Less routine care during Covid-19 is not a crisis
Doctors are sounding the alarm about a serious side effect of the Covid-19 pandemic: people aren’t coming in for their routine medical care. In a recent NPR piece, family physician Dr. Kristen Kendrick advised patients not to miss their routine cancer screenings. “When it comes to finding — and fighting — cancer, timing can make the difference between life and death,” she wrote. Another recent article in ProPublica warns of the impending “crisis of undiagnosed cancers” the country is facing.
Benefits of reduced preventive care
Postponing preventive services like vaccinations or care for chronic conditions is likely to cause harm. However, the decline of routine medical care is not always a bad thing, argue Dr. Alan Roth, chair of family medicine at the Jamaica Hospital Medical Center, and Dr. Andy Lazris, primary care physician in Columbia, MD, in the latest episode in the “Right Care Series” in American Family Physician. Because certain types of routine care are unnecessary, avoiding this low-value care can actually help patients avoid the stress from false positives, additional out-of-pocket costs, harm from cascade events, and other overuse-related harms.
“The pandemic has provided an opportunity to evaluate which medical services are truly necessary and what patients can do without.”Dr. Alan Roth and Dr. Andy Lazris, in American Family Physician
Here are a few low-value services Roth and Lazris identify as commonly overused:
- Diagnostic imaging, like MRIs and CT scans, for patients without serious symptoms (almost all hospitals in the US perform these tests, according to the Lown Institute Hospitals Index)
- Cancer screening in older adults (nearly half of older adults are overscreened for cancer)
- Pain management procedures like vertebroplasty and spinal fusion
Roth and Lazris also point out that “adult wellness examinations,” annual preventive check-ins for Medicare patients, have not been shown to measurably improve health outcomes and often lead to low-value screening tests, such as thyroid function testing, urine culture testing.
Wellness visits also can lead to cardiac testing and subsequent stenting, which has shown to be no better than medical therapy for stable heart disease. (Dr. Lown himself discovered how giving patients cardiac tests almost always led to unnecessary coronary interventions.) Roth and Lazris cite a study of 12 hospitals showing that 47% fewer patients received elective cardiac catheterizations in Spring 2020 compared to 2019.
The financial burden of low-value preventive care
Another study on low-value preventive care published last month in the Journal of General Internal Medicine shows the scope and financial harm from just a few of these services. Dr. Carlos Irwin A. Oronce, fellow at the VA Greater Los Angeles Healthcare System, and colleagues looked at how often Medicare beneficiaries received seven preventive services that have been given a “D” Grade by the US Preventive Services Task Force (USPSTF). The USPSTF gives a “D” grade to services they recommend against because they are at least moderately certain that “the service has no net benefit or that the harms outweigh the benefits.”
Just seven low-value services were performed more than 30 million times each year — that’s 13 low-value services per 100 visits.
The Grade D services measured included screening for urinary infections and cardiovascular disease for asymptomatic adults, screening for certain cancers in older adults, and vitamin D supplements for older women to prevent fractures. Oronce et al. used a sample of about 95,000 patient visits from 2007-2016, in the National Ambulatory Medical Care Survey (NAMCS). From the frequencies of the Grade D services in the sample, they estimate that these seven services were performed more than 30 million times each year — that’s 13 low-value services per 100 visits.
The total estimated cost of these services for Medicare was $477,891,886 per year. They note that three services in particular —screening for asymptomatic bacteriuria, vitamin D supplements for fracture prevention, and colorectal cancer screening for adults over 85 years— alone made up about two thirds of this cost.
Advanced cancer crisis?
Decreased cancer screenings during Covid-19 in particular have gotten a lot of attention. Oncologists have reported seeing more patients than usual in advanced stages of cancer, which is concerning. Many patients avoided seeking medical care for concerning symptoms, like serious pain and swelling, because they were either afraid of viral spread or they had suffered financial consequences from the pandemic. It’s clear that the lack of access to diagnostic services and care early in the process has led to unnecessary suffering, borne disproportionately by people of color, as the ProPublica article points out.
Yet, we have to be careful not to conflate diagnostic cancer tests (performed when someone has symptoms) and screening cancer tests (performed when someone has no symptoms). As we’ve written on this blog extensively, cancer screening often leads to false positives, overdiagnosis, and other harms. Screening tests are also given too often to patients who are too young, too old, or at too low-risk to benefit. This pause in screening tests should be seen not as a crisis but as an opportunity to see whether we can reduce low-value screening.
The path forward
Will patients benefit overall from less low-value care? It’s likely, but we won’t know for sure until we study it. Fortunately, there are some trials in progress now to evaluate how less preventive care (and potential cascade events) have impacted health. For example, the federally-funded Breast Cancer Surveillance Consortium is collecting data from 800,000 women at 100 mammography centers across the country, to evaluate the long-term health impacts of fewer routine mammograms during the pandemic. The National Cancer Institute will also be using two national cancer tracking systems to research how less cancer screening during Covid-19 has impacted the stage at which cancer is diagnosed, STAT reports.
However, doctors don’t have to wait to deliver the right care to patients now. Roth and Lazris acknowledge that “the temptation to go back to normal will be difficult to resist,” but they encourage clinicians to use Covid-19 as a turning point to “stop providing ineffective services that have not been demonstrated to improve patients’ health.”