We provided care for approximately 9,500 inpatient COVID admissions in the first quarter.
This compares to approximately 8,000 COVID admissions during the third quarter and another 14,000 COVID admissions during the fourth quarter of 2020.
In the first quarter on the topline, same-store net revenue growth increased 9.8%.
For the fourth quarter year-over-year same-store admissions were down 4.9%, adjusted admissions were down 7.2% and surgeries were essentially flat.
ER visits continue to lag other volume metrics with same-store ER visits down 17%.
Adjusted EBITDA was $495 million which increased 60% compared to the prior year.
Adjusted EBITDA margin of 16.4% improved 620 basis points year-over-year.
During the quarter, $82 million of pandemic relief funds were recognized.
If we exclude the pandemic relief funds from the quarter's results, adjusted EBITDA was $413 million with an adjusted EBITDA margin of 13.7%.
Excluding pandemic relief funds, first quarter 2021 adjusted EBITDA of $413 million, increased 6% compared to the first quarter of 2019, despite operating 21 fewer hospitals as a result of our portfolio rationalization program.
In the medium term, we continue to target 15% plus adjusted EBITDA margin, positive annual free cash flow generation and reducing our leverage below 6 times.
And over the past three years, we've added nearly 300 new beds to the core portfolio, along with more than 50 new surgical and procedural suites to meet increased demand and to drive higher acuity.
We are seeing good initial results, including volume improvement with nearly 600 providers not being served by the centralized scheduling centers.
Net operating revenues came in at $3,013 million on a consolidated basis, down 0.4% from the prior year due to divestitures.
On a same-store basis, net revenues increased 9.8%.
This was the net result of a 7.2% decrease in adjusted admissions and an 18.3% increase in net revenue per adjusted admission.
Adjusted EBITDA was $495 million, up 60.2%.
This included $82 million of pandemic relief funds.
Adjusted EBITDA, excluding the pandemic relief funds was $413 million, an improvement of 34% over the prior year and an improvement of 6% over the first quarter of 2019.
Our adjusted EBITDA margin was 13.7% versus 10.2% in the prior year and 11.6% in the first quarter of 2019.
Cash flows provided by operations were $101 million for the first quarter of 2021.
This compares to cash flows from operations of $57 million during the first quarter of 2020.
Looking at the quarter-over-quarter increase, cash interest payments were approximately $60 million lower in the first quarter of 2021.
The company repaid approximately $18 million during the quarter related to Medicare accelerated payments due to divestitures and other increases and decreases including improved EBITDA and working capital changes were offset.
Our capex was $105 million compared to $99 million in the prior year, keeping in mind that we are operating fewer hospitals than a year ago.
At the end of the first quarter, the company had $1.3 billion of cash on the balance sheet.
At March 31, the company had no outstanding borrowings and approximately $633 million of borrowing base capacity under its ABL with the ability for that to increase up to $1 billion.
At the end of 2020, we had $104 million of unrecognized pandemic relief funds of which we recognized approximately $82 million during the first quarter of 2021.
At the end of the first quarter we had approximately $11.9 billion of total debt, which was approximately $300 million lower compared to the prior quarter.
On the capital structure side, as a reminder, through 2020 and the first quarter of 2021, we lowered our debt by over $1.3 billion, reduced our leverage ratio by over 2 turns down to 6 times levered compared to over 8 times last year and lowered our annual cash interest by approximately $190 million.
In January, we extended $1.8 billion second lien notes to 2029 and $1.1 billion first lien notes to 2031.
Following these transactions, we call the remaining $126 million of 2022 unsecured notes paying that with cash on hand.
Net operating revenues are anticipated to be $11.7 billion to $12.5 billion, unchanged from our previous guidance and adjusted EBITDA is anticipated to be $1.65 billion to $1.8 billion, which does not include pandemic relief funds.

Summary:
Net operating revenues came in at $3,013 million on a consolidated basis, down 0.4% from the prior year due to divestitures.