COVID fears drive patients to avoid doctors, hospitals

CLINICIANS are bracing for a potential wave of severe non-coronavirus disease 2019 (COVID-19) illnesses as they fear patients with early symptoms of cardiovascular or other serious conditions may have avoided presenting to emergency departments during the COVID-19 crisis.

Dr John Bonning, President of the Australasian College for Emergency Medicine, said there had been substantial reduction in ED presentations across Australia, with data seen so far, as well as anecdotal experiences suggesting declines varying from 10-30% across the jurisdictions.

“This is multifactorial,” he said. “Obviously, [with the social restrictions put in place to reduce COVID-19 infection], we are getting fewer motor vehicle accidents, less sports trauma, fewer alcohol-fuelled issues, although there is probably an increase in mental health presentations where alcohol is often a factor.”

Professor Peter Cameron, Academic Director of the Alfred Emergency and Trauma Centre, said the ED had been “exceptionally quiet” in the weeks since the onset of the COVID-19 pandemic with a 40% drop in presentations compared with the same time last year.

“I have worked in emergency for a long time, and I have never known it to be so quiet,” Professor Cameron said. “I work in Bairnsdale as well, and it was the same there. It is picking up a bit now, but it is really quiet.”

Dr Cameron said while reduced trauma attendances were welcome, there were concerns that fewer attendances for other conditions may result in some major health complications in the coming weeks and months.

“We are worried that attendances for some major problems appear to have decreased, things like heart attacks and strokes and major sepsis conditions and also people with complications from cancer and immunological diseases, or people who have transplants and are immunocompromised,” he said.

Dr Bonning said the UK had reported patients presenting late with bowel conditions, sepsis, appendicitis, and chest pain, and while Australia was in a very different position in terms of COVID-19, there were anecdotes of similar late presentations occurring in Australia and concerns some catch-up on unmet — acute and chronic – health care may be needed over the coming weeks and months.

Associate Professor Dion Stub, an interventional cardiologist at Alfred Health and medical advisor to Ambulance Victoria, said while accurate estimates of presentations would come from the future analysis of Ambulance Victoria and Victorian Cardiac Outcomes Registry data, initial figures indicated that there had been a 30% drop in triple-0 calls for chest pain in the past weeks.

“There is definitely a sense across Victorian hospitals that emergent cardiac work for patients with both ST elevated myocardial infarction (STEMI) and non-STEMI heart attacks is significantly reduced, whether it’s by 20% or 40% is hard to definitely say at this stage, but it’s looking to be significant proportions,” he said.

Associate Professor Stub said there was no obviously plausible biological mechanism that could explain the drop in the number of patients presenting to emergency with cardiovascular symptoms.

“Maybe patients are less active, but there is no obvious reason why heart attack numbers should be down, apart from the real possibility that patients are avoiding coming to hospital, they are not seeing their cardiologist and they are potentially afraid even to see their GPs,” Associate Professor Stub told InSight+.

Professor Garry Jennings, Senior Director at the Baker Heart and Diabetes Research Institute, wrote in the MJA that dramatic falls in ED presentations had been reported in the UK, Europe, Canada and Australia. The US has also reported sharp declines in ED presentations.

He noted that STEMI rates fell by about 40% in reports from Spain and the US.

“It is possible that COVID-19 is associated with plaque stabilisation and lower rates of STEMI, but it seems more likely that some people with heart disease are abandoning the usual medical advice at a time when they may need it the most,” he wrote.

Dr Paul Preisz, acting Director of the Emergency Department at St Vincent’s Hospital, said there had been a decline in ED presentations at the Sydney hospital, but was cautious in attributing this solely to COVID-19 concerns.

He noted that the ED had been unusually busy from October to January this year, and the starkness in the decline in presentations could, at least partly, be attributed to the usual ebb and flow of ED.

However, Dr Preisz shared concerns about the possible consequences of patient reluctance to attend EDs during the COVID-19 crisis.

“That is obviously something that we would worry about and perhaps that is something that has happened overseas,” he said, adding that investigations on international experiences were underway.

“We don’t really have data on [chest pain presentation] at this stage … we will be able to get a sense in the next weeks and months if patients are generally more unwell than they were in a similar period a year ago.”

Dramatic falls in the uptake of other health care services have also fuelled concerns that patients are delaying tests and treatments for fear of COVID-19 infection or facing an overwhelmed health system.

President of the Royal College of Pathologists of Australasia (RCPA), Dr Michael Dray, said between 30% and 40% of private and community pathology testing was currently not being done due to people not visiting their medical practitioner and not having their pathology samples collected.

“This equates to over 60 000 Australians every day, with a similar proportion of patients in New Zealand too. Smaller reductions have also occurred in the public sector,” he said. “It is essential that individuals attend important medical appointments and have pathology tests performed in order to avoid poor health outcomes, potential hospitalisation and increased morbidity and mortality.”

The Royal Australian and New Zealand College of Radiologists (RANZCR) has also raised concerns about patients with cancer delaying or discontinuing treatment based on incorrect assumptions about the safety, availability or capacity of clinical services.

Dr Madhavi Chilkuri, Dean of Faculty of Radiation Oncology within RANZCR, said it was crucial that health care professionals reminded patients with cancer about the importance of continuing treatment.

“Radiation therapy services are essential and still accessible,” she said.

Dr Chilkuri told InSight+ that evidence-based protocols were developed early in the pandemic to address patient safety and health service capacity.

“We considered how to manage safe continuity of services and what sort of cancers could be managed a little differently – whether that be a reduced number of visits to the hospital, delayed treatment, or conducting consultations via telehealth,” she said, noting that any patient decisions to postpone treatment commencement or interrupt current treatment needed to be taken in consultation with their treating oncologist.

Some changes seen in EDs in recent weeks, however, have been welcomed.

In addition to reduced road trauma and alcohol-related injuries, clinicians say there has also been a sharp decline in ED presentations among the “worried well”.

“People with trivial complaints haven’t bothered going to the ED because they are worried about catching COVID-19,” Professor Cameron said. “And that’s not a bad thing.”

The uptake of telehealth too is a trend that could help to reduce EDs’ patient loads in the future.

“Out of every disaster comes opportunity,” Professor Cameron said. “So, initiatives like telehealth, identifying patients who might not need to come to ED and treating them by alternative means, especially the older group, these are the opportunities we can capitalise on.”

Dr Preisz said the crisis has also seen the hospital sector display “remarkable agility” and cooperation.

“We have taken a lot of steps to arrange different clinics in different spaces and organise different ways of seeing patients, because 6–8 weeks ago, we really didn’t know where we would be in April and May,” he said. “While we have been lucky not to have been overrun with COVID-19 cases, we have gone to great lengths to make the hospital a safe place. If there is a need to be in hospital, people shouldn’t be worried about being in hospital.”

Dr Preisz said EDs across the country had been sharing information and swapping ideas to meet the immense challenges of an unknown crisis.

“It’s been an incredible thing to see so many people so willing to give of themselves and that the system has actually worked. It’s been pretty impressive.”