key: cord-0967495-38alj1c0
authors: Feinman, Jared
title: The Waiting is the Hardest Part: Social Isolation and Delayed Healthcare Delivery During the COVID-19 Pandemic
date: 2021-03-04
journal: J Cardiothorac Vasc Anesth
DOI: 10.1053/j.jvca.2021.02.066
sha: 33352b6832aa0c6ed3f1ad6f9de4729818f8cea5
doc_id: 967495
cord_uid: 38alj1c0

nan

conserve limited hospital beds and other resources or patients avoiding care in order to minimize their risk of infection). While the true toll of the COVID-19 pandemic will inevitably remain unclear, we are beginning to learn a little more about how the pandemic has impacted the mental and physical health of even those who have not been infected by the virus.

There is ample evidence from prior natural disasters and major economic crises that elevated rates of depression, anxiety, suicidal ideation, substance abuse, and PTSD follow such events. While there is little reliable data on the mental health effects of previous global pandemics (understandable given the historic periods involved), one would imagine that the consequences of prolonged quarantine/social isolation and the rampant risk of illness and death from COVID-19 infection would be similar. A study by Lei, et al. using survey data from China, the first location where severe lockdowns were instituted, demonstrated high levels of anxiety and depression among the respondents (8.3% and 14.6%, respectively), which rose to even greater levels when the respondent had someone in his/her social circle who was forced to quarantine due to COVID-19 infection or close contact (12.9% and 22.4%, respectively). 1 Another study from India found that 80% of adults surveyed were preoccupied with thoughts of COVID-19 and sleep difficulties, paranoia, and distress were reported by 12.5%, 37.8%, and 36.4% of respondents. Over 80% of study participants perceived a need for additional mental health services. 2 While the psychological effects of the pandemic can affect anybody, it has been conjectured that quarantine and isolation would hit older individuals hardest, especially those who live alone and have small or nonexistent social networks. Based on recent data, such individuals make up around 13.4% of the EU population, giving scale to the extent of this potential crisis. 3 Older patients with depression and/or anxiety are also more likely to have increased malnutrition, healthcare utilization, and even mortality, which can strain an already overloaded healthcare system struggling with the COVID-19 pandemic. 4 Another important factor to consider when assessing the impact of the COVID-19 pandemic is the ramifications of healthcare avoidance by individuals who wish to limit their potential exposure to the virus by restricting contact with physicians and hospitals. It is clear that such avoidance has occurred over the past year on a mass scale, while the impact of this on health outcomes and overall mortality remains debatable. A recent paper in the Journal of the National Medical Association reports that 43% of patients have missed routine preventative care appointments due to the pandemic, and more than a third of adults have not received recommended screening procedures. 5 There is also data that, in addition to skipping routine care, some individuals may be avoiding the hospital for serious or potentially life-threatening medical conditions. Heart failure admission have declined 20-50% across several European countries during the pandemic. While some of this decrement may reflect a reduction in heart failure exacerbations as patients eat out less, work from home, and reduce strenuous activities, this does not account for the entire change. Indeed, when patients do eventually present with heart failure symptoms, they have been sicker than pre-pandemic, with a higher average NYHA Class and more severe peripheral edema. 6 Another study looking at stroke admissions at a single hospital in Hong Kong during the pandemic found similar evidence of medical avoidance. The time from onset of stroke symptoms to presentation at the hospital increased from pre-pandemic levels by almost an hour, and the percentage of patients presenting within 4.5 hours of symptom onset dropped from 71.9% to 54.8%.

Additionally, there was a significant reduction in the number of TIA patients compared to baseline levels, indicating that some of these patients likely stayed home and did not seek medical care for their

TIAs. This can have potentially devastating consequences, as 10-20% of TIA patients will go on to develop a stroke within 90-days without appropriate medical intervention. 7

The healthcare system itself has also contributed to the disruption in routine medical care through the cancellation of outpatient visits and the postponement of elective and semi-elective surgical cases in order to conserve medical resources during the peak(s) of the pandemic. Many health systems cancelled almost all elective surgical cases for a period ranging from a few weeks to several months. Work by the COVIDSurg Collaborative puts the approximate number of surgical cases cancelled during the 12-week peak of the pandemic last spring at over 28 million cases globally. While the vast majority of these cancelled cases would be for benign disease, the same group estimated that 37.7% of oncologic surgeries were also cancelled during this period. 8 Cardiac surgical services were also forced to curtail semi-elective procedures during the pandemic, with one study showing a 54% reduction in overall case volume, with some variability based on the type of cardiac surgery (50% reduction for CABGs, 71% reduction for valve procedures). 9 This postponement of surgical cases unfortunately has a snowball effect on the ability to operate on future patients in a timely manner, as it would be impossible for surgical services to increase their case volume to a large enough degree to rapidly play catch up on all of the cancelled procedures. Indeed, the COVIDSurg Collaborative estimated that even with a consistent increase in surgical volume of 20% over baseline, it would take nearly a year to clear the backlog of cases created just by the 12 weeks of cancellations last spring. 8 The impact of surgical cancellations during COVID-19 also goes beyond potential disease progression and is yet another factor that may contribute to mental health issues during the pandemic. A recent paper by Wilson, et al. examined the perceptions of orthopedic surgical patients who had hip or knee arthroplasties postponed due to COVID-19. Of those patients who participated in the survey, most were understanding of the delay, with only 24.3% stating that they felt they could not wait a month or more to have their operation. Despite this, 67.6% reported emotional distress caused by the cancellation of their scheduled surgery, and 46.8% expressed that, given the choice, they would have surgery immediately despite the risks posed by COVID-19. 10 In TC among the local population in the days and weeks after the events. 12 More germane to the case in question, the Cleveland Clinic published a cohort study examining the rate of TC in patients presenting with symptoms of acute coronary syndrome during the COVID-19 pandemic, and found an incidence of 7.8%, compared to 1.5-1.8% before the start of the pandemic. Notably, none of the patients who developed TC were found to be COVID-19 positive, eliminating the possibility that the rise in TC in the general population is related to a physiologic response to COVID-19 infection itself. 13 The COVID-19 pandemic has turned much of the world's daily life on its head and has created challenges and questions that could not have been anticipated at this time only two years ago. Just as the pandemic has impacted the work routine, social life, and family dynamics of people all over the world, it has also impacted their health, in ways both transparent and not. While our attention as healthcare workers has rightly focused on caring for those with COVID-19 infection, we cannot turn a blind eye to the more subtle health effects that the pandemic has had, and will continue to have, on our patients who remain uninfected by the virus. The article by Felheim, et al. in this issue goes a small way towards bringing these issues into the spotlight.

Declarations of Interest: None.

Comparison of prevalence and associated factors of anxiety and depression among people affected by versus people unaffected by quarantine during the COVID-19 epidemic in southwestern China

Study of knowledge, attitude, anxiety & perceived mental healthcare need in Indian population during COVID-19 pandemic

The potential long-term impact of the COVID-19 outbreak on patients with non-communicable diseases in Europe: consequences for healthy ageing

Social isolation, loneliness and health in old age: a scoping review

Declines in cancer screening during Covid-19 pandemic

Insights into heart failure hospitalizations, management, and services during and beyond COVID-19

Delays in stroke onset to hospital arrival time during COVID-19

Elective surgery cancellations due to the COVID-19 pandemic: global predictive modelling to inform surgical recovery plans

The surge after the surge: cardiac surgery post-COVID-19

Patient Perceptions of COVID-19-Related Surgical Delay: An Analysis of Patients Awaiting Total Hip and Knee Arthroplasty

Covid-19: a stressor for both the patient and the anesthesiologist. J Cardiothorac and Vasc Anesth

Takotsubo syndrome and COVID-19: Associations and implications

Incidence of Stress cardiomyopathy during the coronavirus disease 2019 pandemic