Is Fear of COVID-19 Affecting the Diagnosis, Treatment, and Management of Other Medical Conditions?

By: Yvette C. Terrie, RPh, Consultant Pharmacist

Quarantine! Mitigation! Social Distancing ! Pandemic! These are words that are probably ingrained in our vocabularies because we have all heard them continuously since news of this pandemic started a few months ago. The COVID-19 pandemic has drastically altered our day to day lives and, in many ways, has transformed the manner in which health care is delivered. Many health care providers have changed their day to day practice from face to face patient interaction visits to telemedicine visits. Moreover, both patients and health care providers are wearing PPE during face to face interactions regardless of medical issue. While we are in the midst of this pandemic, news sources from across the country report that health care providers are seeing fewer patients in the ER for other medical emergencies due to patient fears of contracting the COVID-19 virus.

Various news stories report that individuals are so afraid of the COVID-19 virus that some are letting life threatening ailments go unevaluated and untreated. Hospitals across the country are reporting fewer visits for myocardial infarctions, acute strokes and other medical emergencies. There have been reports of ER doctors seeing patients with ruptured appendicitis, more serious signs of stroke or myocardial infarction because they waited at home out of fear and finally came into the ER. For example, several news sources report that ER visits in Maryland and Virginia are decreasing with ER visits in Maryland down by an estimated 50% in recent weeks.¹ In Virginia, ERs have seen declines as well with sources reporting a 39% decrease in ER volume between March 15 and April 15^th.¹ State officials report that visits for cancer related ailments, CVD, and gastric disease have declined since the pandemic started.¹

In a recent article published in USA Today, an ER doctor in Michigan cited ambulance statistics from over the last month, which—based on EMS runs—show that 27 people died at home at this time last year, compared with 147 at-home deaths this year.² He stated that is more than a five-fold increase.²

A poll published at the end of April from the American College of Emergency Physicians and Morning Consult discloses public concerns around seeking medical care during the current COVID-19 pandemic and support for federal efforts to protect those on the frontline.³ The data also confirms a troublesome trend across emergency departments and reveal that individuals are avoiding getting the medical care they need.³ The poll reveals that an estimated one-third of American adults (29%) indicate that they have delayed or avoided medical care because of concerns about contracting COVID-19. Moreover, approximately 73 % of respondents are concerned about overstressing the health care system, and 59 % are concerned they will not be able to get treated by a physician if they need care, with lower-income adults among those most anxious about access.³ The ACEP states that while it’s critical to stay home and follow social distancing guidelines, it’s vital to always know when to go to the emergency department.³  

Additionally, a recent study published in the Journal of the American College of Cardiology reported that admissions for ST-elevation myocardial infarction (STEMI) dropped 38% after March 1, after the pandemic hit.^4,5 In news reports, individuals have specifically cited coronavirus worries as the reason for avoiding hospitals.^4,5 The AHA recently published information on their website to ease patient fears indicating that it is safe for patients to go to the hospital during the COVID-19 pandemic.⁵

Additionally in a recent publication in JAMA exploring the impact of COVID-19 on oncology practices, authors noted that the pandemic has dismantled how care is delivered and forced clinicians to make difficult triage decisions about what types and components of care have limited immediate value and which are essential for optimal outcomes.^6,7 The authors noted that changes to oncology practices due to the pandemic may fall in 4 general categories which include:^6,7

• First, treatment that is not time sensitive has been swiftly transitioned to remote visits. This includes visits for survivorship care or surveillance, and care for low-risk patients receiving hormonal or oral chemotherapy.
• Second, certain treatments that cannot be delivered remotely have been omitted or delayed if it is revealed that it will have only marginal effect on quality of life or survival.
• The third area of oncology care affected by COVID-19 are situations where postponement of care has a moderate clinically significant adverse effect on quality of life or survival.
• Finally, there are certain situations in cancer care where treatment cannot be safely delayed. These include diseases that are more lethal than COVID-19. In this situation, oncologists must consider where the patient would be treated and whether their local center would be in the preparatory, acute, or crisis phase of the pandemic.^6,7
• The authors also noted that it is critical to evaluate the effects of COVID-19 on cancer mortality and which modifications occurring as a result of the pandemic are worth preserving in its wake.^6,7

While the majority of follow-up visits are being conducted via telemedicine and not in person, depending on the patient and or the circumstances of the illness or disease, this is not always an ideal format and challenges may arise.  For example, some health care providers have indicated that several of their patients are not able to take vital signs at home or go to get labs. Furthermore, since many annual physicals, routine preventative screening tests including mammograms, colonoscopies and lab work have been temporarily postponed in several states, many health care providers wonder what impact these delays will have on patient health in the future.

After discussing the impact of the COVID-19 pandemic on other diseases with various health care professionals, many cited fear and anxiety as common concerns for several of their patients. Their statements also revealed that the pandemic has affected the way they delivered patient care. Below are some comments from health care professionals in various settings from around the country.

• An internist stated that, “The use of video/telephonic visits have provided a bridge allowing care to continue during the pandemic. Although patients like the convenience, it has clinical limitations and are not a substitute for in office visits (as some patients desire). As a result of lack of information and monitoring some chronic health conditions may not be adequately controlled.  For geriatric patients, the pandemic has especially instilled a hesitancy to come back into the office even when restrictions are lifted. They fear exposure to COVID-19 more than consequences of chronic diseases that are not evaluated and may become uncontrolled.”
• A statement from a certified physician’s assistant practicing in an oncology setting stated, “As someone who works in the field of oncology there is a lot of uncertainty with how this pandemic will affect patient outcomes. We have not stopped treating patients on active treatment because of the threat of COVID-19 but have delayed treating patients if they are COVID-19 positive. Only time will tell if this delay will affect their outcome. We are still seeing newly referred patients; however, many of those patients do not want to come and do not get important imaging, bloodwork and procedures out of fear of contracting COVID-19. We also know that primary care providers are almost exclusively doing telemedicine which could mask important physical exam findings and other red flags for cancer. Screening tests also have been pushed back which could affect the outcomes of many. A prime example is lung nodules. They are asymptomatic and a patient can have no other reason to have a scan except for screening. Many lung cancers are found on screening low dose chest CT scans. Another example is colonoscopies. Polyps have varying degrees of risk depending on their characteristics which can only be determined via the scopes. The delays have placed a large burden on our schedulers who are likely to miss things or make errors with scheduling which certainly could cause patients to fall through the cracks and negatively affect their outcomes. Cancer is not likely to increase because of COVID-19, but those that have it may have worse outcomes because of delayed diagnosis and treatment.”
• An RN practicing in the hospital setting indicated that, “The hospital is seeing admissions due to exacerbations of conditions because patients are fearful of contracting COVID-19 if they go to the ER. Many are waiting until they are in dire straits or under the advisement of their doctors primarily because of fear of COVID-19. We are seeing patients with CHF exacerbations, patients with fluid overload because they are not going to dialysis and patients with COPD exacerbations not seeking medical care due to fear of the virus. We recently had a patient who has a history of angina that finally came to the ER after having chest pain for two to three weeks. This patient ended up needing a triple bypass due to severe blockage.”
• Another physician stated, “The pandemic has changed how we as health care providers can interact with our patients while providing care. The use of PPE and social distancing due to COVID-19 in many ways has depersonalized patient care to some extent. Our offices have been closed and we have implemented telemedicine visits which is not always optimal and in some ways may decrease provider/patient interactions. For example, it is difficult to assess certain symptoms via telemedicine. Many patients especially the elderly patient population was not prepared for telemedicine because of lack of access to the internet or not having knowledge of technology. Additionally, patients may not always take their vital signs or may not know how to take them or may be taking them incorrectly. Some patients are refusing to get routine labs done because of fear of contracting COVID-19 or because some labs are closed. Fear of contracting the virus has been a big obstacle for many patients in going to the ER as well."
• A pharmacist practicing in the retail setting stated, “There are some patients that are not getting medications refilled because they are afraid to leave their homes and more patients are using the drive thru or delivery services.”

Every day, health care providers continue to be warriors in the fight against COVID-19 while still providing quality health care to patients all over the country and globally for all medical conditions and disease. Studies have revealed that some underlying conditions may impact or exacerbate COVID-19 outcomes. As a result, we as clinicians should utilize the lessons learned thus far from this pandemic to promote the critical significance of preventative and routine health care and encourage patients to take an active role in their health. As one of the most accessible health care professionals, pharmacists can be an asset to patients and ease patient fears during this pandemic by acting as patient advocate and patient educator. All health care providers can reassure patients that health care facilities are practicing the best infection control measures and precautions to keep them safe especially during this time. It should be interesting to learn more about the true impact that COVID-19 pandemic has had on the diagnosis, treatment and management of other health conditions. The news reports of declines in ER visits for other medical emergencies is a concern for many health care providers. I believe that many health care providers are hoping that this is NOT the calm before the storm.

To all the health care heroes and heroines out there, THANK YOU for your dedication, service and care!! Together, we will get through this challenging time.

Yvette C. Terrie, is a consultant pharmacist, medical writer, and creator of A Pharmacist’s Perspective (https://apharmacistsperspective.blogspot.com/ ).

References

1. Antonio Olivo RC. Amid coronavirus pandemic, fewer Maryland, Virginia residents seek ER treatment. The Washington Post. https://www.washingtonpost.com/local/amid-coronavirus-pandemic-fewer-maryland-residents-seek-er-treatment/2020/05/07/acc42a20-9068-11ea-9e23-6914ee410a5f_story.html . Published May 7, 2020. Accessed May 8, 2020.
2. Baldas T. ER visits plummet amid pandemic: 'More people are dying at home'. USA Today. https://www.usatoday.com/story/news/local/michigan/2020/05/05/er-visits-plummet-amid-pandemic-we-know-more-people-dying-home/3067993001/ . Published May 5, 2020. Accessed May 8, 2020.
3. Public Poll: Emergency Care Concerns Amidst COVID-19. EM Physicians website. https://www.emergencyphysicians.org/article/covid19/public-poll-emergency-care-concerns-amidst-covid-19 . Accessed May 8, 2020.
4. Garcia S, Albaghdadi MS, Meraj PM, et al. Reduction in ST-Segment Elevation Cardiac Catheterization Laboratory Activations in the United States during COVID-19 Pandemic [published online ahead of print, 2020 Apr 9]. J Am Coll Cardiol. 2020;S0735-1097(20)34913-5. doi:10.1016/j.jacc.2020.04.011
5. Is it safe to go to the hospital during COVID-19 pandemic? Doctors say yes. American Heart Association website. https://www.heart.org/en/news/2020/05/04/is-it-safe-to-go-to-the-hospital-during-covid-19-pandemic-doctors-say-yes   Published May 4, 2020. Accessed May 7, 2020.
6. Schrag D, Hershman DL, Basch E. Oncology practice during the COVID-19 pandemic [published online April 13, 2020]. JAMA. doi: 10.1001/jama.2020.6236
7. Lawrence L. COVID-19 Pandemic Brings Changes to Cancer Care. Oncology Nurse Advisor website. https://www.oncologynurseadvisor.com/home/cancer-types/general-oncology/covid19-coronavirus-cancer-care-pandemic-brings-changes/ . Published April 28, 2020. Accessed May 7, 2020.