Populational Perceptions Regarding Decision to Visit the Emergency Room with Chest Pain During COVID-19

The world is witnessing a tremendous surge in the number of hospitalizations and deaths related to the coronavirus (COVID-19) pandemic. While promising treatment modalities and vaccines are underway, significant mortality and morbidity are still expected to be observed for the foreseeable future. In addition to its direct pathologic effects, the COVID-19 pandemic has led to many downstream ramifications regarding people’s other physical, psychological and economic well-being, which is a phenomenon that has been observed in prior crises of similar scale [1]. According to the US Department of Health and Human Services, emergency department (ED) visits in the United States decreased significantly during the pandemic [2, 3]. Notably, in New York, the volume of ED visits underwent a greater than 60% decline during the height of the early surge in the spring of 2020. The reasons behind this observation are presumed to be multifactorial and are incompletely understood, but it is likely in part due to perceived risk of contracting COVID-19 from visiting the ED and potentially becoming hospitalized. Within the cardiovascular domain, this has correlated with a notable decline in patient presentations for acute conditions such as ST-segment elevation myocardial infarction (38%) and type A aortic dissections (77%) [4‐6]. This is concerning because timely revascularization and surgical repair are the standard of care for these respective disease processes, and sequelae of delay in recognition and treatment can be fatal. Early signs of potentially harmful effects of COVID-19-related interruption of longitudinal care have also been noted in heart failure populations [7, 8].

Understanding the interplay between perceived risk of COVID-19 and decision to present to the ED with symptoms associated with serious cardiovascular conditions may help inform public health officials and healthcare providers about the types of fears and concerns that need to be addressed with patients to minimize collateral morbidity from COVID-19. This survey aimed to understand the salient factors which comprise this decision within a large, nationally representative sample, utilizing Likert scale-based questions and choice-based conjoint analysis.

During the enrollment period, 1111 participants completed the survey. After eliminating those who did not meet the test criteria for comprehension, 1003 (90.3%) were included in the analysis. Of the whole, 29.5% (n = 296) were between 18 and 29 years of age, 47.2% (n = 473) were between 30 and 49, and 23.3% (n = 234) were older than 50. The sample was 68.2% (n = 684) White, 14.6% (n = 146) Asian or Pacific Islander, 6.6% (n = 66) Black, and 6.5% (n = 65) Hispanic. The cohort was highly educated, with 47.1% (n = 472) having a bachelor’s degree and 18.9% (n = 190) having a master’s or more advanced degree. Many were employed for wages (62.0%, n = 622), while 9.4% (n = 94) were not, with 76.3% (n = 765) of participants having an average annual income below $100,000. Of the total, 21.9% (n = 220) stated their occupation as within healthcare. Many reported having been admitted to the hospital in the last 5 years for any reason (41.8%, n = 419), or having condition(s) that predispose to higher risk of dying from COVID-19 (31.4%, n = 315). Many had a friend or a family member admitted to the hospital (43.0%, n = 431) or who died from COVID-19 (27.8%, n = 279) (Table 2).

To our knowledge, this is the first large-scale survey study to evaluate salient perceptions and factors associated with people’s decisions to present to the ED with cardiovascular symptoms during the COVID-19 pandemic. It is concerning that participants overall perceived the risk of viral transmission in the ED to be higher than what is empirically supported, and a significant percentage reported they would wait at home despite experiencing severe chest pain and other symptoms that could be insidious or atypical presentations of acute cardiac events. Young age, unemployment, religiosity, having lost a loved one to COVID-19, and working in healthcare predisposed participants to waiting. Based on discrete conjoint analysis, severity of symptoms was the most impactful feature behind people’s decision to come into the ED. Fear of transmitting the virus to other people afterwards was the most significant motivation to avoid the hospital.

COVID-19 is a potentially lethal disease that primarily causes respiratory collapse. However, in addition to its direct pathologic effects, the pandemic has also led to ramifications across other vital operations within our society. At a global level, we observed a significant decrease early on in the number of hospitalizations and ED presentations for treatment of acute cardiopulmonary diseases as well as other conditions such as cancer and common pediatric conditions, in addition to COVID-19 [13‐15]. Some of these changes concerned patients at elevated risk of cardiovascular diseases such as ST-segment elevation myocardial infarction (STEMI), type A aortic dissections, and heart failure exacerbations [16]. As there is no evidence or rationale to suggest that the natural incidence of such deleterious cardiovascular conditions has decreased during the pandemic, we assume that other barriers must have emerged to negatively influence these patients’ abilities or choices to present to the hospital. Moreover, limited or altered provision of basic primary and other outpatient care, in addition to significantly increased financial and social stressors related to the pandemic, will surely continue to result in exacerbations of many patients’ health downstream. In addition to these patients, surely, those who may not carry prior diagnoses or comorbidities, but nevertheless experienced severe illness such as acute pulmonary embolism, arrhythmia, early-onset cardiomyopathy, myocarditis, or endocarditis, were also confronted with the difficult decision of whether to seek care during the pandemic.

Faced with these challenging circumstances, we must re-imagine the role of a comprehensive cardiovascular provider beyond the conventional medical aspects. The psychosocial and economic factors that influence patients’ decision-making and behaviors may have equally dramatic consequences for their health. We must strive as a community to become more aware of our patients in a holistic sense, and tailor our medical guidance and communication accordingly.

One such barrier to address during the pandemic may be fear. Among all participants, ED was consistently perceived as conferring a high risk of COVID-19 transmission, ranked second only to indoor dining in restaurants and bars, which drastically overestimates the risk of nosocomial COVID-19 infections in the ED [17]. These findings are consistent with previous studies’ findings that people and even healthcare providers may have heightened or exaggerated fears of being infected with the virus in hospital settings, indicating the need for more explicit and targeted communication [18, 19]. In a retrospective study by Wee et al. analyzing nearly 2000 patients who presented to the ED with respiratory symptoms, there were zero confirmed cases of COVID-19 transmission. Although the prevalence of COVID-19 patients in the ED was low (~ 4%), their study demonstrated that transmission risk can be effectively mitigated with safe triage policies and preparations.

Severe chest pain and slurred speech appropriately elicited the highest sense of urgency to present to the ED; however, even in these scenarios, nearly a third of the participants planned to wait at home. What is perhaps more concerning is that the majority of the participants indicated they would wait at home with symptoms that may accompany insidious or atypical presentations of acute, deleterious cardiac events such as shortness of breath, syncope, chest discomfort, nausea, and back pain. Younger, unemployed, and religious participants were more likely to delay presentation, which may be due to their having a higher threshold for seeking medical help given their youth, lack of finances/insurance, and reliance on other forms of support. Intuitively, older age was one of the most important factors that led to the decision to present to the hospital with symptoms, and correlated in a dose-dependent manner. Those who have lost loved ones to COVID-19 were also intuitively deterred. Notably, healthcare workers also belonged to this group, perhaps because we may feel more self-assured about our ability to monitor and discern the seriousness of our symptoms at home. Although these scenarios are hypothetical and it is impossible to calculate the true percentage of patients who report immediately to the ED as opposed to waiting at home with these symptoms during and prior to the pandemic, these results may partially explain the significant decrease in the observed volume of STEMI activations and type A aortic dissections over the last 9 months, and provide guidance on specific communication strategies [4, 6].

The results of the conjoint analysis support the general findings in the survey while providing additional insights. Naturally, the relative weight of severe chest pain in the decision to present to the ED is high; however, risk aversion to COVID-19 features carried substantial weight, ranging from 19 to 31% of that of chest pain. The potential of exposing family members was more important than ED COVID-19 census and almost as important as risk of severe personal injury from the virus. It is unclear whether this is altruistic, but it serves to emphasize that social context plays a particularly important role in caring for patients during this time. Overall, the findings of this study offer compelling evidence of the need for improved communication and education regarding safe practices during COVID-19, particularly with regard to seeking acute, potentially life-saving medical care.

This study has several limitations. First, intrinsic or unintended bias in sampling may lead to a limited representation of the at-risk population for these conditions, although it is unclear which direction our findings may have been skewed due to sampling bias. MTurk users are more likely to be young, White, educated, and savvy with technology, signifying privilege, as described in their demographic profiles. These participants’ viewpoints are not directly generalizable to patients who are at risk of or currently have cardiovascular diseases, many of whom are more socioeconomically disadvantaged, and may lack access to technology or healthcare systems. Yet it does bear some relevance to the population at large, who share minimal, yet universal risk of experiencing conditions such as acute pulmonary embolism, arrhythmia, myocarditis, and endocarditis. Second, although discrete conjoint analysis simulates more realistic decision-making conditions, there are inherent limitations in simulating health-related decisions. While significant findings can inform future hypothesis generation or direction of education, policy, or communication initiatives, they should acknowledge the fact that people’s behaviors can differ from what they predict. Third, features and levels, although informed by prior studies and known statistics, may not be entirely comprehensive and generalizable regarding people’s decision-making. Future studies are warranted to replicate these findings in different settings and populations. Fourth, this initial set of data was collected during one of the first waves of COVID-19. While attitudes may have shifted during consequent waves of COVID-19, this study’s findings are resemblant of general human tendencies that hold relevance for future waves of COVID-19 or other transmittable diseases.

Perceptions regarding COVID-19 may result in delayed presentation to the ED for potentially life-threatening cardiovascular symptoms, including severe chest pain. This may be driven by an at times inflated fear of contracting or spreading COVID-19 as a result of visiting the ED. While severity of chest pain was the most important motivator in the decision to present to the ED, those who are young, unemployed, or religious, as well as those who work in healthcare or experienced a death of a close contact due to COVID-19 were less likely to present to the hospital. These findings can help inform communication strategies for cardiovascular providers to ensure prompt and adequate treatment of potentially life-threatening conditions.