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COVID-19 and a Lack of Emergency and Intensive Care Access: This is Not Just an Urban Problem

Published: April 3, 2020

Updated: April 8, 2020

Daily headlines are dominated by reports of total cases and deaths in the United States. While stories about the sheer volume of cases are compelling and critical for identifying hotspots, understanding the per capita and per healthcare provider case rate highlights dire issues of access to critical and emergency care in places in the country that aren't (yet) making headlines due to number alone.

Using population, hospital- and provider-level data, in this post I look at the intersection of COVID-19 patients and access to emergency rooms (ERs, often the first step for COVID patients getting care) and intensive care units (ICUs, where COVID patients with extremely dire symptoms are transferred and cared for, including being connected to a ventilator). Whenever I mention per capita analysis, I am referring to the number of people with confirmed, reported cases of COVID-19 for every 1,000 residents in their county or state.

At its most basic, per capita analysis shows where cases are concentrated and health systems are more likely strained. For example, the crisis in New York City is not just a factor of its large population – New York has the highest case volume in the country in total cases and among the top cases per-capita as of the publish date of this post.

Per capita analysis also shows that some towns and rural areas are being hit hard, especially in the South and Midwest. The COVID crisis is not merely an urban or coastal problem -- not by a long shot. Some of the counties that have high per-capita infection rates are also relatively high in total case count as well. For example, at the time of this post, counties in Idaho, Colorado, Georgia, and Louisiana that have populations among the smallest 30% in the country are nevertheless in top 80% in total case count and cases per capita.

Queens County, NY First in the Country for Total COVID Cases, and Blaine County, ID Leads Country in Cases Per Capita

Confirmed COVID Cases Per Capita

Confirmed COVID cases per 1,000 county residents

Blank areas on the map represent counties with no reported COVID cases

There is also a widely documented shortage of hospital beds, intensive care unit (ICU) beds, and ventilators nationwide due to the COVID-19 pandemic. You can find projections on that here. New York State’s Governor, Andrew Cuomo, has repeatedly emphasized the need for ventilators and intensive care units in his state. However, with thousands of cases per intensive care doctor in NYC, there’s a critical shortage of doctors who can even treat the patients who receive those respirators -- which healthcare professionals across the country and the world have been raising the alarm on for months. In fact, at the time of this post, hundreds of healthcare professionals and first responders are on their way to New York City to relieve some pressure here.

Not all communities have proportional access to healthcare – in some parts of the country, there’s not even an ICU to receive a potentially lifesaving ventilator. In those places, like my colleagues’ home states, residents have to drive over an hour to the nearest regional hospital. In the case of the top 20 higest per-capita cases as of publishing this, six have fewer than ten emergency medicine specialists^[1] and nine have no intensive care specialists^[2]. Three have no hospital at all in the county^[3].

Confirmed COVID cases per Emergency Medicine Doctor

Confirmed COVID cases per Emergency Medicine Specialist

Blank areas on the map represent counties with no reported COVID cases and/or no emergency medicine specialists

Confirmed COVID cases per Intensive Care Doctor

Confirmed COVID cases per Intensive Care Specialist

Blank areas on the map represent counties with no reported COVID cases and/or no intensive care specialists

Sources and Caveats

This analysis uses the county-level confirmed case data that is being maintained by the New York Times and the NYC Department of Health, healthcare provider data maintained by the US Department of Health and Human Services’ National Provider Identifier registry, and US Census county population data. Analysis is limited to the fidelity of each of those datasets. I would love your suggestions for additional information and sources that would improve this analysis. Given the pace that information is changing and evolving, this post has less fact-checking than usual, but I'll continue to improve the analysis as needed.

Nurses are no less critical to responding to the crisis than doctors. Unfortunately, the NPI database does not specify nursing specialties beyond registered nurse, nurse practitioner, and nurse midwife. I’d love to expand the analysis below to address specialist nursing shortages, as well.

Of course, not every COVID patient needs treatment in an emergency room (ER) or an ICU. Because the best available national hospital data does not list whether hospitals have ERs or ICUs, showing cases per specialist is a proxy variable, and just one way to estimate healthcare access shortage. In further analysis, I'd like to address the need for ER and ICU access for illnesses and injuries completely unrelated to coronavirus. Those ER and ICU doctors have other patients whose medical treatment cannot be postponed until after the coronavirus crisis subsides, so by listing just the number of COVID patients per ER and ICU doctor, I am not estimating those doctors' total patient case loads.

Doctors may practice at locations in more than one county or even more than one state - only one practice location address is available in NPI data. NPI data does not include county, only zipcode. A surprisingly large number of zipcodes are in two or more counties. For the purpose of this post, zipcodes were assigned to the county in which the majority (or plurality, as the case may be) of its residential population is located, according to the Census.

Footnotes

1. Blaine County, ID; Early County, GA; Randolph County, GA; St. James Parish, LA; St. John the Baptist Parish, LA; Terrell County, GA

2. Blaine County, ID; Early County, GA; Randolph County, GA; St. James Parish, LA; St. John the Baptist Parish, LA; Terrell County, GA;Dougherty County, GA; Orange County, NY; Terrell County, GA;

3. Blaine County, ID; Terrell County, GA; St. John the Baptist Parish, LA;