Hospitals aren't just seeing reductions in elective procedures, like knee and hip replacements, amid the COVID-19 pandemic. They are also reporting significant drop offs in acute conditions that require immediate care, including heart attacks and appendicitis, raising concerns about whether people are avoiding necessary care for fear of becoming infected by coronavirus.
These reports of declines in hospitalizations for acute conditions have been largely anecdotal, coming from emergency physicians and cardiology specialists who say their departments are empty of the kinds of cases they would normally see before the coronavirus crisis hit and state governors issued orders for people to stay home.
Now, clinical researchers at Cigna Corp. said a review of the insurer's claims data and preauthorizations over the past few months confirms these reports, revealing often-steep declines in the rate of hospitalizations for a variety of acute conditions.
"What we found was that there is—concerningly—care deferral," said Dr. Saif Rathore, head of data and analytics innovation at Cigna. "This is not just about heart attacks missing, or appendicitis cases missing. This runs the gamut to things like (transient ischemic attacks), which are early manifestations of stroke, GI bleeds, seizures, and atrial fibrillation."
Researchers combed through pre-authorization requests and claims for Cigna's 14 million commercial members in the United States. They found that the rate of hospitalizations for seven acute conditions decreased between February and March to varying degrees. Hospitalization rates for atrial fibrillation decreased 35% over the two months, while rates for transient ischemic attacks—a temporary blockage of blood flow to the brain—fell 31%.
Hospitalizations decreased 28% for epilepsy and seizures, 24% for gastrointestinal bleeds, and 22% for aortic aneurysms and dissections. Hospitalizations for acute appendicitis and acute coronary syndromes, which include heart attacks, dropped 13% and 11%, respectively.
Rathore said some of the decrease hospitalization rates may be explained by normal month-to-month variation, but the magnitude of the declines across multiple serious conditions suggests it's related to the COVID-19 pandemic.
"We suspect that it's fear," said Dr. Glen Stettin, senior vice president and chief innovation officer at Express Scripts. "We suspect that people are minimizing their symptoms and staying at home, or at least some people are, when they are really having serious symptoms that need to be evaluated emergently and could be putting their life in danger."
Similar trends in decreased hospitalizations are being observed at hospitals across the country.
Chris Van Gorder, CEO of Scripps Health in San Diego, Calif., said cardiac work at the Scripps Prebys Cardiovascular Institute has dropped 20% compared with normal workload. People are likely afraid to come to the hospital, he wrote in an email. But after Scripps' chief medical officer went on television to assure the community that hospitals were safe, cardiologists noticed a 40% jump in work the following Monday.
Dr. John Puskas, chairman of the department of cardiovascular surgery at Mount Sinai Morningside similarly said fear is likely to blame for the 70% to 90% declines in acute coronary events being seen at hospitals across New York City.
Puskas said he suspects that patients are having heart problems but they are not seeking care like they normally would and are either surviving and recovering at home or dying. There are 200 unaccounted deaths each day in metro New York, in addition to the 250 patients dying each day from COVID-19, he said.
Patients are also seeking care later than they normally would, Puskas said. Some have been showing up to the Mount Sinai Morningside emergency department with a ruptured appendix, rather than coming earlier when symptoms begin, he said. They end up having to undergo more complex and dangerous surgical procedures than they otherwise would have.
"We're seeing patients present for medical attention much later in the course of their disease than they normally would because I think the threshold for being willing to come to the hospital is much higher just now in New York City than it was prior to the COVID pandemic."
But Dr. Samin Sharma, director of the cardiac catheterization lab at Mount Sinai, argued that lower levels of air pollution, better eating habits, improved medication adherence and better mental and physical health have resulted in less heart attacks overall.
Fewer people are commuting to work or flying in planes, and some factories have temporarily closed, resulting in less air pollution, which is a major trigger of coronary problems, he said. Moreover, people have swapped restaurant meals for home-cooked ones, which tend to have less salt. Sharma suspected also that people are benefiting from less work-related stress while isolating at home and have more time to spend exercising or relaxing.
He doubted that many patients are dying at home from heart attacks. "I would know it, because all my patients have my cell number, and I'm getting their phone calls. Some of them do have some angina, but symptoms can be managed with telemedicine," he said.