Systems Now Face the Costs of COVID Care Delays

The Gazette (Colorado Springs, Colo.)

In the early days of the pandemic, emergency department physicians looked around and wondered: Where is everybody?

There were COVID-19 patients, of course, and the providers treating them had their hands full: a new virus, a shortage of protective gear, no well-identified treatments, a battery of unknowns.

But downstairs, ERs felt like ghost towns. Volumes plummeted, just as hospitals were bracing for an unprecedented rush. Sky Ridge Medical Center set up a tent outside of its emergency department, ready for a surge of COVID-19 patients on top of the regular stream of traumas and heart attacks and strokes.

"That tent was not used for one single day," said Adam Barkin, an ER doctor and medical director at Sky Ridge. "...It was eerily quiet in the emergency departments around town and at Sky Ridge because we were waiting for the patients to come, and they never came in."

The ER volume at Sky Ridge was down by as much as 40% in those early months. Nationwide, it fell by 42%, according to the Centers for Disease Control and Prevention. Urgent care and primary care clinics reported similar trends. Fewer trauma cases made sense: People were home, not driving or riding motorcycles or flying down mountains. But where were the heart attacks? Where were the strokes? Where were those patients who normally kept Barkin and his peers busy?

Rampant Fear

In those early days, COVID-19 fear was rampant, and it's hard to criticize it: The virus was brand new. Little was known about how it spread, who was at risk, what could be done to treat it. Hospitals were seen not as safe harbors but as dangerous places, contaminated and full of COVID-19 patients.

People stopped going, to hospitals and to their primary care providers. They delayed going to the ER even in crisis, with the type of chest pain that screams heart attack or the abdominal agony that heralds appendicitis. A Harvard study found that one in five Americans delayed care or weren't able to receive it in those early months; hospitals across the country canceled all but the most urgent surgeries, to preserve bed space and resources.

"There was not a massive drop-off in people having (heart attacks), strokes, all these other illnesses," Barkin said. "They were still happening. It was just happening at home."

The ramifications of that delayed care will burden the healthcare system for years, said the half-dozen providers who spoke to the Denver Gazette for this story. Hospitals are already feeling it: Patients are coming in higher numbers, far sicker than what could've been expected based on pre-COVID years.

They often come to the emergency room first, as opposed to specialists or primary care offices, because they're in worse shape, and the opportunity to catch diseases early has passed. Hospital stays are longer, further stressing hospitals worn down by staffing shortages and an ever-changing, seemingly never-ending pandemic. There will be a steady increase in mortality.

Not even two years since the start of the pandemic and the situation is already unprecedented, providers said. There are some analogues — the H1N1 situation in 2009, the West Nile surge before that — but even those don't match what hospitals are seeing now.

"Never in my life have I seen this," said Richard Zane, an emergency physician with UCHealth. "And my first day was in 1993."

No-Win Decisions

With the sheer scale of the unknowns the novel coronavirus brought with it in early 2020, healthcare providers and national leaders made a series of what officials have said were no-win decisions.

Nursing homes were locked down to prevent the virus from tearing through them. But the isolation negatively affected their residents' health and contributed to an increase in Alzheimer's deaths. Lockdowns and stress, coupled with the growing presence of fentanyl, have aided a surge in overdose deaths. School closures helped keep transmission in those buildings low, but they've contributed to an unprecedented spike in mental health crises among America's youth.

The same is true of the attitudes and decisions that contributed to people delaying care, providers said. Even with the gift of hindsight, inherently not afforded to policymakers and hospital leaders in March 2020, they said they weren't sure anything could've been done differently.

"In thinking about a pre-vaccine COVID time, I don't think we had great alternatives," said Allison Staley, a gynecologic oncologist with Swedish Medical Center. "We did the best we could with universal mask use, which we know is very effective now, but in the beginning, we didn't really know how this virus was even being transmitted."

Not to say they were ignorant: COVID dominated all else back then, they said, but many still knew in the back of their mind that there would be consequences from the empty emergency rooms and primary care offices.

Early concerns came from those primary care providers, said Marsha Hamner, a hospitalist and the medical director for the hospitalist program for Banner Health in Northern Colorado. But grimmer warnings came from ambulance crews.

"The ambulance services keep track of, for lack of a better term, deaths on arrival," she said. "When they get called and the patient's already passed away by the time they get there — those percentages went up with statistical significance during that first surge. That was an indicator to us that, in the acute settings, we were losing lives because people were not seeking acute medical care."

"Ordinarily, the family would've called 9-1-1 right away," Barkin added, "but they were literally just dying at home. EMS, paramedics — they were finding people who had sadly passed away from an illness that just months ago, they would've called 9-1-1 and been brought to the hospital."

A May 2020 survey from the Primary Care Collaborative found providers were already anxious about what would come next. Thirty-eight percent said they expected non-COVID-related deaths to increase because of delayed care. Sixty percent predicted more patients would present with avoidable illnesses. Providers from Colorado responded to that survey in higher numbers than those from almost every other state.

Those early fears have proven true, and providers see it in real time. Staley said she's seeing more advanced disease in her patients, which translates to worse prognoses and more invasive treatments, like more radiation or chemotherapy. Substance abuse appears to have risen sharply, visible in ER visits; so, too, have behavioral health emergencies.

Hamner said one patient in particular sticks in her mind: They had been diagnosed with cancer at the beginning of the pandemic but didn't seek treatment until later this past summer.

"What was a very treatable illness suddenly became something that we could no longer treat," she said. "That's very tragic."

Acute and Existential

The impact of this trend will be felt most personally and most severely by patients and their families. But the threat to hospitals is both acute and existential, contributing to a capacity crisis that in November was at its worst point of the pandemic. It's already affecting staffing shortages, fueled by pandemic-related burnout and exhaustion, and it threatens to worsen because of delayed care repercussions.

Acuity — meaning the severity of patients' conditions — is at unprecedented highs, providers said. Within HealthONE, the largest hospital system in Colorado, the severity of non-COVID admissions has increased by 11% compared to pre-pandemic levels, said spokeswoman Stephanie Sullivan. The average length of stay for patients has increased 9%.

Over the past two months at Banner Health, a primary hospital provider in Northern Colorado, an index tracking the severity of patients' illness has been at its highest-ever point for both COVID and non-COVID patients, spokeswoman Sara Quale said. Barkin, the Sky Ridge ER doctor, said volume is up 35% compared to pre-pandemic; urgent care volume is up nearly 55%. Similar trends are emerging at UCHealth.

"UCHealth is seeing far more patients in our hospitals, emergency departments and urgent cares than we averaged prior to the COVID-19 pandemic, and those patients tend to be more sick," spokesman Dan Weaver said in an email. "In some of our emergency departments, 25-30% of all patients need admission to the hospital, which is far higher than in years prior to 2020. In our hospitals, the overall length of stay has increased as patients need a longer period of time for critical and acute care before they are able to be discharged."

A Grim Quandary

There is no magic bullet for more severe cancer patients or for those whose hearts are more damaged because they delayed treatment for heart attacks. These impacts will outlast the pandemic as it exists today.

Hospitals will likely need to increase capacity and will have to find a way to recruit and retain more staff, said Gary Winfield, the chief medical officer for HealthONE, to deal with the influx of sicker patients, which he said would be the "new normal for the next few years." But there's a national provider shortage, and hospital systems will be competing against each other for those people who are available.

This presents a grim quandary: Hospitals need more staff to adopt to an extended period of higher acuity patients. But there are fewer staffers to hire, and the ones that have continued to work through unprecedented circumstances will only become more fatigued by the continued acuity crisis.

"We're going to see the effects of this for a long time," Hamner said. "We will get through this pandemic. It will end. It won't end soon enough for any of us, but the aftereffects of how this has changed healthcare and the effects of people having not sought care for the past 18 months as regularly as they would've otherwise — I don't know if we know how long it'll last."

Zane said UCHealth was "hanging on, from a staffing perspective, only because staff have just done herculean work." They're working more with less, in what seems like a never-ending crisis, as many COVID patients and their families become more hostile.

"This is like brinksmanship," he said. "We're skirting the treetops. We need a reprieve so we can regroup.... It can get a lot worse."

What has happened with delayed care is now unavoidable; those diseases have already progressed. But the leak can be capped: Every provider urged patients to seek preventative care, to get mammograms and Pap smears and colonoscopies, to go to the hospital if you feel chest pain, to get regular check ups with your providers. With their bevy of infection-control measures, hospitals may be the safest place to be these days, they said.

That's one piece of advice. The other is even simpler, more readily available and can give hospitals the reprieve and space they need to face what comes next.

"The solution is vaccination, vaccination, vaccination," Zane said. "Getting vaccinated is a societal responsibility, an act of patriotism, an obligation and a responsibility. If you don't get vaccinated, this will go on forever."