As COVID-19 hospitalizations mounted in the U.S. last year, forward-looking physicians were also worried about the admissions that didn't happen.
“We've definitely seen it here at the VA [Veterans Affairs], that rates of admissions for non-COVID problems really declined,” said Colette DeJong, MD, a chief resident in internal medicine at the University of California, San Francisco, and the San Francisco VA Medical Center. “And sometimes when people were coming in, their disease was worse.”
While it's impossible to quantify exactly how much essential hospital care has been deferred, a study published last October by JAMA Internal Medicine found a substantial decline in the number of non-COVID-19 hospitalizations during the pandemic's peak in New York City compared to during the same time period in 2018 and 2019. There was a significant decrease in hospitalizations for several diagnoses, including heart failure, myocardial infarction, stroke, and chronic obstructive pulmonary disease (COPD).
Another study, published last November by the American Journal of Emergency Medicine, found a 32% decrease in hospital admissions from 12 EDs in Massachusetts during the period of March 11 through Sept. 8, 2020. Asthma, COPD, and heart failure admissions declined the most, and Medicare patients had the largest drop in admissions across insurance coverage categories.
Where are the patients?
At Tulane University Health Sciences Center in New Orleans, the amount of patients deferring hospital care at a given time seems to be related to the amount of COVID-19 in the community, said Jeffrey G. Wiese, MD, MACP, senior associate dean for graduate medical education. As COVID-19 infection rates waned, he said, more patients were willing to come back to the hospital.
“But then, as it surges again, it feels like the community is just staying away from the hospitals,” Dr. Wiese said in December. “And that concerns me because I think they may not fully appreciate the magnitude of this deferred care issue for another six months to a year.”
There are a number of potential reasons patients may be staying away, such as financial concerns.
“One of the many tragedies of COVID is that so many people and families around the country are having to make a decision between paying their rent, picking up their prescriptions, or putting food on the table,” said Dr. DeJong. Many have also lost coverage for hospitalization, she noted. “I think a huge part of this is probably because so many people not only lost their jobs, but lost their health insurance at the exact same time that they lost their income.”
In addition, many people have new child or elder care responsibilities and the concerns that come with those, Dr. DeJong said. “People might not just be worried about COVID in themselves but also worried about bringing COVID home to their loved ones or their children.”
All these concerns may contribute to hospitalists' observations that some patients who don't entirely avoid hospitalization are presenting with greater disease severity. Particularly for those with diabetes and heart failure, accessing prescription medications has been difficult during the pandemic, Dr. Wiese said.
“What we are seeing a lot of is patients running out of their prescriptions and going without their medications for prolonged periods of time,” he said. “I think part of that is the fear of going to pharmacies, I think part of it's the difficulty and fear of coming to clinic visits. But that seems to be a big part of what’ . . . driving people to come into the hospital maybe later than they should have and with a severity of illness much higher than what we're used to seeing.”
The clinical consequences of deferred medical care for patients will vary according to the disease, Dr. Wiese said. For example, a hospitalization for heart failure might lead to prescriptions being adjusted to optimize cardiac function and potentially reduce additional infarctions and arrhythmias, he said. “There's mortality benefit for many of the things we do for heart failure.”
There may also be more immediate consequences of patients' reluctance to bring their symptoms to an ED. A systematic review of 10 studies conducted in the U.S. and throughout the world found a 120% increase in out-of-hospital cardiac arrests since the pandemic started. Patients with arrests were also less likely to survive to hospital admission and discharge in recent months, owing mainly to out-of-hospital factors, such as increased time from call to ambulance arrival, according to results published last October by Resuscitation.
Delays in cancer care are another area of concern. Cancer can be identified during hospitalization, particularly in patients without routine access to clinic visits, said Dr. Wiese. “To be admitted for a pneumonia and then to find a cancer as a first diagnosis is really not rare in an underserved health care population.”
Plus, with so many hospitals canceling elective surgeries, patients may also experience delays in necessary treatment, Dr. DeJong noted. “I think our chair of medicine, Bob Wachter, [MD, MACP,] said this so well, that when people hear ‘elective surgeries,’ it may sound like something voluntary or unnecessary, but often that means a cancer surgery, resection of a tumor—something really, incredibly important and time sensitive, although it's elective,” she said, adding that cancer survivors may also be delaying their surveillance tests.
On the other hand, there's the possibility that some patients may actually benefit from the reduction in hospitalizations, suggested David A. Asch, MD, MBA, professor of medicine at the University of Pennsylvania in Philadelphia. “We should be working to make patients comfortable getting care and doctors and hospitals ready to provide it. But we should also be open to the possibility that the impact of delays of care may, in some cases of overuse, be positive,” he said. “We shouldn't just take it on faith that every single thing doctors do is good or is in the right amount.”
An example of this “less may at times be more” phenomenon of care was a study published in February 2015 by JAMA Internal Medicine. Researchers found that high-risk patients with heart failure and cardiac arrest who were hospitalized in teaching hospitals had lower 30-day mortality when admitted during dates of national cardiology meetings, when the cardiologists were out of town.
The results suggested that “The way to save people from dying of heart disease was to keep them away from their cardiologists,” Dr. Asch said, “which would make sense if there are times when too much care is being delivered and that actually hurts you.”
The myriad ways in which hospitalizations can harm patients, from post-hospital syndrome to nosocomial infection, have been well described. Research finding significant variation in admission rates by region of the country has also suggested that some proportion of admissions occurring in normal times are unnecessary.
Dr. DeJong said her hospital is using the same criteria for hospital admission as always, but she wonders if some patients and primary care or ED clinicians are having different conversations about the risks and benefits of hospitalization due to the pandemic. “For instance, when it is a gray area whether the patient needs to be admitted, such as a mild heart failure exacerbation, patients and their doctors may decide to try to manage things at home first,” she said.
Of course, the net effects of deferred care will remain uncertain for some time. “I suspect that after the pandemic, we will look back and learn more about what types of care were sorely missed (e.g., fewer in-person diabetes checkups leading to increased risk of heart attack or stroke); what types of care were easily transitioned to virtual and will stay virtual; and what types of care were eliminated without any apparent problem, and thus are revealed to be unnecessary or low-value,” said Dr. DeJong.
“We can easily measure now what kind of care isn't happening. What we can't easily measure now is, on balance, what was the outcome?” agreed Dr. Asch. “A lot of health services researchers are going to be poring over the data from Medicare and other sources and attempting to answer this question for years.”
What hospitalists can do
Hospitalists can't control who comes into the hospital, but there are ways for them to help their patients get the essential care they need.
These include making adjustments to discharge planning, since access to tests, exams, and follow-up after discharge may be more difficult, said Dr. DeJong. “What we've found at our hospital is that there are certain types of things that traditionally we might include in our discharge plan, such as getting an outpatient echo[cardiogram] or getting an outpatient procedure, where, paradoxically, sometimes it's easier to get more of those things done while the patient is in the hospital, COVID-tested, already here,” she said.
Hospitalists can also help with convincing patients that the hospital is a safe place to be, noted Dr. Asch, who wrote a perspective on the topic, published last May by JAMA Internal Medicine.
“This is a problem, that there are people who, in the setting of lots of mixed messaging, are underusing care and underusing emergency services,” agreed Dr. DeJong.
Strong hospital policies, such as visitor restrictions, universal masking, and floor markings to promote physical distancing, demonstrate a commitment to patient safety, she noted. “[Those] are all practically really helpful and also signal to our patients that we have a system and a protocol in place and that we're committed to making our hospitals and clinics a safe place for all people.”
The availability of rapid testing (which wasn't an option in March) means that now ED staff quickly know who is COVID-19 positive and who is not, Dr. Wiese said. “Of all the places in the community, it might be the hospital is much safer than the grocery store. . . . There's been a lot of safety precautions put into the hospital infrastructure, which is great.”
It's also more important than ever to make sure transitions of care are tight and that patients are set to either go back to their primary care clinician or to a hospital clinic after discharge, whether they're seen in-person or virtually, said Dr. Wiese.
“That's always been a feature of hospital medicine, which is great transitions of care,” he said. “But I think in today's environment, it becomes even more important to provide that assurance—particularly if you're planning on having [patients] come back via telemedicine—and to invest the time, case management, [and] social work to ensure that they have the resources or can find resources to engage in telemedicine.”
As health systems endure this pandemic, they are discovering which types of in-person care, such as follow-up visits, may be effectively provided over telemedicine, with potentially increased patient uptake as a result. “I don't think we've figured out how to give heart attack care,” said Dr. Asch, “but I think a lot of other care can be delivered that way.”
While telemedicine may help keep patients connected to care outside the hospital, it's also important for health systems to emphasize to patients that they can still expect safe inpatient care if they need it, said Dr. Wiese. “Telemedicine's really been the focus for patient engagement for us, and I think messaging to the community that not only are we open, but we never closed, and we created a safe environment.”
That's a key message for hospitalists to share, especially on social media, noted Dr. DeJong. “Get the word out that the hospital is trying to be as safe a place as possible, that our doors are open, and that we're seeing people for all kinds of medical needs and not just COVID,” she said.