Providers try to address mounting delays in care as pandemic stretches on

Like many primary-care physicians across the country, Dr. Trevor Huber is using telehealth to triage patients for COVID-19 symptoms.

In one of these recent visits, a man in his mid-60s was complaining of chest pain, thinking it may be the virus. Huber wasn’t convinced, urging him to come into his practice in Little Elm, Texas, right away to make sure he wasn’t having a heart attack. 

After hooking the patient up to an electrocardiogram, it was clear the patient was in cardiac arrest. Huber’s team called 911 right away. 

This patient recovered, but others haven’t been so lucky. Three patients of the practice, called Modera Clinic, have died of heart attacks since the COVID-19 pandemic began. After discussions with the families, Huber learned the patients were complaining of symptoms for weeks, but they went unaddressed. “It’s basically when they are collapsing, having a terrible heart attack, and having to run a code in the field” when they finally call for help, Huber said. 

Experiences like Huber’s are becoming more common for providers across the country as research shows patients are ignoring symptoms and putting off needed care during the COVID-19 pandemic, largely out of fear of contracting the virus in the healthcare setting. Providers are worried as the pandemic stretches on—and worsens this fall and winter season—about the long-term implications for patients who continue to delay seeing their doctors and getting emergent services. Conditions such as stroke, heart attack and diabetes can lead to lasting negative outcomes for patients that impact their quality of life if they go untreated and may even result in death. 

“It’s a shame when people who are eligible for these treatments don’t come into the hospital to get them because they are scared of contracting COVID,” said Dr. Charles Matouk, associate professor of neurosurgery at Yale New Haven Health who has seen stroke presentations to the health system drop during the pandemic. “In comparison to not getting the treatment, the risk benefit analysis would cut to getting the treatment rather than staying at home.”

Untreated strokes can result in permanent paralysis and speech impairments that require long-term care services. 

There are also costs to the healthcare system to worry about, said Julius Chen, assistant professor of health policy and management at Columbia University. If morbidity and disease severity worsen because of people delaying care, it’s likely healthcare spending will rise as well, he said. Chen is urging for research into the long-term implications of delaying care on healthcare spending, health outcomes and mortality. He said the research can be used by providers and policymakers to understand how to best invest more resources in the years to come. Studies so far are largely focused on evaluating delays in care across a variety of conditions. 

“As we move forward, health policy researchers need to think about what happens when people delay routine or preventive services,” Chen said. “If we don’t plan on studying it now, it’s going to be too late by the time these effects manifest a few years down the line.”

For their part, providers are trying to encourage patients to seek out needed care. Take for instance Dr. Ada Stewart, a primary-care physician based in Columbia, S.C., and president of the American Academy of Family Physicians. 

Stewart said she calls her patients to tell them what the practice has done to keep them safe from contracting COVID-19 during a visit, such as mask-wearing, frequent cleaning of surfaces and social distancing. Most of Stewart’s patients have come back for their in-person visits since the pandemic began, but some still don’t feel comfortable. Stewart relies on telephone and video visits to stay connected with them. All her patients also have her cellphone number so they can call her anytime. 

Stewart said there are limits to virtual visits, though. She recently saw a patient with diabetes for the first time in-person since the pandemic began, checking in on her only through the phone over these last eight months. After running labs, the patient’s hemoglobin A1C score and blood pressure levels were alarmingly high. The patient was herself surprised by the findings because her home readings weren’t so bad. Now Stewart is working with her to help get her diabetes back in control.

“A lot of times we don’t know what is going on with our patients until we see them,” Stewart said.

Other providers, particularly large health systems, have used marketing to send the message about not delaying care. Connecticut-based Yale New Haven Health joined a campaign with the American Heart Association urging people not to delay symptoms of stroke and heart attack. Yale has also created videos featuring Yale physicians explaining the signs of stroke and heart attack as well as the safety precautions the system has put in place to ensure patients won’t contract COVID-19 while in the emergency department. 

The health system initiated these marketing efforts after seeing significant declines in the number of stroke and heart attack patients to its EDs. From mid-March to late April, stroke presentations declined by 30% at four Yale hospitals compared to the same period last year. 

While stroke cases have since rebounded, Matouk said he’s concerned people will start delaying care again as COVID-19 cases rise in Connecticut. Yale is beginning to organize COVID-19 units again as it sees hospitalizations climb for those stricken with the coronavirus. “We remain concerned that we are going to start to see less of these emergent and urgent cases like strokes and heart attacks because people are scared to come to the hospital,” Matouk said. 

He said people may be ignoring signs of stroke because they aren’t aware of what they are. There hasn’t been as much public education about the symptoms and treatments of stroke compared to heart attack, he said. There are now treatments that can vastly improve outcomes from a stroke, but they are time sensitive. “The public isn’t as aware as they should be of the signs and symptoms of a stroke and how important it is to get to the hospital,” Matouk said.

Similarly, at WellStar, based in Georgia, emergency department visits dropped 40% to 50% in the first few months of the pandemic. More recently, ED volumes are still 15% below levels compared to the same period last year. Additionally, strokes and heart attack presentations continue to be lower than prior to COVID-19 and patients whodo show up are in worse shape.

WellStar has tried to raise awareness by engaging with local media to inform the public about the ED’s safety precautions, such as mandatory mask-wearing, physical barriers in the waiting room to encourage social distancing and using texts so patients can wait for their appointment in their car. The system has also advised its emergency medical services partners to tell patients about the hospital’s precautions if a person resists going to the hospital, even if they have an emergency.

“We are still seeing some people delaying care a little bit longer than they should,” said Dr. Brett Cannon, chief of emergency medicine at the system. “In cases of strokes and heart attacks where the minutes really do matter, we do want to encourage and communicate to everyone that hospitals are safe.” 

At Huber’s primary-care practice in Little Elm, Texas, its marketing budget was boosted by about 20% to 25%, now spending about $1,600 a month to let patients know it’s open and ready to serve.

In July, the practice launched its first marketing campaign, blasting videos on social media and emailing patients about all the social distancing and sanitation precautions being used. Staff also began reaching out directly to patients encouraging them to make appointments. Most patients have come back, but Huber said some are still worried. About 15% of visits continue to be performed through telehealth; that’s much higher than prior to COVID, when telehealth accounted for about 1% of visits.

While ED volumes and primary-care practices have showed signs of rebounding, vaccination and cancer screening rates still worry physicians. 

Studies show screenings for breast, colon, prostate and lung cancer have dropped significantly during the pandemic. One analysis of Medicare claims representing about 5% to 7% of the population found that at the pandemic’s spring peak, breast cancer screenings dropped by 85%, while colonoscopies dropped 75%. 

Huber’s clinic has responded by adding a campaign focused mainly on mammography and colonoscopy screening, stressing their importance. Staff have also begun to reach out directly to women who are due for the screening.

Huber said mammography continues to be low because women don’t want to go to labs to get the test done. Colonoscopy screenings, on the other hand, have rebounded to a greater degree in recent months. 

“They are trying to put it off until after the vaccine, so there is a lot of education that we are trying to invest in to try to get them to get their mammograms done,” Huber said.

Vaccination rates for children have also taken a hit. The pediatric department at Johns Hopkins Medicine in Baltimore has seen children fall behind on vaccinations for measles during the pandemic because fewer parents are bringing their children in for wellness visits. 

“We know there are measles outbreaks when there is low herd immunity and that can happen and be more widespread when kids get back to school or are back in other group settings—that’s a big concern,” said Dr. Barry Solomon, professor of pediatrics at Johns Hopkins. 

Another challenge among patients who are still only doing virtual visits is missing out on blood pressure, weight and growth monitoring that can signal early signs of obesity, diabetes and developmental delay in children. “I have seen a number of kids gained more weight when they have made it in for a visit, so those visits are a time to talk about diet and exercise,” Solomon said. 

In addition to concerns about not seeing as many children in his office, Solomon said he’s worried about potential increases in mental health challenges as some kids struggle with at-home schooling and lack of socialization. 

“I know schools are trying hard, but I think the impact on children is going to be pretty significant as they get older,” Solomon said.