Health Leaders urge patients not to defer critical screenings and appointments as they did during and in the weeks after the spring surge of the virus. Richard Nesto, MD (CMO, BILH) says a hospital environment is, in many ways, safer than walking around town or going to a store. BILH’s special hours to reduce exposure in common areas are highlighted as some of the measures local health systems have taken.

Boston Globe – November 30, 2020

Doctors have message for patients: Don’t skip non-urgent appointments

People waited in the emergency department at UMass Memorial Medical Center instructing people that only patients are allowed in the waiting room.Erin Clark / Globe Staff

Health leaders, even as they confront a tidal wave of COVID-19 infections, are urging anxious patients not to defer critical screenings and appointments as they did during and in the weeks after the spring surge of the virus.

Across the country, non-urgent surgeries and other medical appointments were halted in March to free up health care workers to treat COVID-19 patients and to conserve precious protective equipment like masks and gowns. But when the surge ebbed in May, droves of patients still shied away from doctors’ offices and outpatient hospital visits for such things as childhood vaccines and cardiac care, fearful of being infected with the virus by other patients or caregivers.

Some of those delays led to serious complications and more preventable illnesses. Doctors are hoping to avoid a repeat this time.

“It’s something I worry about a lot,” said Dr. Kimiyoshi Kobayashi, chief quality officer at UMass Memorial Medical Center and medical group in Central Massachusetts.

Kobayashi and administrators at other health care networks statewide say all of the precautions now taken at doctors’ offices and outpatient hospital settings, including COVID-19 testing, robust ventilation systems, and far fewer patients in waiting rooms, make them safer than many routine settings residents encounter in their communities.

“A hospital environment is, in many ways, safer than walking around town or going to a store,” said Dr. Richard Nesto, chief medical officer of Beth Israel Lahey Health, which includes 13 hospitals in Eastern Massachusetts.

Yet fears persist. A survey of about 1,000 Massachusetts residents by the state Public Health Department in early July, during a lull in COVID infections and hospitalizations, highlighted the lingering unease about going to doctors’ offices. The survey was designed to measure residents’ likelihood of getting aflu shot and how the pandemic may have affected those sentiments.

Of those who indicated they were not likely to get a flu shot this year, the number one reason was fear of being exposed to COVID-19 in the process.

“Even if the number of people in the space is controlled it still makes me nervous that many different people will have passed in and out,” one respondent said.

Such uneasiness has recently prompted 61-year-old Richard McFadyen to defer a battery of scans to determine whether the melanoma skin cancer he was treated for five years ago is still at bay.

McFadyen, who lives in the MetroWest area, said he was nervous about being exposed to the coronavirus from other patients while waiting and moving from room to room at the Dana-Farber Cancer Institute during and between the battery of scans. He was anxious because the hospital, like many others in the state, does not routinely test for COVID-19 among outpatients who are undergoing scans, such as X-rays and MRIs.

“I decided my risk of having any serious outcome from a six-month delay in my final scans was a lower risk than going into Boston and having the scans done,” McFadyen said.

He has rescheduled them for the spring. “Hopefully,” he said, “I will have a COVID vaccine at that point.”

Dana-Farber said in a statement the institution has been “unwavering in providing a very safe environment for every patient and every person on our workforce.” It said its ventilation system meets and exceeds state codes and federal guidance and it follows Centers for Disease Control and Prevention recommendations for mask use, safe distancing, and which outpatients should be tested for COVID-19.

McFadyen’s wife, Cynthia Iris, 66, did keep her appointment at Newton-Wellesley Hospital for a routine colonoscopy in October. She said she felt safe from being exposed to the virus by patients because the hospital required her to undergo a COVID-19 test before that procedure.

But then, she heard about two small COVID-19 outbreaks at Newton-Wellesley later in October and early November. Now, she’s thinking about delaying her annual physical, scheduled for December, until the spring.

“If it were not for COVID, I would absolutely get the blood tests and have my physical,” she said.

While health care administrators say they have not seen a measurable drop in outpatient visitsrecently, they are keenly aware of the heightened anxieties.

Mass General Brigham is running “Don’t Delay Care” ads on social media and television, imploring patients to keep current with screenings, appointments, and childhood vaccinations.

Beth Israel Lahey Health advertises its special hours at some primary care locations for patients at high risk of developing severe complications from COVID-19, including older adults and those with compromised immune systems. The special hours, the health system said, are “to reduce their exposure to other people in common areas, such as waiting rooms.”

And Atrius Health, a large Eastern Massachusetts group practice with 30 sites, reminds patients of their options for telehealth visits.

While patients admitted to the hospital undergo routine COVID-19 testing, policies for outpatient visits differ. The tests are recommended by federal regulators for certain outpatient procedures that are higher risk for releasing tiny droplets into the air and transmitting the virus.

Rules about who should get tested have been a source of confusion for patients, and a concern for health care leaders.

With the pandemic raging again, administrators worry about having sufficient testing supplies and whether current rules are adequate.

“It’s a landscape that is quite in flux,” said Dr. Erica Shenoy, associate chief of infection control at Massachusetts General Hospital.

Shenoy said Mass General Brigham’s COVID-19 testing policy for outpatients has evolved with the science about which procedures create risk for virus transmission. Even more than eight months into the pandemic, there continues to be a debate about which procedures should require advance testing. The CDC provides a list of procedures for guidance, such as certain ones that insert tubes to examine deep into patients’ noses or throats, but notes there is “neither expert consensus, nor sufficient supporting data, to create a definitive and comprehensive list.”

Among the procedures now under review at Mass General Brigham are ones that include upper and lower endoscopy — inserting tubes to examine deep into the upper digestive tract or into the colon, such as a colonoscopy. Shenoy said the health system is constantly reviewing ways to improve its approach for keeping patients and workers safe.

“I encourage patients to ask questions so I can explain the rationale,” Shenoy said. “We have thought really, really hard about this.”

Dr. Joe Kimura, chief medical officer at Atrius Health, is worried about how to reshape COVID-19 outpatient testing, once again, post-Thanksgiving. Doctors expect infections to surge still higher after family gatherings and travel.

“It’s getting harder and harder, as the prevalence of COVID is kicking up in the community, should we be expanding that criteria?” Kimura asked. “That is an active conversation with our infectious disease team about how much should we do.”

Kimura said ideally they would have unlimited supplies available to test outpatients more broadly, but they are still plagued by shortages of testing swabs.

“We all have PTSD from the spring,” he said, when they would tighten or ease testing protocols seemingly weekly, based on supplies.

”We are all very spooked,” Kimura said “Do we have enough, as we head into the second wave?”