Factors associated with emergency department avoidance during the COVID-19 pandemic and alternatives sought: a cross-sectional, telephone-based survey of frequent emergency department users in Beirut, Lebanon

OBJECTIVES: To explore avoidant behaviour of frequent emergency department (ED) users, reasons behind ED avoidance and healthcare-seeking behaviours in avoiders during the COVID-19 pandemic. DESIGN AND SETTING: Cross-sectional, telephone-based survey administered between March and August 2021 at a tertiary care centre in Beirut, Lebanon. PARTICIPANTS: Frequent ED users (defined as patients who visited the ED at least four times during the year prior to the first COVID-19 case in Lebanon). PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was ED avoidance among frequent ED users. Secondary outcomes included reasons behind ED avoidance and healthcare-seeking behaviours in avoiders. RESULTS: The study response rate was 62.6% and 286 adult patients were included in the final analysis. Within this sample, 45% (128/286) of the patients reported avoidant behaviour. Male patients were less likely to avoid ED visits than female patients (adjusted OR (aOR), 0.53; 95% CI 0.312 to 0.887). Other independent variables associated with ED avoidance included university education (aOR, 1.76; 95% CI 1.004 to 3.084), concern about contracting COVID-19 during an ED visit (aOR, 1.31; 95% CI 1.199 to 1.435) and underlying lung disease (aOR, 3.39; 95% CI 1.134 to 10.122). The majority of the patients who experienced acute complaints and avoided the ED completely (n=56) cited fear of contracting COVID-19 as the main reason (89.3% (50/56)). Most of the ED avoiders (83.9% (47/56)) adopted alternatives for seeking acute medical care, including messaging/calling a doctor (46.4% (26/56)), visiting a clinic (25.0% (14/56)), or arranging for a home visit (17.9% (10/56)). Of the avoiders, 64.3% (36/56) believed that the alternatives did not impact the quality of care, while 30.4% (17/56) reported worse quality of care. CONCLUSIONS: Among frequent ED users, ED avoidance during COVID-19 was common, especially among women, those with lung disease, those with university-level education and those who reported fear of contracting COVID-19 in the ED. While some patients resorted to alternative care routes, telemedicine was still underused in our setting. Developing strategies to reduce ED avoidance, especially in at-risk groups, may be warranted during pandemics.