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Gwen Darien is a three-time cancer survivor. When she was thirty-five, she was diagnosed with lymphoma; in her fifties, she was treated for breast cancer; two years ago, she learned that she had endometrial cancer. With curly black hair and an indomitable personality, she embodies vibrancy, courage, and resilience. Even so, last month, when she received a call from her doctor’s office about an upcoming visit, she decided to postpone it indefinitely. “I was very unnerved,” she told me. “I thought about all the risks. First, I’d have to get transportation—Uber or train or subway. Then I’d have to walk into the doctor’s office, near a hospital with COVID-19 patients. Then I’d have to be in the office with other people, even if they are socially distanced. I’d much rather just wait.”
During the pandemic, many patients and physicians have felt this kind of hesitation. Some people with chronic illnesses, fearful of entering a medical setting or even venturing outside, have stopped seeing doctors altogether. Others have tried to make appointments but found clinics closed and routine care suspended. At many hospitals, non-urgent or “elective” care has been postponed for months. It’s difficult to say for sure what the effects of such postponements have been and will be. But statistics show that, across the United States, so-called excess deaths—deaths beyond those that are historically typical—have surged. Although many of these deaths can be attributed to COVID-19, delayed or cancelled care is probably a contributing factor, too. An analysis of death certificates shows that a fifth of the twenty-four thousand excess deaths that occurred in New York City between March 11th and May 2nd were caused by factors other than COVID-19; according to a study currently in pre-publication review, hospitals saw a thirty-eight-per-cent drop in serious heart-attack cases in March alone, suggesting that even people with acute, life-threatening illnesses have been avoiding medical visits. (The American College of Cardiology has gone so far as to issue a statement urging people to seek medical attention if they’re having cardiac symptoms.) A nationwide survey conducted in April found that a quarter of cancer patients receiving active treatment had seen their care delayed. Ultimately, it’s not just people with COVID-19 who are suffering; those with other illnesses are affected by the pandemic, too.
The coronavirus crisis itself continues to deepen. Although the first peak has passed in a few major cities, cases have held steady in many parts of the country and are rising in twenty-six states. North Carolina saw its highest single-day increase in coronavirus cases on June 12th; Florida, Arizona, and Texas saw record spikes this week. Some of this growth reflects increased testing, but, in many places, deaths caused by the virus are also rising—a sign that the spike is real and not a statistical artefact. The U.S. still records more than thirty thousand new cases each day; according to projections from the Centers for Disease Control and Prevention, the national death toll could reach a hundred and forty thousand by the Fourth of July; the country’s public-health response remains scattershot, with grossly inadequate testing and contact tracing; and mass protests and planned reopenings, which are continuing despite the risks, have given the virus new breathing room. America as a whole seems to have entered a long viral plateau. The pandemic is now a rolling collection of mini-epidemics that surge and subside as the virus bobs and weaves its way across the country. It will be a long time before life returns to normal.
The persistence of the pandemic is creating serious challenges, many of them unforeseen, for the health-care system. Even before the pandemic, many hospitals were in precarious financial condition: in 2018, the average hospital had a two-per-cent operating margin and less than two months of cash on hand; the situation was worse for rural hospitals, a fifth of which were already at risk of closing due to financial problems. Having lost billions of dollars in revenue, hospitals must now figure out how to reintroduce routine care while keeping patients safe and preparing for possible surges of COVID-19. (As my colleague Atul Gawande has written, it is possible for hospitals to reopen without becoming vectors for the virus; doing so, however, requires time, resources, and personnel.) Hospitals in Massachusetts are losing $1.4 billion in revenue per month, and project total losses of five billion dollars by the end of July. The Mayo Clinic alone, which runs twenty-three hospitals nationwide, is set to lose three billion dollars this year. The American Hospital Association estimates that, altogether, U.S. hospitals are bleeding fifty billion dollars a month during the pandemic. The hundreds of thousands of doctors in independent practice have more limited capital reserves, and many may be forced to shutter their operations or merge them with others.
In the context of the economy as a whole, these losses are substantial. According to the Department of Commerce, the American economy shrank by nearly five per cent in the first quarter of 2020. Nearly half of this change—the biggest single-quarter drop since the Great Recession—had to do with reductions in health care. In a few months’ time, the coronavirus has accomplished what lawmakers have been trying to do for decades: by flattening the curve of infection, we have bent the curve of health-care spending. But it’s been bent haphazardly, by the hurried cancellation or postponement of colonoscopies and mammograms, hip replacements and cataract surgeries, stress tests and root canals—and those unsustainable choices will have real consequences for the health of patients. As the virus continues to spread, the clinical damage will almost certainly compound.
It’s vitally important, therefore—both for the health of individuals and of the system as a whole—for doctors to resume seeing patients who don’t have COVID-19. In April, medical organizations, including the American Hospital Association, began releasing road maps for the resumption of regular care; since then, governors have
announced various protocols in their own states. The details vary, but the basic principles are the same: wait for a sustained reduction in COVID-19 cases; insure an adequate supply of personal protective equipment (P.P.E.); test constantly; and plan to throttle back on the expansion of services if the virus surges again. The more fine-grained question, of exactly which procedures should be prioritized and which delayed, is usually left unanswered.
Vivek Prachand, a surgeon at the University of Chicago, has been thinking about this problem since early March, when hospitals first started grappling with how to rank procedures in terms of their clinical urgency. Often, he told me, the decisions were being made by individual physicians or small committees within hospitals. “It was really just surgeons saying, ‘O.K., go ahead,’ or, ‘No, we need to hold off,’ ” he said. “You can imagine the emotional and ethical challenges of being in that position.” He and his colleagues have developed a rubric to help guide such decisions during the pandemic, which they call the Medically Necessary, Time-Sensitive System, or MENTS.
Prachand dislikes referring to care as “elective,” because the term suggests that procedures are optional or unnecessary; really, elective care is just care that can be scheduled. (Setting a broken arm is “urgent” care; brain surgery, most of the time, isn’t.) To help set the schedule, the MENTS protocol asks three kinds of questions. First, it assesses procedural factors, such as how long the surgery will take, how many clinicians will be exposed, how much P.P.E. will be used, and how likely the patient is to be intubated or require a prolonged stay in the hospital. Second, it grades the dangers presented by the problems the surgery hopes to solve, asking how bad the condition will get if doctors wait, and whether there are any effective non-surgical remedies. Finally, it sizes up how much viral risk the operation poses to the patient. Is she immunosuppressed? Does she have an underlying lung disease? What are the chances that she’s already been exposed to the virus? The answers to all of these questions are combined into a formula that yields a recommendation about when the team should proceed.
Michael Novakhov – SharedNewsLinks℠