Delay or Avoidance of Medical Care Because of COVID-19–Related Concerns

United States, June 2020

Mark É. Czeisler; Kristy Marynak, MPP; Kristie E.N. Clarke, MD; Zainab Salah, MPH; Iju Shakya, MPH; JoAnn M. Thierry, PhD; Nida Ali, PhD; Hannah McMillan, MPH; Joshua F. Wiley, PhD; Matthew D. Weaver, PhD; Charles A. Czeisler, PhD, MD; Shantha M.W. Rajaratnam, PhD; Mark E. Howard, MBBS, PhD

Disclosures

Morbidity and Mortality Weekly Report. 2020;69(36):1250-1257. 

In This Article

Abstract and Introduction

Introduction

Temporary disruptions in routine and nonemergency medical care access and delivery have been observed during periods of considerable community transmission of SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19).[1] However, medical care delay or avoidance might increase morbidity and mortality risk associated with treatable and preventable health conditions and might contribute to reported excess deaths directly or indirectly related to COVID-19.[2] To assess delay or avoidance of urgent or emergency and routine medical care because of concerns about COVID-19, a web-based survey was administered by Qualtrics, LLC, during June 24–30, 2020, to a nationwide representative sample of U.S. adults aged ≥18 years. Overall, an estimated 40.9% of U.S. adults have avoided medical care during the pandemic because of concerns about COVID-19, including 12.0% who avoided urgent or emergency care and 31.5% who avoided routine care. The estimated prevalence of urgent or emergency care avoidance was significantly higher among the following groups: unpaid caregivers for adults* versus noncaregivers (adjusted prevalence ratio [aPR] = 2.9); persons with two or more selected underlying medical conditions versus those without those conditions (aPR = 1.9); persons with health insurance versus those without health insurance (aPR = 1.8); non-Hispanic Black (Black) adults (aPR = 1.6) and Hispanic or Latino (Hispanic) adults (aPR = 1.5) versus non-Hispanic White (White) adults; young adults aged 18–24 years versus adults aged 25–44 years (aPR = 1.5); and persons with disabilities§ versus those without disabilities (aPR = 1.3). Given this widespread reporting of medical care avoidance because of COVID-19 concerns, especially among persons at increased risk for severe COVID-19, urgent efforts are warranted to ensure delivery of services that, if deferred, could result in patient harm. Even during the COVID-19 pandemic, persons experiencing a medical emergency should seek and be provided care without delay.[3]

During June 24–30, 2020, a total of 5,412 (54.7%) of 9,896 eligible adults completed web-based COVID-19 Outbreak Public Evaluation Initiative surveys administered by Qualtrics, LLC.** The Human Research Ethics Committee of Monash University (Melbourne, Australia) reviewed and approved the study protocol on human subjects research. This activity was also reviewed by CDC and was conducted consistent with applicable federal law and CDC policy.†† Respondents were informed of the study purposes and provided electronic consent before commencement, and investigators received anonymized responses. The 5,412 participants included 3,683 (68.1%) first-time respondents and 1,729 (31.9%) persons who had completed a related survey§§ during April 2–8, 2020. Among the 5,412 participants, 4,975 (91.9%) provided complete data for all variables in this analysis. Quota sampling and survey weighting¶¶ were employed to improve cohort representativeness of the U.S. population by gender, age, and race/ethnicity.

Respondents were asked "Have you delayed or avoided medical care due to concerns related to COVID-19?" Delay or avoidance was evaluated for emergency (e.g., care for immediate life-threatening conditions), urgent (e.g., care for immediate non–life-threatening conditions), and routine (e.g., annual check-ups) medical care. Given the potential for variation in interpretation of whether conditions were life-threatening, responses for urgent and emergency care delay or avoidance were combined for analysis. Covariates included gender; age; race/ethnicity; disability status; presence of one or more selected underlying medical conditions known to increase risk for severe COVID-19; education; essential worker status***; unpaid adult caregiver status; U.S. census region; urban/rural classification†††; health insurance status; whether respondents knew someone who had received a positive SARS-CoV-2 test result or had died from COVID-19; and whether the respondents believed they were at high risk for severe COVID-19. Comparisons within all these subgroups were evaluated using multivariable Poisson regression models§§§ with robust standard errors to estimate prevalence ratios adjusted for all covariates, 95% confidence intervals, and p-values to evaluate statistical significance (α = 0.05) using the R survey package (version 3.29) and R software (version 4.0.2; The R Foundation).

As of June 30, 2020, among 4,975 U.S. adult respondents, 40.9% reported having delayed or avoided any medical care, including urgent or emergency care (12.0%) and routine care (31.5%), because of concerns about COVID-19 (Table 1). Groups of persons among whom urgent or emergency care avoidance exceeded 20% and among whom any care avoidance exceeded 50% included adults aged 18–24 years (30.9% for urgent or emergency care; 57.2% for any care), unpaid caregivers for adults (29.8%; 64.3%), Hispanic adults (24.6%; 55.5%), persons with disabilities (22.8%; 60.3%), persons with two or more selected underlying medical conditions (22.7%; 54.7%), and students (22.7%; 50.3%). One in four unpaid caregivers reported caring for adults who were at increased risk for severe COVID-19.

In the multivariable Poisson regression models, differences within groups were observed for urgent or emergency care avoidance (Figure) and any care avoidance (Table 2). Adjusted prevalence of urgent or emergency care avoidance was significantly higher among unpaid caregivers for adults versus noncaregivers (2.9; 2.3–3.6); persons with two or more selected underlying medical conditions versus those without those conditions (1.9; 1.5–2.4); persons with health insurance versus those without health insurance (1.8; 1.2–2.8); Black adults (1.6; 1.3–2.1) and Hispanic adults (1.5; 1.2–2.0) versus White adults; young adults aged 18–24 years versus adults aged 25–44 years (1.5; 1.2–1.8); and persons with disabilities versus those without disabilities (1.3; 1.1–1.5). Avoidance of urgent or emergency care was significantly lower among adults aged ≥45 years than among younger adults.

Figure.

Adjusted prevalence ratios*,† for characteristics§,¶,**,†† associated with delay or avoidance of urgent or emergency medical care because of concerns related to COVID-19 — United States, June 30, 2020
Abbreviation: COVID-19 = coronavirus disease 2019.
*Comparisons within subgroups were evaluated using Poisson regressions used to calculate a prevalence ratio adjusted for all characteristics shown in figure.
95% confidence intervals indicated with error bars.
§"Other" race includes American Indian or Alaska Native, Native Hawaiian or Pacific Islander, or Other.
Selected underlying medical conditions known to increase the risk for severe COVID-19 were obesity, diabetes, high blood pressure, cardiovascular disease, and any type of cancer. Obesity is defined as body mass index ≥30 kg/m2 and was calculated from self-reported height and weight (https://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/index.html). The remaining conditions were assessed using the question "Have you ever been diagnosed with any of the following conditions?" with response options of 1) "Never"; 2) "Yes, I have in the past, but don't have it now"; 3) "Yes I have, but I do not regularly take medications or receive treatment"; and 4) "Yes I have, and I am regularly taking medications or receiving treatment." Respondents who answered that they have been diagnosed and chose either response 3 or 4 were considered as having the specified medical condition.
**Essential worker status was self-reported. For the adjusted prevalence ratios, essential workers were compared with all other respondents (including those who were nonessential workers, retired, unemployed, and students).
††Unpaid caregiver status was self-reported. Unpaid caregivers for adults were defined as having provided unpaid care to a relative or friend aged ≥18 years to help them take care of themselves at any time in the last 3 months.

*Unpaid caregiver status was self-reported. The definition of an unpaid caregiver for adults was having provided unpaid care to a relative or friend aged ≥18 years to help them take care of themselves at any time in the last 3 months. Examples provided to survey respondents included helping with personal needs, household chores, health care tasks, managing a person's finances, taking them to a doctor's appointment, arranging for outside services, and visiting regularly to see how they are doing.
Selected underlying medical conditions known to increase the risk for severe COVID-19 included in this analysis were obesity (body mass index [BMI] ≥30 kg/m2), diabetes, high blood pressure, cardiovascular disease, and any type of cancer. BMI was calculated from self-reported height and weight as BMI = weight (lb)/[height (in)]2 x 703 (https://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/index.html). The remaining conditions were assessed using the following question: "Have you ever been diagnosed with any of the following conditions?" with the following four response options: 1) "Never"; 2) "Yes, I have in the past, but don't have it now"; 3) "Yes I have, but I do not regularly take medications or receive treatment"; and 4) "Yes I have, and I am regularly taking medications or receiving treatment." Respondents who answered that they have been diagnosed and chose either response 3 or 4 were considered as having the specified medical condition.
§Persons who had a disability were defined as such based on a qualifying response to either one of two questions: "Are you limited in any way in any activities because of physical, mental, or emotional condition?" and "Do you have any health conditions that require you to use special equipment, such as a cane, wheelchair, special bed, or special telephone?" https://www.cdc.gov/brfss/questionnaires/pdf-ques/2015-brfss-questionnaire-12-29-14.pdf.
Eligibility to complete a survey during June 24–30, 2020, was determined following electronic contact of potential participants based on a minimum age of 18 years and residence within the United States. Age and residence were assessed using screening questions without indication of eligibility criteria before commencement of the earliest survey (recontacted respondents: April 2–8, 2020; first-time respondents: June 24–30, 2020). Residence was reassessed among recontacted respondents during June 24–30, and one respondent whose primary residence had changed to outside of the United States was excluded from the analysis. Country-specific geolocation verification via IP address mapping was used to ensure respondents were responding from the United States. Informed consent was obtained electronically during June 24–30, 2020, before enrollment into the study as a participant. All surveys underwent Qualtrics, LLC data quality screening procedures, including algorithmic and keystroke analysis for attention patterns, click-through behavior, duplicate responses, machine responses, and inattentiveness. Respondents who failed an attention or speed check, along with any responses that failed data quality screening procedures, were excluded from the analysis (6.6%).
**The COVID-19 Outbreak Public Evaluation (COPE) Initiative (www.thecopeinitiative.org) is designed to assess public attitudes, behaviors, and beliefs related to the coronavirus disease 2019 (COVID-19) pandemic, and to evaluate the mental and physical health consequences of the pandemic. The COPE Initiative surveys included in this analysis were administered by Qualtrics, LLC (https://www.qualtrics.com/), a commercial survey company with a network of participant pools comprising hundreds of suppliers and with varying recruitment methodologies that include digital advertisements and promotions, word-of-mouth and membership referrals, social networks, television and radio advertisements, and offline mail-based approaches.
††45 C.F.R. part 46, 21 C.F.R. part 56; 42 U.S.C. Sect. 241(d); 5 U.S.C. Sect. 552a; 44 U.S.C. Sect. 3501 et seq.
§§ https://www.medrxiv.org/content/10.1101/2020.04.22.20076141v1.
¶¶Statistical raking and weight trimming were employed to improve the cross-sectional June cohort representativeness of the U.S. population by gender, age, and race/ethnicity according to the 2010 U.S. Census.
***Essential worker status was self-reported. For the aPRs, essential workers were compared with all other respondents (including those who were nonessential workers, retired, unemployed, and students).
†††Rural-urban classification was determined by using self-reported ZIP codes according to the Federal Office of Rural Health Policy definition of rurality. https://www.hrsa.gov/rural-health/about-us/definition/datafiles.html.
§§§Reference groups were chosen for ease of interpretation. For example, the household income level of $50,000–$99,999 was selected as the reference group because the median household income was $61,937 in the United States in 2018. https://www.census.gov/content/dam/Census/library/publications/2019/acs/acsbr18-01.pdf.

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