%) 4058 (70.8%) Public 858 (30.7%) 1464 (28.1%) 997 (27.9%) 1533 (26.7%) Other 72 (2.6%) 141 (2.7%) 87 (2.4%) 127 (2.2%) Unknown 22 (0.8%) 9 (0.2%) 28 (0.8%) 14 (0.2%) Median household income ($, USD)b   .22   .036
<$40 000 603 (21.6%) 1063 (20.4%) 801 (22.4%) 1190 (20.8%)$40 000–$89 999 1942 (69.5%) 3633 (69.6%) 2463 (69.0%) 3961 (69.1%)$90 000 or more 197 (7.1%) 428 (8.2%)  248 (7.0%) 468 (8.2%)
Unknown 51 (1.8%) 93 (1.8%)  58 (1.6%) 113 (2.0%)
Eating disorder diagnosisc   .007   .002
Anorexia nervosa 1734 (62.1%) 3348 (64.2%)  2356 (71.0%) 4231 (73.8%)
ARFID 298 (10.7%) 590 (11.3%)  450 (12.6%) 686 (12.0%)
Bulimia nervosa or BED 117 (4.2%) 150 (2.9%)  106 (3.0%) 114 (2.0%)
Other specified eating disorder 116 (4.2%) 182 (3.5%)  123 (3.5%) 151 (2.6%)
Eating disorder unspecified 528 (18.9%) 947 (18.2%)  355 (9.9%) 550 (9.6%)

ARFID, avoidant/restrictive food intake disorder; BED, binge eating disorder; USD, US dollar.

a

P value testing for difference between pre- and postperiod from 2-sample t test for continuous age and χ2 test for all other variables.

b

Median household income by zip code.

c

Based on principal diagnosis code (Supplemental Table 2).

The monthly trends in eating disorder visit volume overall and indexed to total ED visits are presented in Fig 1. Before the pandemic, ED visit volume for eating disorders was increasing slightly over time (β = 1.50 per month; 95% confidence interval [CI]: 0.46–2.55; P = .006; Fig 1). Post–COVID-19 onset, there was an immediate decline in the number of visits (β = −48.7; 95% CI: −79.1 to −18.2; P = .002), followed by a significant increase over time (β = 12.9 per month; 95% CI: 9.2–16.6; P < .001) through the first year in March 2021. In the second year postonset through the end of the study period (April 2021–June 2022), visit volume decreased over time (β = −6.3 per month; 95% CI: −9.0 to −3.5; P < .001).

FIGURE 1

Pre– and post–COVID-19 onset trend in monthly ED visits for patients with eating disorders discharged from 38 PHIS hospitals (N = 8010 visits over 54 months). Reference line corresponds to March 15, 2020, as the approximate onset date of the COVID-19 pandemic and related restrictions (eg, school closures, stay-at-home orders) in the United States.

FIGURE 1

Pre– and post–COVID-19 onset trend in monthly ED visits for patients with eating disorders discharged from 38 PHIS hospitals (N = 8010 visits over 54 months). Reference line corresponds to March 15, 2020, as the approximate onset date of the COVID-19 pandemic and related restrictions (eg, school closures, stay-at-home orders) in the United States.

Close modal

Indexing to total ED volume indicated a slight increase over time in eating disorder visits per 100 000 total ED visits before COVID-19 (β = 1.5% per month; 95% CI: 0.8%–2.1%; P < .001; Fig 1), followed by an immediate shift postonset (β = 29%; 95% CI: 8.1%–55.0%; P = .006), and an increase over time through the first year postonset (β = 3.9% per month; 95% CI: 1.6%–6.1%; P = .001). In the second year postonset through the end of the study period, there was a decrease over time (β = −4.2% per month; 95% CI: −5.8% to −2.7%; P < .001).

The monthly trend in total ED visit volume for all patients pre- and postonset of the COVID-19 pandemic is presented in Fig 2. After a steep drop immediately postonset, total patient ED visit volume increased significantly over time through the first year of the pandemic, followed by a leveling-off in the second year and beyond with stable volumes over time similar to prepandemic volumes.

FIGURE 2

Pre– and post–COVID-19 onset monthly trend in total ED visits and inpatient discharges from 38 PHIS hospitals. Reference line corresponds to March 15, 2020, as the approximate onset date of the COVID-19 pandemic and related restrictions (eg, school closures, stay-at-home orders) in the United States.

FIGURE 2

Pre– and post–COVID-19 onset monthly trend in total ED visits and inpatient discharges from 38 PHIS hospitals. Reference line corresponds to March 15, 2020, as the approximate onset date of the COVID-19 pandemic and related restrictions (eg, school closures, stay-at-home orders) in the United States.

Close modal

The monthly trend in eating disorder admission volume overall and indexed to total inpatient volume are presented in Fig 3. Pre–COVID-19, inpatient eating disorder volume was increasing slightly over time (β = 1.70 per month; 95% CI: 0.70–2.71; P = .001; Fig 3). Post–COVID-19 onset, inpatient volume immediately declined (β = −46.3; 95% CI: −75.6 to −17.0; P = .003), followed by a significant increase over time (β = 11.9 per month; 95% CI: 8.4–15.5; P < .001) through the first year in March 2021. In the second year postonset through the end of the study period (April 2021–June 2022), inpatient volume decreased over time (β = −7.6 per month; 95% CI: −10.2 to −4.9; P < .001).

FIGURE 3

Pre– and post–COVID-19 onset trend in monthly inpatient discharges for patients with eating disorders discharged from 38 PHIS hospitals (N = 9302 admissions over 54 months). Reference line corresponds to March 15, 2020, as the approximate onset date of the COVID-19 pandemic and related restrictions (eg, school closures, stay-at-home orders) in the United States.

FIGURE 3

Pre– and post–COVID-19 onset trend in monthly inpatient discharges for patients with eating disorders discharged from 38 PHIS hospitals (N = 9302 admissions over 54 months). Reference line corresponds to March 15, 2020, as the approximate onset date of the COVID-19 pandemic and related restrictions (eg, school closures, stay-at-home orders) in the United States.

Close modal

Indexing to total inpatient volume indicated an increase in eating disorder discharges per 10 000 total discharges over time pre–COVID-19 (β = 1.3% per month; 95% CI: 0.8%–1.9%; P < .001; Fig 3), with no evidence of an immediate shift post–COVID-19 onset (β = 0.4%; 95% CI: −14.1% to 17.3%; P = .96), and evidence of an increase over time through the first year postonset (β = 3.1% per month; 95% CI: 1.2%–5.1%; P = .002). In the second year postonset through the end of the study period, there was a significant decrease over time (β = −3.7%; 95% CI: −5.0% to −2.3%; P < .001).

The monthly trend in total inpatient admission volume for all patients pre- and postonset of the pandemic is presented in Fig 2. After an immediate steep drop postonset, total inpatient admission volume increased significantly over time through the first year, followed by a leveling off and return to prepandemic levels in the second year and beyond.

In a diverse cohort of patients from tertiary care pediatric hospitals across the United States, we found a twofold increase in both ED visits and inpatient admissions for patients with eating disorders, in the first year postonset of the pandemic, followed by a decline in the second year and beyond. Despite this decline in the second year, absolute volumes were still elevated relative to prepandemic levels 27 months after pandemic onset, particularly for ED visits. In addition, we found eating disorder inpatient admissions were slightly longer postonset of the pandemic, which, in combination with increased volume, resulted in a nearly 66% increase in monthly average cumulative bed-days. We found small but significant differences in patient sociodemographic factors and eating disorder diagnosis comparing those seen pre– and post–COVID-19 onset; importantly, however, these differences were too small to likely be clinically meaningful, though they are indicative of ongoing disparities in access to quality eating disorder care by insurance and sociodemographic factors.

The COVID-19 pandemic has led to a mental health crisis, particularly for children and adolescents whose daily routines and support systems were completely disrupted as a result of school closings.2,6,7  Previous studies have found increasing incidence and worsening symptomatology for patients with eating disorders after the onset of the pandemic, which has resulted in an unprecedented increase in the volume of patients seeking eating disorder care across multiple settings.12,1517,20,28  Similar to previously reported findings,1416  we report an approximate doubling in emergency visits and inpatient admissions to pediatric hospitals in the first year after onset of the pandemic. Though we were unable to examine severity in eating disorder presentation in this study, previous studies have indicated that patients presenting for eating disorder care during the COVID-19 pandemic are higher acuity compared with those prepandemic.1921,26  Thus, there is marked strain on emergency and inpatient resources in caring for a population of children and adolescents with eating disorders.

Care for patients with eating disorders is complex, and providing that care in ED settings is particularly difficult.24,25  Providing quality eating disorder care in ED settings requires intensive care coordination and specialized medical care from providers often unfamiliar with management and treatment strategies.24,25  In addition, patients presenting for emergency care since the pandemic have a significantly increased medical and psychiatric burden, with increased signs of dehydration, increased bradycardia, and increased concurrent mental illness.20,26  These changes in severity of illness means additional workup and consultation must be performed in the ED, further straining an environment already facing challenges in managing the current mental and behavioral health crisis.27  Additional studies are needed to quantify the resource utilization in eating disorder populations relative to other populations cared for in EDs, as well as to identify variation across hospitals that may identify best practices in an effort to improve care.

Our findings and others demonstrating increasing patient volume and severity underscore the importance of upstream interventions occurring before the ED visit, such as eating disorder prevention and early detection, providing benefit to both patients and the health care system in general.13,14,16  Specialty eating disorder programs at every level, from outpatient to residential to inpatient, have seen increased demands similar to our findings among emergency and inpatient medical settings.1517  As a result, our experience is that more eating disorder care has remained in primary care settings while patients await access to specialized care. Supports have been established in an ad hoc manner at our institution (eg, urgent outpatient consultations, primary care trainings) but may not be enough to sustain the needs. Innovative strategies to both increase comfort and skill levels of primary care clinicians while simultaneously increasing the eating disorder-specialized workforce are needed to prevent further burdening ED and inpatient medical settings. Disparity in access to eating disorder care, particularly private, nonhospital programs, by insurance and other factors is another important consideration and an issue likely exacerbated by the pandemic. Urgent insurance reform is needed, incentivizing payers to provide more-robust payments to specialized centers for residential or partial hospitalization treatment options, thereby improving access and shifting some of the burden from emergency and inpatient settings.

This study has several limitations. First, pediatric tertiary care hospitals in PHIS may not be generalizable to other care settings (eg, community hospitals, adult tertiary care hospitals, or general EDs), though, generally, the most severe pediatric patients with eating disorders are typically seen in settings with specialty care provided by pediatric specialists. We were also unable to examine visit or admission rates among the population of patients with eating disorders or a broader population-level denominator because this information was not available. Second, we identified patients with eating disorders by principal discharge diagnosis, which may underestimate the volume of patients seeking care for eating disorders because secondary diagnoses were not included. Third, we approximated the start of the COVID-19 pandemic in late March 2020 and considered April 2020 as the first postpandemic month, which does not account for geographical variation in either the onset of the pandemic or pandemic-related restrictions and school closures. However, stay-at-home guidelines were fairly universally enacted at the beginning of the pandemic. PHIS does not release zip codes or any additional geographic information code to link school closure data, which may be an important factor associated with eating disorder volume. Finally, in this study, we examined total unadjusted eating disorder visit volume rather than sex- or diagnosis-specific changes; though consistent with previous studies, most visits were among females with anorexia nervosa.16  Future studies should examine changes in volume over time adjusted for and/or stratified by sex, diagnosis, and other sociodemographic and clinical factors to determine which patient-level factors are driving increases in volume.

Since the onset of the COVID-19 pandemic, the volume of patients seeking emergency and inpatient care for eating disorders at pediatric hospitals has increased dramatically. Our findings have important implications for pediatric hospital staffing and capacity, as well as outpatient or residential treatment accessibility, particularly if the demand for eating disorder care continues to remain above prepandemic levels.

Ms Milliren conceptualized and designed the study, planned the analyses and methodology, acquired the data, conducted the initial analyses, reviewed initial and final results, drafted the initial manuscript, and revised the manuscript; Drs Richmond and Hudgins conceptualized and designed the study, reviewed the planned analyses and methodology, reviewed initial and final results, and critically reviewed and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: No external funding.

CONFLICT OF INTEREST DISCLAIMER: The authors have indicated they have no conflicts of interest relevant to this article to disclose.

CI

confidence interval

COVID-19

coronavirus disease 2019

ED

emergency department

IQR

interquartile range

LOS

length of stay

PHIS

Pediatric Health Information System

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