By Liora Engel-Smith
As the coronavirus quickly spread across the United States in February and March, hospital systems, fearing a flood of patients and worried about having enough personal protective equipment for their workers, suspended many routine appointments and elective procedures in a move to conserve resources.
When clinics and hospitals resumed appointments and surgeries in late spring, most patients were hesitant to return. But even as health systems report a return to business as usual, it appears that some patients have stayed away.
The pandemic will soon enter its 10th month in North Carolina, and experts worry that forgone cancer and other screenings, dental care and delayed child vaccinations could cause a host of other public health problems.
Nationally, coronavirus delayed care accounts for thousands of delayed appointments and procedures, said Cynthia Cox, vice president of the Kaiser Family Foundation.
“We know we’re only back up to 80 or 90 percent of where we were before the pandemic in terms of numbers of visits,” Cox, who recently spoke at the North Carolina Institute of Medicine’s annual meeting, said.
“If we were making up for all those losses, you would expect utilization to be not just 100 percent, but over a hundred to capture those people who missed care.”
The implications of canceling care are particularly salient as health systems across the state wrestle with rising coronavirus hospitalizations. Though some regions are slated to run out of beds as early as January, health care leaders have not spoken publicly about once again delaying care or deferring elective procedures.
But the public health effects of previous delays could have lasting effects in infectious disease control, cancer and chronic disease treatment, dental health, and mental health.
The first effects of this delayed care are already becoming apparent. According to data from the Centers for Disease Control and Prevention, almost 300,000 excess deaths were tallied in the United States between January and mid-October 2020. Two-thirds of these deaths are of people who got coronavirus. The rest of the deaths are attributed to other causes, some of which could have included delayed medical care.
Mental health visits have not kept up with demand
The advancement of telemedicine has been a bright spot in a pandemic that has already claimed thousands of lives across the state. Nationally, Cox said, one-in-ten visits are now performed via telehealth. At the same time, in-person care has plummeted, and telehealth has not grown enough to make up for that lost care. Most televisits in the country — roughly 60 percent — are for mental health conditions, Cox added, a trend that makes sense as the pandemic’s uncertainty and isolation prompted a rise in mental health conditions.
Blue Cross Blue Shield of North Carolina, the insurer with the largest market share in the state, has seen similar trends, said Ish Bhalla, associate medical director of Behavioral Health Value Transformation. Bhalla, who also spoke at the NCIOM meeting, said telehealth visit claims increased by 7,000 percent since March, many of these claims come from psychiatric health providers.
Whereas the number of people reporting depression and anxiety quadrupled from 10 percent to 40 percent, the increase in telehealth visits hasn’t kept pace, according to Cox.
“There were still tremendous access barriers for mental health services before the pandemic,” she said. “And I’m sure with this many more people needing mental health services it’s gotta be worse.”
Concerns over parallel outbreaks
This year’s flu vaccination rates have been stronger than last year in both children and adults, according to Cox, but vaccinations for other contagious diseases have been weak.
Nationwide, the pandemic caused almost 300,000 kids to miss their vaccinations, she added.
If enough children miss their vaccinations, rates of contagious diseases such as measles and rubella could increase, particularly as restrictions lift and children return to school, according to the state Department of Health and Human Services.
Forgone cancer screenings and procedures
A sizable portion of patients are delaying other types of care too, including dental visits, specialty visits such as for dermatology and cancer. Collectively, one in four adults delayed some medical care because of coronavirus, according to Cox. In the world of cancer screening, that amounts to 300,000 delayed breast cancer screenings, 100,000 missed colonoscopies and 40,000 forgone Pap smears nationwide.
During that time, the number of new cancer diagnoses decreased, but it isn’t because fewer people were getting cancer, Cox said, it’s because fewer cancers were being detected. Elective procedures — which can include removing small, non-aggressive tumors — have also yet to fully rebound, according to Cox.
Emmanuel Zervos, surgical oncologist at Vidant Health said similar forces are at play with Vidant’s patients, many of whom already face significant barriers in accessing care. Zervos, who also spoke at NCIOM’s annual meeting, said that roughly 4,500 Vidant patients missed their cancer screenings since the pandemic began.
“We have no idea whether they dropped out altogether, or rescheduled their screening,” he said. “In order to recover these patients, you would expect to see a surge in screenings rather than a return to baseline.”
Patients who had a cancer diagnosis when the pandemic began are also at risk for poorer outcomes because of coronavirus restrictions. A 71-year-old breast cancer patient, for example, refused to get surgery in the spring because COVID restrictions dictated that her husband wouldn’t be able to visit her after the procedure, according to Zervos.
Other patients, particularly those in clinical trials, also experienced delayed care as studies got suspended in the spring, he added.
The long-term implications of these delays will likely become clearer in months or even years. Interruptions in care, however, will likely result in worse health outcomes even for patients who have non-aggressive cancers.
These delays and disruptions in cancer diagnosis and care have disproportionately affected African Americans in eastern North Carolina, Zervos said, noting this is a group that already experiences significant disparities in cancer diagnosis and treatment.