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VOL. 46 | NO. 20 | Friday, May 20, 2022

How long since you’ve seen your doctor?

COVID-19’s other risk: Postponed medical care

By Nicki Pendleton Wood

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Time passed differently in the pandemic, the days moving slowly and the years were flying past. Many of the usual “bookmarks” of time – celebrations, events and milestones – were canceled.

Among those missing milestones was apparently visits to health care providers. Some 21% of primary care visits were skipped in 2020, Medical Xpress News reports. For some specialties, the numbers were much higher.

Nashvillian Elizabeth Moss Evans knows from personal experience. “I did not see my ophthalmologist during the pandemic, and when I called for my appointment, I said it had been two years (since her last appointment).”

“They told me it had been four years! I had blocked out the two years of the pandemic in my mind. So to me, I was calling on schedule to see my ophthalmologist.”

Whether through brain fog, reluctance or concern for contagion, visits to practitioners were way down. Now, with the worst of the pandemic in the rearview mirror, the focus is on coaxing patients back for routine exams and important procedures.

Some fared better, some worse

A number of specialties saw declines only at the onset of the lockdown in 2020, followed by a full comeback.

Orthopedics, for one. Another was dermatology. Michael Schneider, a Memphis-area dermatologist, says that although visits dropped by 70% during the March-May 2020 lockdown, they rebounded somewhat in May and fully after that.

“Our practice was full and even experienced a backlog to work through within two weeks. We have remained busy and never slowed down since, even through the variants and spikes in cases.”

For some specialties, though, the numbers were higher – and the patients fewer – with consequences more serious.

Mammography is federally regulated, so visits and diagnoses are tracked. In April 2020, breast cancer screening mammograms dropped off more than 90%. They rebounded to about 90% of pre-pandemic levels by July 2020 but remained lower for Asian and Hispanic women.

Diagnostic mammograms, which focus on a previous finding or known condition, also decreased early in the pandemic. More urgent than a screening mammogram, these procedures rebounded to 98% of pre-pandemic levels by July 2020.

Screenings for prostate health also fell, by 65%, Physicians Weekly reports. After June 2020, prostate and other genitourinary screenings rebounded and ultimately surpassed pre-pandemic levels.

Kids’ vaccinations down

Pediatric routine office visits were down by 50% or more (44-59% depending on who you ask) in 2020.

“When [the pandemic] first began, the messaging for parents was ‘stay home, avoid the doctor’s office’” to keep yourself and children safe, says Joseph Gigante, professor of pediatrics at Vanderbilt Children’s Hospital in Nashville. “Many well-child visits were canceled.”

Well-child appointments have been slowly making a comeback but still have not recovered to pre-pandemic levels. One partial explanation cited is a 10% nationwide drop in kindergarten enrollment (about 400,000 children) as reported in MedPage Today, a New York-based medical news service. Public kindergartens typically require vaccinations for enrollment.

“When we look at Vanderbilt vaccination rates of children less than 2 years old, we’re behind,” Gigante acknowledges. “We are not meeting the benchmarks for the percentage who should be fully vaccinated by age 2.”

Preventative medical visits, including mammograms and well-child pediatric appointments, fell during the pandemic and have not fully recovered.

-- Photo By Nicki Pendleton Wood | The Ledger

A well-child screening includes growth and development, height and weight. Gigante says the clinics saw how much these were affected by the pandemic.

“At a well-child visit, we look at kids’ growth and development, recognize if kids are not growing well.” That can mean not gaining weight or its opposite – obesity.

Pediatricians saw “kids way above the growth curve, above the upper limit of normal,” Gigante adds. They called it “The Pandemic 20” and attributed it to “the double whammy” of kids not going outside and sitting around and eating. “If you’re sitting at home, it’s natural to not be physically active, and to sit and eat.”

A well-visit, post-pandemic appointment is, he says, an opportunity “to talk to parents about child obesity and maybe changes in diet.”

Older Americans also stayed home but found telehealth an appealing new modality. Medicare Advantage has offered telehealth visits for some years, though uptakes were slight.

In 2019, just 4,400 telehealth visits were noted. During the same period in 2020, the same population made 600,000 telehealth visits.

Teeth left behind

The pandemic also was the perfect excuse for many to skip the dreaded dental visit. More than half of people surveyed by the American Association of Endodontists said they’d skipped a dental checkup.

A similar study found snacking to be compounding the problem, as well as less brushing and more tooth-grinding among those surveyed. Plus, stress reduces saliva production, and saliva is key to preventing bacteria from flourishing.

Dentists surveyed report more broken teeth, lost teeth and more advanced tooth decay. Those are the short-term results. An August 2020 survey of dental practices, 98% reported they were open for business, but only half reported patient volumes at pre-pandemic levels.

Consequences for children

In addition to routine visit losses were many abandoned tests, screenings, biopsies and imaging.

Missed mammograms seem to be the cause for a jump in new advanced (Stage 4 or metastatic) cases of breast cancer, from 1.9% pre-pandemic to 6.2% during the pandemic.

Among children, delayed visits and missed vaccines might have affected herd immunity, Gigante explains. “You worry about – and it was discussed a lot – the issue of having herd immunity, enough to protect those who couldn’t be vaccinated.

“If a large enough population of children are not immunized, we will have measles & chickenpox. Especially measles. Over last 10 to 20 years we see pockets of measles outbreak in particular populations that are unimmunized. We haven’t seen any yet, but it’s a possibility.”

A missed well-child visit also could impair children with speech delays and differences, putting those in need of speech therapy even further behind.

It’s all expected to add up: NIH director Norman Sharpless, writing in “Science” magazine in June 2020, suggested an extra 10,000 deaths can be expected from the delayed screenings. See the article: [https://www.science.org/doi/10.1126/science.abd3377#con]

Patients please!

So, what is the medical community doing to bring patients back?

Gigante says practices at Children’s Hospital are using phone calls and letters to encourage patients to schedule children’s missed office visits. “We proactively reach out to parents whose child is due for a checkup and scheduled vaccines.”

The American Dental Association offered members a patient tool kit to “help your patients return with confidence.”

A visual “patient prep” guide readied patients for waiting in their cars, for starters. Practices were offered scripts for social media posts and text messages. For some patients, it was their first time to be texted by a provider. Practices were encouraged to publicly be proactive and transparent about safety and risks in dental visits.

Nashville’s Premiere Radiology St. Thomas found a clever and highly visible way to nudge patients toward a mammogram. In a waiting room for X-ray, CT or MRI , the soft drink refrigerator door carries a big sticker that reads “Mammo NOW” and “if not now … when?”

COVID-19 epidemic and pandemic-era drug overdoses caused a record number of deaths in 2021. The state’s clinicians hope to get Tennesseans on a healthier track for 2022 and beyond with an office visit and a clean bill of health.

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