Long-term effects of missed care get more pronounced as data emerges

• A large number of cancer screenings that were missed in the spring still have not occurred, according to research.
• Patient volumes remain 10% to 20% below their pre-pandemic levels.
• Providers can take steps to get more patients to reengage with needed care.

Data showing a persistent decrease in patient volumes — long after the initial surge of COVID-19 and the related shutdowns — is raising alarms from researchers that broad deteriorations in patient health could be occurring.

Recent data collected by Epic from millions of patient records found that the large drop-off in cancer screenings from the spring was never made up later in the year. Epic’s estimates include:

• 285,000 missed breast cancer screenings
• 95,000 missed colon cancer screenings
• 40,000 missed cervical cancer screenings

“What is the most potentially concerning is that missed care, and we may not see that for some time as these things play out,” Christopher Mast, MD, vice president of clinical informatics for Epic, said in a webcast hosted by the Kaiser Family Foundation.

The missed screenings are in addition to a continued lag in patient volumes.

For instance, through Sept. 11, medical claims analyzed by IQVIA rebounded only to 80% to 90% of pre-pandemic levels, even when telehealth visits were included.

“We’re not yet over 100% in any of these periods, which means we’re not catching up,” said Michael Kleinrock, lead research director of the Institute for Human Data Science at IQVIA.

He noted that COVID-19 treatment comprises a very small share of the rebound in inpatient and outpatient volumes. And far fewer hospital ICUs are nearing capacity now, compared with March and April.

Similarly, elective procedures in September remained 22% lower year-over-year.

“There’s still that lingering issue of, the ‘Where-didthey-go-people’ — that we see a month or two months‘ worth of significant absence of normal patient flows,” Kleinrock said. “Those are particularly a concern going forward, especially if we remain at this sort of sub-baseline level for the rest of this year and into 2021. That could have longer-term impacts on chronic disease outcomes and so [is] definitely worth watching.”

Issues could arise with early detection

That decline in patient volumes could leave apparently healthy people without the early disease detection that’s critical for better management and cost control.

“When you need a patient to turn up, when you need a regular flow of asymptomatic people to find out they have high blood pressure, those things not happening is a concern for us,” said Luke Greenwalt, vice president of the Market Access Center of Excellence for IQVIA.

Greenwalt said the effort to get patients to return for needed preventive care or chronic disease management also has been affected by reduced provider capacity created by social-distancing protocols and cleaning requirements in response to the pandemic.

One bright spot in IQVIA’s analysis was that despite an overall decrease in adult and pediatric vaccinations in 2020, flu vaccinations are trending higher than in 2019.

Epic’s Mast also highlighted the potential long-term consequences of missed opportunities for early detection.

“There’s definitely a ripple effect to this, as well,” Mast said. “What we’re seeing and going through right now is just the first wave of what’s like to play out over the next three to five years as we see delays in care manifest themselves in costs elsewhere.”

The pandemic has fueled a massive expansion in the use of telehealth, but Mast warned that it remains unclear which patient populations can successfully substitute telehealth for in-person care.

Early data indicates that telehealth is an equivalent or better option for the delivery of mental health services.

“But for other things, it remains to be seen,” Mast said.

How providers should respond to the trend

Mast said providers should push for screenings and immunizations and use predictive models and risk analysis tools to identify patients at high risk for health complications, then get them to come for needed visits and engage them in their own care.

The researchers acknowledged that in addition to the effect of broad government lockdowns, the decrease in patient volumes and screenings likely also stems from patient fears about contracting COVID-19 at healthcare facilities.

Nichole Quick, MD, a clinical informaticist as Epic, said providers need to educate their patients that “some of the risk factors for a poor outcome from COVID are chronic diseases that need to be managed well” during the pandemic.

Quick said providers should encourage their patients to use portals and then direct patients who are wary of coming in for care to the appropriate channel through which to receive needed preventive care.

Kleinrock also underscored a need for a multitude of provider public outreach campaigns, which use broadcast and Internet ads to encourage patients to return to local providers for needed care.

“Those are definitely positives in light of these lingering absences of patients,” Kleinrock said.