The COVID-19 pandemic has shocked the healthcare system and changed the manner care is being supplied as well as demanded by patients. Over the past year, the United States has seen demand shifts for many health procedures as there is a widespread deferral of care, including patients missing recommended screenings as well as a necessary treatment for chronic conditions. Physicians have voiced concern that the pandemic will bring collateral damage, as once Americans feel comfortable receiving care again, they will return to doctors’ offices sicker and requiring costlier care. Below I will focus specifically on mammograms and colonoscopies, two screening procedures medically recommended to most patients. Both these procedures have seen drastic declines and provide context to estimate the extent COVID may impact non-COVID patient health and future health outcomes.
Delayed and Forgone Care during the Pandemic
Patients’ fear of contracting the virus meant the United States saw a substantial decline in routine health visits, with many people delaying or entirely forging necessary care. From March 2020 through November, around one-third (36 percent) of Americans had delayed one or more types of care, including 56 percent of those with chronic conditions delaying care and 45 percent of those with cancer delaying care. People with chronic conditions require careful monitoring or physicians warn they may see considerable health declines. Of those who delayed care, 27 percent reported that it worsened one or more of their health conditions. As a precautionary measure to prepare hospitals for the pressure brought by the pandemic, many providers temporarily suspended elective surgeries and other types of health care. While fears of virus exposure were one of the top reasons for forgoing care, 82 percent reported that health facilities being closed or operating at a limited capacity was what led them to skip care. Unemployment and income loss was another factor which prevented people from pursuing their necessary care.
With 1 out of every 6 Americans vaccinated and COVID infections lowering after peaking during the holiday season, is there hope that we will see a return in screenings? As of March 14, many Americans were still wary of returning to normal, with only 43 percent saying they felt comfortable resuming their daily routine. Still, in October, when COVID infections were at a similar level to where they are now, 68 percent of adults said they would be comfortable seeing their primary care physician. This increased comfortability explains the increase in screenings during the fall months, and suggests this is a trend which could be expected to continue as COVID numbers decline.
Still, these screening declines during the height of the pandemic are concerning for a number of reasons. As seen in the large declines in health spending, the pandemic is expected to bring widespread collateral damage, including long-term health consequences nationwide. Some experts have even voiced concerns that the impact of COVID on those not affected by COVID may be more devastating than the virus itself.
Declines and Returns in Preventative Screenings
Focusing on breast cancer and colorectal cancer screening and diagnosis trend changes gives two examples of other causes of death which may see increases as a result of the pandemic. Mammograms are recommended every one to two years for women over the age of 40, with a 15 percent reduction in deaths for women who were tested regularly. The American Cancer Society recommends annual colorectal cancer screenings for those over the age of 45. Both these procedures are generally agreed upon to be high-value screenings, meaning they offer patients benefits worth the harm and potential cost.
Between March 15 and June 16 of 2020, patients missed 285,000 breast exams (a 63 percent decline from historical averages) and 95,000 colon exams (a 64 percent decline from historical averages). Using Preverity Inc. medical claim data comprising 50 percent of the commercial population in the US, it is evident there was significant volume loss and returns for the US overall as well as for selected states. Noteworthy findings include that the return of volume began in May, though the rate of return for these screenings varied by state. By October of 2020 mammogram and colonoscopy procedures had generally returned to pre-COVID levels. Still, there is not evidence of a surge in volumes to compensate for the lost volumes during the COVID shutdown. California is of particular significance, as their screening volumes still remain below pre-COVID levels, raising questions of how state policy response may impact citizen health. The declines in screenings likely contributed to a decline in cancer diagnoses, which is concerning given that later discovery could mean a poorer prognosis and fewer treatment options.
Patient Health Outlook
Together these two cancers account for about 1 out of every 6 cancer deaths, with cancer being the third leading cause of death in the U.S (with COVID now the first). Around 40,000 people die of breast cancer in the United States annually. The decline in mammograms becomes significant when contextualized with the fact that 18 percent of women will be diagnosed and 3 percent of all women are expected to die of breast cancer. It is estimated that the COVID-19 pandemic will contribute to an additional 10,000 deaths from breast and colorectal cancer over the next decade, representing a 1 percent increase in deaths of this type.
More generally, providers and insurers alike are concerned that under-treatment during the pandemic will bring sicker patients requiring costlier care in the months to come. Though we still remain in the dark about just how drastic these impacts will be, 37 percent of physicians reported that their patients with chronic conditions, such as diabetes and hypertension, were in “noticeably worse health resulting from the pandemic.” Broadly, 56 percent of physicians surveyed reported seeing an increase in health burdens, which they attribute to delayed care.
While the full extent of the spillover remains unclear, it is evident that the health implications of COVID-19 will extend beyond just those who contract the virus. The care deferrals seen across the U.S. will have lasting impacts which physicians will see in the months and years to come