Deferral of Care for Serious Non–COVID-19 Conditions: A Hidden Harm of COVID-19

The harms of the coronavirus disease 2019 (COVID-19) pandemic have been innumerable, including illness, death and disability, unemployment and devastation of small businesses, hunger, educational losses, and amplification of racial and social inequities. In this issue of JAMA Internal Medicine, 2 articles shed light on another cost: deferral of care for serious non–COVID-19 conditions, such as myocardial infarction and stroke.

Blecker et al¹ and Bhambhvani et al² examined admissions to hospitals in New York and California during the pandemic and found dramatic reductions in presentations for non–COVID-19 conditions compared with prior years. These included medical emergencies, such as appendicitis, for which the true incidence was unlikely to have changed. There was also a decrease in admissions for exacerbations of chronic disease, such as heart failure. Bhambhvani et al² found greater reductions at a hospital in New York than one in California, suggesting that deferral of care may be associated with the intensity of the surrounding epidemic.

It is possible that certain types of care can be forgone without harm; indeed, in some cases, patients may have been receiving unnecessary care. Other forms of care have been successfully transformed during the pandemic, such as through increased use of remote visits and home blood pressure monitoring. Some drops may be due to fewer exposures to other transmissible infections. However, there can be little doubt that deferral of care for stroke and other emergencies leads to harm and contributes to the rise in at-home deaths during the pandemic.

What could drive patients to defer essential care? Many may be concerned about putting themselves or their families at risk of COVID-19, especially in viral epicenters. Some may be forced to defer care because of lost income, loss of employer-based insurance, or primary caregiving responsibilities for children or older adults. Others could be affected by grief, anxiety, or depression, making it harder to seek care.

What can be done? Patients need to feel that hospitals and clinics are safe for them. Social distancing markers, universal screening, and wearing of masks could help people feel safe returning to the hospital.³ The importance of seeking urgent and preventive care (eg, age-appropriate immunizations, cancer screening) should be publicized by departments of health and reinforced by primary care clinicians and triage lines. The pandemic can provide an opportunity for us to teach patients which parts of medical care are of highest value and encourage them to seek that care, as we simultaneously maximize our use of non–hospital-based options for health care delivery.

Published Online: October 26, 2020. doi:10.1001/jamainternmed.2020.4016

Corresponding Author: Colette DeJong, MD, Department of Medicine, University of California, San Francisco, 505 Parnassus Ave, Room M-987, San Francisco, CA 94143 (colette.dejong@ucsf.edu).

Conflict of Interest Disclosures: Dr Covinsky reported receiving grants from the National Institute on Aging. No other disclosures were reported.