A nurse examines an elderly patient at a clinic in Guerneville in February 2020. Doctors fear that delays in medical care due to the pandemic could harm health. Anne Wernikoff’s photo for CalMatters.
###
At his clinic in eastern Los Angeles, Dr. Efrain Talamantes recently saw three patients – all elderly with dementia – who had not visited his office in over a year. Finally, seeing them in person, after being vaccinated, was a great victory. But Talamantes fears that many patients have escaped the cracks, putting their health at risk by delaying the treatment of their illnesses during the pandemic.
“As we focus on recovery, we have to ensure that we are vaccinated,” said Talamantes, “but also that we have a joint effort to control chronic diseases that have not received the necessary attention to avoid complications.”
In addition to COVID-19, Californians died last year at similar rates for most major causes. A little more people died from the number one killer – heart disease – and strokes, while cancer deaths remained roughly equal to pre-pandemic rates. One exception is a rather large increase in Alzheimer’s disease; about 11% more people died of the disease in the past year.
Doctors and other health experts predict that, in the near future, delays of one year in patients seeking medical attention may cause worsening health conditions, delays in diagnosis and premature deaths.
“Unfortunately, we know that we will see some tragedies related to the delays.”
– Dr. Wiley Fowler, oncologist at Dignity Health in Sacramento
The consequences are likely to be most felt in high-risk color communities – such as the one Dr. Talamantes serves – that face the most dangers with the interruption of medical care. For patients with life-threatening chronic illnesses, such as diabetes and asthma, routine care is essential.
When the coronavirus swept California last spring, many people canceled their personal medical appointments or their providers temporarily closed their doors. Telehealth visits skyrocketed last year, but doctors and nurses can do a lot with a screen. Dental visits, mammograms and annual wellness checks have been suspended.
About a third of Californians who had an urgent health problem unrelated to COVID-19 and wanted to see a doctor did not receive care, according to a survey of 2,249 adults conducted last summer by the California Health Care Foundation. And almost half of the respondents did not receive care for their non-urgent physical health problem.
Feeling more confident after receiving the COVID-19 vaccines, many Californians, especially the elderly, are finally attending medical appointments. But others are still lagging behind in routine care.
Dr. Wiley Fowler, an oncologist at Dignity Health in Sacramento, observed a steady increase in people who returned in the past two months. But your patient’s volume is still only about 85% of what it should be.
“There is a reason and justification behind the recommendations for interval monitoring. We encourage people to go to their doctors and go ahead, ”he said.
“Unfortunately, we know that we will see some tragedies related to the delays.”
Top killers
About 48,000 Californians died in 2020 than in 2019 – largely because of the 25,971 deaths attributed to the pandemic last year, according to state data. (January 2021 was the deadliest month for COVID-19).
But heart disease and cancer remained the leading cause of death in 2020.
About 2,846 more Californians died of heart disease last year than in 2019, and 2,545 more than in 2018, an increase of about 4%, state data show. There were also 917 more deaths from stroke than in the previous year, an increase of 5%.
As visits to non-COVID-19 emergency rooms fell across the country by about 42% in the first months of the pandemic, some experts theorize that people may have suffered worse results because they avoided hospitals after heart attacks and strokes.
Cancer deaths have remained roughly the same, with a decline of less than 1% in 2020 compared to the previous two years.
However, this status quo may be temporary: the National Cancer Institute predicts that pandemic-related delays in examining and treating breast and colorectal cancers alone can result in almost 10,000 excess deaths in the U.S. over the next 10 years . That would translate into approximately 1,200 more deaths in California from these two types of cancer. Experts say it is a conservative estimate because it represents only a six-month delay in service, and people are delaying care for longer than that.
“Instead of finding out on a mammogram … the patient now comes because she feels something and we are making the diagnosis later in the course of the disease, which unfortunately means less chance of a cure,” said Dr. Richard Bold, MD head of UC Davis Comprehensive Cancer Center.
Because of Alzheimer’s disease, 1,883 more Californians died last year than in 2019. While it is difficult to pinpoint the exact reasons, experts say it may have been caused by the isolation and abrupt closure of support services from which patients with Alzheimer’s depend.
“We are all trying to maintain our mental health with technology, but that is not always an option for these individuals,” said Elizabeth Edgerly, executive director of the Alzheimer’s Association, Northern California. “They lost physical contact – those who lived in congregated environments were confined to their rooms.”
For some cancer patients, “we are making the diagnosis later in the course of the disease, which unfortunately means less chance of a cure”.
– Dr. Richard Bold, chief physician, UC Davis Comprehensive Cancer Center
California also had about 12,000 additional “other” deaths – a category that includes any causes in addition to the top 13 monitored by the Centers for Disease Control and Prevention. State health officials were not available to explain the reason or provide details before publication.
Interestingly, Bold said he heard from colleagues who have seen more serious illnesses in the past two to three months.
This may be because people have delayed exams and other tests. During the state’s first stay-at-home request, cervical cancer tests fell by about 80% for 1.5 million women on the Kaiser Permanente Southern California network, according to a study. After the order was suspended, exhibits increased again, but were still between 24% and 29% below what they were in 2019.
Many children have also stopped going to the doctor.
As of last March, substantially fewer babies and children have visited doctors in person or via telehealth under the state’s Medi-Cal program, which serves low-income residents. Before that, visits increased, but decreased dramatically as soon as the pandemic began. In August, visits plunged 40% compared to August 2019, according to preliminary data from the Department of Health and Human Services.
Going back to the doc’s office
Howard Dalton suspended his first colonoscopy last year. The 50-year-old Sacramento resident also skipped routine physical examinations and visits to the dentist.
The only face-to-face service he sought in the past year was a routine blood test, which is required of someone who has been infected with HIV for 20 years. But everything else was out of the question; he just doesn’t feel comfortable sitting in a waiting room with other people.
“I am very obsessive about my health and it bothers me that whatever stage I was at, I am probably late now,” he said.
Dalton recently had his first COVID-19 injection, which has already given him some mental relief. He is waiting for the second dose before he even thinks about going back to the doctor’s office. And he said, “I will probably wear a mask until next winter.”
Bold, of the Davis cancer center, said there was no longer any reason for patients to postpone tests and other care. He said doctors’ offices are safe – healthcare workers are widely vaccinated, everyone is urged to wear a mask and patients are screened for COVID-19 as they enter the facility.
Talamentes, an intern and operations director at AltaMed, said his clinic in eastern Los Angeles continues to operate with limited capacity to allow for adequate safety protocols. When face-to-face places become available, they are booked almost immediately, he said.
AltaMed, a federally qualified health center, has been offering vaccinations to patients and their families, and when they go to have the injection, they are reminded to schedule wellness checks and dentist visits.
Last year, AltaMed’s clinics treated about half the number of people with hypertension – high blood pressure – than in previous years, Talamantes said. The concern is that late treatment may progress to more serious and uncontrolled heart disease, which makes them more vulnerable to diseases such as COVID-19. Diabetes and obesity are two other very common conditions in their patient population who also need treatment and routine care.
One positive point, said Talamantes, is that some of his patients have become more in tune with their health after suffering devastating losses in their families.
“If someone in your family died (from COVID-19), we often hear ‘well, they didn’t take care of themselves, were fat, so I need to take care of myself ‘”.
###
The coverage, translation and distribution of CalMatters COVID-19 are supported by generous donations from the Blue Shield of California Foundation, the California Wellness Foundation and the California Health Care Foundation.
CALmatters.org is a non-profit, non-partisan media venture that explains California’s policies and policies.