Should COVID still force us to postpone elective surgery or forgo a trip to the ER?

The Hill – October 18, 2020

In this opinion article, the author references a study released earlier in the year led by Dhruv Kazi, MD, MSc, MS (Cardiology, BIDMC) that quantified the effect of the COVID-19 pandemic on the numbers of patients seeking medical attention for select potentially life-threatening diagnoses. 

In March, the Centers for Disease Control and Prevention (CDC) urged people to stay away from crowded emergency rooms and put-off elective surgery, including heart procedures, to reduce potential coronavirus exposure. As early as April, doctors worried that people experiencing life-threatening emergencies were avoiding hospitals. Those fears were validated. 

In Boston, Beth Israel Deaconess Medical Center’s March/April data showed heart attack hospitalizations down by 33 percent, stroke hospitalizations down by 58 percent, and referrals for breast and blood cancers down by more than 60 percent from the two months prior. Even those who experienced a heart attack or stroke avoided hospitals; one study showed a 38 percent drop in patients treated for ST-Elevation Myocardial Infarction, a life-threatening narrowing of a vital artery to the heart. 

By June, 41 percent of Americans reported having had avoided some care due to Covid fears. The CDC found that emergency visits across the U.S. declined 23 percent for heart attacks from March to May and 20 percent for strokes. Though the World Health Organization (WHO) still urges people to avoid routine dental and health care visits, following that guidance can produce unintended consequences, some long term. 

With ailments such as cardiovascular disease, delay in treatment can lead to preventable deaths or permanent disabilities. Virginia Commonwealth University and Yale University researchers looked at excess deaths — the number of deaths over what would be expected based on previous years — in March and April. They concluded that overall. 56,246 (65 percent) of the 87,001 excess deaths in the U.S. during those two months were attributed to COVID-19. 

However, in 14 states, including populous California and Texas, more than 50 percent of excess deaths were attributed to other causes, most commonly heart disease, the leading cause of death in America. A person whose primary cause of death is cardiovascular or pulmonary may have also had COVID 19. The five states with the most COVID-19 deaths also experienced large proportional increases in deaths due to pre-existing chronic conditions: diabetes (96 percent), heart diseases (89 percent), Alzheimer’s disease (64 percent), and cerebrovascular diseases (35 percent). New York City experienced the largest increases, notably those due to heart disease (398 percent) and diabetes (356 percent).

But with diseases like cancers, delayed treatment and delayed diagnoses cause impacts that won’t be felt immediately. Those delays are mounting up. One national study of U.S. patients who received testing from Quest Diagnostics between January and April found the mean weekly number of new diagnoses for six common cancers dropped by 46 percent, with breast cancer diagnoses in March and April declining the most (52 percent), compared to the two months prior. Data from 20 U.S. health care institutions found breast cancer screenings down by 89 percent and colorectal cancer screenings down by 85 percent in the first four months of 2020, compared to the same period last year.

These delays are highly likely to result in increased mortality. A study in the Lancet using data from the UK estimated that diagnostic delays in four major tumor types (breast, colorectal, lung, and esophageal) from March through June could result in 3,291 to 3,621 avoidable deaths and an additional 59,204 to 63,229 years of life lost. Additionally, a systematic review in Nature demonstrates that delaying radiotherapy more than eight weeks after surgery doubles local recurrence risk in breast cancer patients. In June, the National Cancer Institute, modeling the potential impacts of a delayed diagnosis(assuming a 75 percent reduction in mammography and colorectal screening) and delayed treatment (assuming one-third of diagnosed patients delay treatment for six months) over a period of six months, predicted a one-percent increase (an additional 10,000 deaths) in the United States from breast and colorectal cancers alone over the next decade. 

Whether or not we are at risk for cancer or heart disease, dental care is one area where delays mean problems, now and later, for each of us. There’s been widespread reluctance to visit the dentist due to the perceived risk of transmission from an infected patient spreading COVID-19 to dental staff or the next patient. Despite these potential risks, there have been no reported cases of COVID-19 transmitted in a dental office in the U.S. so far, according to the CDC. The American Dental Association (ADA) “respectfully yet strongly disagrees” with WHO’s recommendation to delay “routine” dental care, which can have a cascading effect on other aspects of your health, as gum disease is associated with a higher risk of dementia, heart disease, and rheumatoid arthritis, among other conditions.

Dentists and the ADA have been a model of how to approach COVID-19 safety proactively. In mid-May, in sync with the ADA, the CDC issued guidance for dental practices, which continues to be periodically updated, calling for the highest level of PPE available — masks, goggles and face shields. ADA’s interim guidance calls for the use of rubber dams and high-velocity suction whenever possible, and hand scaling when cleaning teeth rather than ultrasonic scaling to minimize potential COVID-19 droplets from becoming aerosolized.

At this point, should you delay surgery or other procedures termed “elective?” It’s critical that you talk to your physician and review information on reported COVID-19 cases associated with the hospital or surgery center where you would have the procedure; It’s important to check that the facility rigorously enforces a comprehensive set of safety protocols: 

  • Screening patients, workers and visitors on the entry for COVID-19 symptoms and risk factors
  • Testing all admitted patients
  • Requiring universal masking and appropriate protective equipment/PPE
  • Cleaning facilities thoroughly and disinfecting for a range of organisms and viruses
  • Minimizing the number of people in facilities while requiring physical distancing 

And when should you go to the emergency room?  Johns Hopkins recommends you visit the ER if you have:

  • Chest pain or pressure, palpitations, shortness of breath, or other symptoms of heart attackor other heart problems
  • Sudden numbness, weakness, confusion, loss of vision, problems with speech or balance, or other symptoms of stroke
  • Unexplained or worsening shortness of breath, or other breathing problems
  • High fever
  • Intense or unexplained pain
  • Severe injury or trauma, including deep, large, or severe cuts
  • Possible broken bones
  • And any other problems that you consider an emergency

Many have been neglecting care for too long, and it’s time for federal and local health authorities to modify their guidance regarding avoiding so-called elective procedures. Public health officials and agencies should be reminding people not to avoid the ER if they have an emergency and get back on schedule for evidence-based screening and needed treatments and surgeries.  Lastly, and most importantly, public health authorities must remind everyone to consult with their care providers to determine what procedures, treatments and screenings shouldn’t be further delayed. 

Jonathan Fielding M.D., who headed public health for Massachusetts and Los Angeles County, is a UCLA professor of Health Policy and Management.