In a JAMA article published in April 2020, Renata Thronson, MD writes that “[long] after the last patient in the United States recovers from [COVID-19], many others will still be afflicted.” There are many reasons why this might be true. For one, the pandemic has caused many people to lose their jobs and, with it, their health insurance. Many patients have also delayed or altogether avoided treatments, procedures, and emergency care out of fear that visiting their healthcare provider might expose them to the virus.
This decision to postpone essential care comes with serious health implications for any patient, but poses additional risks for one patient subset, in particular: those living with chronic diseases or conditions.
How many people in the U.S. have a chronic disease or condition?
According to the Centers for Disease Control and Prevention (CDC), chronic disease affects six out of every ten adults in the United States. In fact, four in every ten adults in the U.S. live with two or more chronic diseases.
These conditions can be quite debilitating and impact many different body functions, ranging from heart, liver, kidney, and lung function to digestion, mental acuity, and mobility.
For patients living with chronic conditions, regular treatments and therapy regimens are a critical part of disease management. In many cases, forgoing or even postponing this care can result in serious complications or even death.
Often, people living with chronic conditions also face compromised immune systems, heart failure, or decreased lung function—side effects that not only make them more vulnerable to infection, but also more likely to face fatal complications.
With these increased risk factors, many people with chronic illnesses worry about how an unpredictable respiratory infection like COVID-19 will affect them. As cardiologist Dr. Michelle Kittleson explains in an NEJM article, patients are now experiencing a “fear of the unknown” that is preventing them from making appointments with healthcare professionals or proceeding with recommended treatments. This fear is impacting patients’ care decisions—including whether to seek care at all.
After all, most treatments and medical procedures have a well-defined, predictable set of risks associated with them. Although those may include things like heart attack, stroke, or even death, some patients might weigh these as small risks compared to the other relief that treatment would provide them. With so many unknowns to consider in the face of COVID-19, however, it is more difficult to make an informed decision.
What happens when patients postpone care?
According to a report from the CDC and the National Syndromic Surveillance Program (NSSP), emergency department visits declined 42 percent at U.S. hospitals during the early months of the COVID-19 pandemic. Other reports estimate that this decline could be as high as 50 percent. Many physicians and other healthcare providers fear that such a marked drop in patient visits will result in an increased number of serious, or even fatal, post-pandemic health complications.
In a recent survey from the Primary Care Collective, 60 percent of physician respondents reportedly believe that their patients will most likely experience avoidable illness due to delayed or avoided care. Thirty-eight percent of primary care physicians surveyed believe some of their patients will die from non-COVID-19-related causes as a result of delayed or avoided care.
Facilities are beginning to contend with health complications as patients reluctantly return to hospital emergency departments. For instance, Dr. Evert Eriksson—a trauma medical director at the Medical University of South Carolina (MUSC)—says that “70 percent of the appendicitis on [his] service right now are late presentations.”
If these patients sought out medical care when their symptoms first presented, they would have received a routine appendectomy procedure and might have been discharged after a night spent in the hospital. These late presentations instead result in difficult surgical procedures to remove the ruptured appendix, and a long inpatient hospital stay to address abdominal abscesses or infections.
What happens when chronic disease patients postpone care?
These complications are even more pronounced for patients living with a chronic disease. Dr. Abhineet Chowdhary—a neurosurgeon at the Overlake Neuroscience Institute in Bellevue, Washington—treated a stroke patient who delayed care for nearly a week because of the coronavirus.
By the time she arrived at the hospital, the patient was diagnosed with a massive brain bleed and, sadly, passed away due to the severity of her condition. Dr. Chowdhary says that situations like this one can be mitigated, or even prevented, if patients seek lifesaving care right when symptoms first begin.
Healthcare providers are particularly concerned about the effect that this delay will have for heart disease patients. Many hospitals have reported a significant decline in heart attack patient admissions, despite the fact that patients are most certainly still suffering from cardiac distress.
Heart attack patients who delay or avoid care risk suffering from an ST-Elevation Myocardial Infarction (STEMI)—a life-threatening full blockage of one of the heart’s major arteries.
In an effort to decrease heart attack mortality and encourage patients to seek emergency care, the American College of Cardiology has launched a “Cardiosmart: Coronavirus and Your Heart” campaign. This is part of a wider healthcare industry effort to help assuage patient fears about visiting the hospital during the COVID-19 pandemic.
How does COVID-19 impact excess mortality rates?
State and national health agencies have been regularly reporting on COVID-19-related fatalities since the virus began ravaging the U.S. in early March. But the figures that these agencies are reporting relate to the number of confirmed deaths occurring as a result of COVID-19—a figure that may not reflect all of the people who have died from non-virus-related causes.
Epidemiologists and public health experts use excess mortality rates to measure the impact of a given crisis—like a natural disaster or, in this case, a pandemic. “Excess mortality,” sometimes referred to as “mortality displacement,” refers to the number of deaths within a certain population that far exceed expected norms.
With so many patients delaying or avoiding essential care because of COVID-19, many healthcare providers worry that high-risk patients—particularly those living with chronic diseases—may make up a significant portion of those excess deaths.
In New York City, for instance, the total number of 911 calls related to cardiac arrest have dramatically increased during the pandemic. From March 20 to April 5, 2019, the Fire Department of New York (FDNY) reported an average of 69 cardiac calls per day. Thirty-eight percent of those calls, or an average of 26 calls per day, ended in patient deaths.
During the same two-week time period in 2020, the FDNY reported an average of 195 cardiac calls per day. Sixty-six percent of those calls, or an average of 129 calls per day, ended in patient deaths—an increase of 28 percent from 2019 numbers.
Although respiratory infections like COVID-19 can increase heart attack risk, healthcare experts don’t necessarily attribute this rise in deaths to the virus. Many providers believe that fear of coronavirus, and not the virus itself, has caused patients to delay calling 911 until symptoms have progressed too far for paramedics to successfully administer medical care.
Patients who don’t face a fatal health complication now will likely be dealing with other medical issues or complications as a result of postponing care. We won’t see the full effects of this delayed healthcare for months or years to come.
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