Hidden ailments

Avoiding coronavirus has meant avoiding necessary physical and mental health treatments

By Anne-Frances Hutchinson

When the WHO declared Covid-19 a global pandemic in early March, the American College of Surgeons issued a recommendation that physicians should “thoughtfully review all scheduled elective procedures with a plan to minimize, postpone, or cancel electively scheduled operations, endoscopies, or other invasive procedures until we have passed the predicted inflection point in the exposure graph and can be confident that our health care infrastructure can support a potentially rapid and overwhelming uptick in critical patient care needs.”

Aimed at keeping hospital beds open for the gravely ill, preserving a limited supply of PPE, and protecting people from needlessly contracting the virus, the guidance moved US Surgeon General Jerome Adams to offer this advice via social media: “Hospital & healthcare systems, PLEASE CONSIDER STOPPING ELECTIVE PROCEDURES until we can #FlattenTheCurve!”

Adams’ tweet launched fierce pushback from hospitals and healthcare systems facing the economically devastating tightening of margins that would come with such sweeping, open-ended directive. Hospital systems rescheduled surgeries for cataracts, joint replacements, early-stage cancer and the like, resulting in a precipitous drop in the revenues they were projected to deliver—and sparking dread in millions of Americans already rattled by the nascent crisis.

The CDC reported that from March to April, ER visits were 42% lower than during the same time in 2019. At the same time, CDC data showed that heart disease and non-Covid deaths were higher than normal. While the reasons for the uptick in those death rates are difficult to clearly ascertain, avoidance of emergency care is thought to be a contributing factor.

According to Brian Hasselfeld, assistant medical director for Digital Health Innovations at Johns Hopkins, the number of patients his medical group is seeing has dropped by 20% to 30%. “People are trying to observe physical distancing and avoiding unnecessary exposure, such as going to the grocery store,” he wrote in a recent blog. “But in terms of medical care, providers are worried, since ignoring serious signs and symptoms can be dangerous.”

Addressing the American Hospital Association, John Haupert, CEO of Atlanta-based Grady Health System, noted that while the rate of essential and elective surgeries at Grady initially plummeted by 38%, as of mid-July that drop had begun to stabilize. “We’re now still off our baseline by 19%. Part of what we’re seeing there is reluctance of patients to come to the hospital or to seek services in emergency departments. As patients are returning to the ER, many have significantly exacerbated chronic disease conditions—hypertension, diabetes, congestive heart failure, pulmonary disease—because they have not sought the care they needed.”

The American Heart Association noted that “the number of heart attacks and strokes are not necessarily declining. While ongoing research may uncover other underlying reasons for decreasing numbers of heart attack and stroke patients in hospitals, the prevailing theory is that people just aren’t calling 911.”

Telehealth to the rescue?

 CDC guidance stressed that increased adoption of telehealth can be a vital aid to the ill and infirm during the pandemic. “Maintaining continuity of care to the extent possible can avoid additional negative consequences from delayed preventive, chronic, or routine care. Remote access to healthcare services may increase participation for those who are medically or socially vulnerable or who do not have ready access to providers. Remote access can also help preserve the patient-provider relationship at times when an in-person visit is not practical or feasible.”

In addition to promoting telehealth as an alternative to in-person treatment where appropriate, the CDC recommends that healthcare providers communicate with insurers and other payers to understand the availability of covered telehealth, telemedicine, or nurse advice line services, and to use tele-triage protocols to assess and caring for patients in areas where virus transmission rates are high.

Given that a significant percentage of the people most vulnerable to the virus in rural or underserved communities may not have ready access to broadband, they also urge providers to reach out to patients with limited technology and connectivity and “offer flexibility in platforms that can be used for video consultation, or non-video options, when possible.”

Hasselfeld estimated that nearly 100% of providers at Johns Hopkins Medicine have telemedicine available, and that today, over 80% of his team’s daily patient visits take place virtually.  “First and foremost, providers’ goals should be ensuring patients get the care they need, regardless of method,” he stressed. “Video and telephone can deliver that care in a safe way.”

In a recent week the Johns Hopkins system facilitated 5,000 remote visits each day. “Video visits can help doctors take a history and even perform some aspects of a physical exam. Obviously, where technology is today, it’s not a total replacement for in-person care, but it’s providing us a means of diagnosing and advising patients,” he reported.

Treatment access and mental health

 In a May policy brief, the United Nations underscored the need for a coordinated approach to coping with mental health issues arising from the pandemic. Isolation, job losses, loss, and the fear of contracting the virus have laid a foundation for a global mental health crisis that may last for decades.

Virtual counseling services are on the rise, including sites such as TalkSpace, Betterhelp, ReGain couples counseling, Pride Counseling for LGBTQ+ individuals, and MDLive.

As UN researchers explained, “During the past few months, there have been efforts initiated to support people in distress and to ensure care for people with mental health conditions. Innovative ways of providing mental health services have been implemented, and initiatives to strengthen psychosocial support have sprung up.

“Yet, because of the size of the problem, the vast majority of mental health needs remain unaddressed. The response is hampered by the lack of investment in mental health promotion, prevention and care before the pandemic. This historic underinvestment in mental health needs to be redressed without delay to reduce immense suffering among hundreds of millions of people and mitigate long-term social and economic costs to society.”

Ameliorating the crisis will require a “whole-of-society” approach to improve the quality of programming, help people build coping skills during the pandemic, reduce suffering, and to help quicken the pace of community recovery and rebuilding.

A blend of community action that strengthens social cohesion, solidarity, and healthy coping, access to remote counseling and support, and the recognition by healthcare providers and insurers that mental health care should be defined as an essential service is part of the foundation the UN sees as a bridge to keeping this new crisis under control.

For many, fear of the virus may be as damaging as actually contracting it, but now is not the time to add to the crisis by avoiding our own care. Metaphorically speaking, we need to do for ourselves what airlines have long advised: “Put on your own mask before helping others.” The experienced diagnosticians, caregivers, and essential workers of your preferred healthcare system are ready and able to keep you safe and well.