All this year, patients stayed away from doctors’ offices in droves, postponing tests and treatments. Maybe there’s a silver lining.
For years, health researchers bemoaned what they saw as excessive medical care in the United States. Too many tests and treatments, they said, are unnecessary or even harmful, and add to the huge cost of health care in this country.
The coronavirus has given them an unique chance to find out if they were right.
“If we can separate signal from noise, maybe we can learn there are a lot of things we don’t need to do,” said Dr. Scott Ramsey, a co-director of the Hutchinson Institute for Cancer Outcomes Research in Seattle. “Maybe patients will do better.”
The stakes are high, both for health and for the economy. Before the pandemic, an estimated 50 million American patients were subjected to one or more instances of health care overuse each year, at a cost of $106 billion, according to a recent analysis in the journal Health Affairs.
“We see a unique methodological opportunity to evaluate the harms of low-value care,” wrote Allison H. Oakes, a health services researcher at the University of Pennsylvania, and Dr. Jodi B. Segal, a professor of medicine at Johns Hopkins.
As the pandemic took hold, elective surgeries were canceled and radiology equipment stood abandoned as patients and doctors avoided CT scans, M.R.I.s, mammograms and colonoscopies. Even prescriptions for antibiotics plummeted.
“We are in the midst of an unprecedented natural experiment that gives us an opportunity to determine the effect of a substantial decline in medical care utilization,” said Dr. H. Gilbert Welch, a senior investigator at the Center for Surgery and Public Health at Brigham and Women’s Hospital in Boston.
No researcher denies the untoward effects of deferred medical care. Too afraid to go to the emergency room, many patients in the throes of heart attacks or strokes, for example, died or experienced life-altering consequences this year.
In March and April alone, visits to doctors’ offices plunged by 70 to 80 percent compared with pre-Covid levels, according to IQVIA, a health care analytics company. Lab tests resulting from emergency room visits and visits to doctors’ offices fell by 90 percent. The number of mammograms plunged by 87 percent, colonoscopies by 90 percent and Pap smears by 87 percent. PSA tests for prostate cancer declined by 60 percent.
But was it all bad? Or were there benefits? The answers to those questions won’t be known for some time. Still, scientists are drawing up plans for deciphering what needs to be done in the doctor's office, and what doesn’t.
One priority will be to examine what has happened to the downstream signs of unnecessary medical care. Dr. Oakes and Dr. Segal described that phenomenon, so familiar to many American patients, as “a cascade of further testing, treatments, office visits, hospitalizations, and new diagnoses.”
If downstream care declines during the pandemic without a significant impact on hospitalization and death rates, then researchers will have strong evidence that those procedures aren’t worthwhile and should be limited.
Researchers might compare the health of patients scheduled for questionable procedures — like a colonoscopy in a person over age 85 — before and after those elective procedures were suddenly shut down, Dr. Oakes and Dr. Segal proposed.
President Trump has hailed the rise of telemedicine as a significant unexpected benefit of the pandemic. But some scientists aren’t so sure.
Video patient visits may be accelerating some forms of “low-value” care, like unnecessary antibiotic prescriptions. Yet telemedicine also seems to put patients more in contact with primary care physicians, and in past research that trend has been linked to a decrease in unnecessary health care.
Orthopedics is another area that is ripe for revision following the pandemic, said Dr. Vinay Prasad, associate professor of medicine at the University of California, San Francisco. There have long been questions about steroid injections for aching backs and common surgeries to shore up spines and painful knees.
The question now: Did patients who could not get these treatments during the pandemic recover on their own? How often?
In February, Shelton Mack, a 28-year-old assistant wrestling coach at Columbia University, leaned onto his foot while training for the Olympic wrestling trials. He heard a pop and felt searing pain.
“It felt like the bottom of my foot went almost completely flat,” he said. Dr. Justin Greisberg, an orthopedist at Columbia, diagnosed a Lisfranc fracture — broken bones in the middle of his foot.
The usual treatment is surgery, but then the coronavirus intervened. “Everything was shutting down,” Mr. Mack said.
Unable to get the operation, he healed on his own and is training again. If he had undergone the procedure, Mr. Mack would have been unable to wrestle for nearly a year. “If it wasn’t for Covid, I would have been completely out,” he said.
The pandemic also provides a unique opportunity to re-examine cancer screenings. Some cancers, like kidney cancer and thyroid cancer, tend to be diagnosed incidentally — a patient gets a scan for another reason and doctors find a mass that turns out to be a tumor.
It is not known whether patients whose cancers are diagnosed incidentally fare better than those whose cancers are not discovered until later, when the patient has symptoms, said Dr. John Gore, a urology professor at the University of Washington in Seattle. But incidentally detected cancers might be easier to treat, in which case these screenings might be justified.
Mammography has long been a special area of concern. Some researchers estimate that as many as one in three cancers that are diagnosed by mammograms could have safely gone undetected and left alone.
Now the Breast Cancer Surveillance Consortium, a federally funded research group, is prospectively collecting data during the pandemic from more than 800,000 women and nearly 100 mammography centers across the country.
Millions of women missed their regular mammograms in the first wave of the pandemic.
Before the pandemic, about 100,000 women had screening mammograms each day in the United States. In the spring, nearly all mammogram centers shut down for three months, and even though they began opening again in the summer, it was not until October that nearly all were operating normally. That may change with the surge of new coronavirus infections, but for now, women who want mammograms can get them.
Clinics had to slow the rate at which they do mammograms because of Covid-19 precaution requirements, including physical distancing and cleaning of equipment between exams. But they are making up for the delays by keeping longer hours and opening on weekends.
The situation may be different for women who have worrisome findings, like a lump or a suspicious finding on a mammogram. The wait for diagnostic imaging and biopsies can be long, stretching out for weeks or months, said Dr. Christoph Lee, a professor of radiology and health services researcher at the University of Washington.
Doctors expect that many women who missed their mammograms last spring will not return now that they can have the screening test again, some because they fell out of the habit but others because of the pandemic’s social and economic effects. Women may have to stay home to care for children or may have lost jobs and health insurance.
The breast cancer consortium should have the first results of the effects of the screening shutdown on patient outcomes in six months, Dr. Lee said.
“We’ve never been able to argue to stop screening for a period, because the standard of care is regular screening,” Dr. Lee said. “We are trying to see if less screening leads to more or to less harm.”
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