Hospital Volumes Declined Amid Springtime COVID Pandemic

By Lisa Rapaport

October 28, 2020

(Reuters Health) - Hospitalizations for emergencies like heart attacks and strokes, injuries, ectopic pregnancies, and a broad range of chronic conditions declined during peaks in the COVID-19 pandemic this spring, two new U.S. studies suggest.

Both studies point to a hidden public health emergency - people dying at home from treatable conditions, said Dr. Colette DeJong, chief resident in the department of medicine at the University of California, San Francisco and co-author of an editorial accompanying the studies in JAMA Internal Medicine.

"We urgently need to get the message out that, while going to the hospital is a risk, the risk of staying home with new, severe, or worsening symptoms could be far greater," Dr. DeJong said by email.

One study focused on daily hospital volumes for five common emergencies at Stanford University Medical Center in California and NewYork-Presbyterian/Weill Cornell Medical Center (NYP) in New York City before and after the start of the COVID pandemic. Researchers performed an interrupted time series single-group analysis using data on patients aged 18 and older treated between March 1, 2018 and May 22, 2020; they defined the start date of the COVID period as March 1, 2020.

Compared to the pre-COVID period, researchers found that during the COVID period, daily case volumes for all five emergencies dropped at both centers: acute myocardial infarction (relative risk 0.74 at Stanford and RR 0.61 at NYP); ischemic stroke (RR 0.84 and 0.51); nontraumatic subarachnoid hemorrhage (RR 0.79 and 0.67); appendicitis (RR 0.85 and 0.58); and ectopic pregnancy (RR 0.76 and 0.52).

"Even when patients have very serious symptoms, they may be unable to access care due to financial or family-care commitments, or are unwilling to seek help due to concerns about contracting COVID," said Dr. Melanie Hayden Gephart, co-director of the Stanford Brain Tumor Center at Stanford University Hospital and Clinics and a study coauthor.

These results underscore the importance of clinicians finding ways to meet patients where they feel safest and most comfortable, and enabling remote visits whenever possible, Dr. Gephart said by email.

"Patients may suffer adverse consequences if they do not have access to or seek appropriate medical care for serious, life threatening conditions," Dr. Gephart added. "Delays in treatment may lead to conditions being more serious and difficult to treat."

A separate study focused on weekly admission rates for non-COVID diagnoses at New York City's New York University Langone Health System (NYU) over four time periods: pre-COVID (March 1 to May 9 in the years 2018 and 2019); early COVID (March 1 to March 21, 2020); peak COVID (March 22 to April 11, 2020); and late COVID (April 12 to May 9, 2020).

Researchers looked at weekly non-COVID admissions based on principal discharge diagnoses for system-level categories as well as for the 20 most common diagnoses from the pre-COVID period.

Overall, weekly NYU non-COVID admissions were similar for the pre-COVID and early COVID periods (604.3 vs 584.5). They decreased during the peak COVID period (247), and then rebounded somewhat during the late COVID period (309.3), the study found.

During the peak COVID period, there was a dramatic decline compared with pre-COVID in weekly hospitalization rates for a wide variety of common diagnoses including chronic conditions like COPD and heart failure, acute emergencies like myocardial infarction and appendicitis, and injuries. A marked decrease was also seen in hospitalizations for common clinical classifications such as pregnancy; diseases of the skin and subcutaneous tissue; endocrine, nutritional and metabolic diseases; and respiratory diseases.

One limitation of both studies is that they looked at administrative data, and didn't have information on whether declining hospital volumes might have been driven by physician recommendations, patient preferences, or other factors.

The breadth of the decrease suggests multiple factors may be involved, including avoidance of hospitalization by both providers and patients, said coauthor of the NYU study Dr. Saul Blecker, an assistant professor of population health and medicine at NYU Grossman School of Medicine.

"The economic toll of COVID may also be playing a role: unemployment and the related loss of health insurance may have led to avoidance of hospitalization for fear of related cost," Dr. Blecker said by email.

Some positive effects of the pandemic, such as healthier home-cooked meals, might also be keeping some patients from requiring hospital care, Dr. Blecker added. "The pandemic has led to changes in people's lifestyles, which could have impacted courses of disease," Dr. Blecker said.

SOURCE: https://bit.ly/2J95ubX , https://bit.ly/3oz992T and https://bit.ly/31OX7Zx JAMA Internal Medicine, online October 26, 2020.

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