Drop-off in diagnostic care likely is multifactorial

Cardiovascular testing fell early in the Covid-19 pandemic, survey data showed.

“Covid-19 was associated with a significant and abrupt reduction in cardiovascular diagnostic testing across the globe, especially affecting the world’s economically challenged,” wrote Andrew Einstein, MD, PhD, of Columbia University in New York City, and co-authors in the Journal of the American College of Cardiology. “Further study of cardiovascular outcomes and Covid-19-related changes in care delivery is warranted.”

Einstein and colleagues conducted a global survey of 909 inpatient and outpatient centers in 108 countries, looking at noninvasive and invasive cardiac testing and comparing volumes for March and April 2020 with March 2019.

They found, with P<0.001 for all:

  • Overall diagnostic procedure volumes were 42% less in March 2020 and 64% less in April 2020 than they were in March 2019.
  • Transthoracic echocardiography decreased by 59%, transesophageal echocardiography 76%, and stress tests 78% from March 2019 to April 2020.
  • Coronary angiography (invasive or CT) decreased 55% from March 2019 to April 2020.

Location in a low-income and lower-middle-income country was associated with an additional 22% reduction in cardiac procedures and less availability of personal protective equipment (PPE) and telehealth.

“How should the data of Einstein et al, which was generated during the first wave of the pandemic, help us deal with broader health system issues during the second or future waves? Clearly, the overwhelming priority should be emphasizing the importance of public health measures to prevent the spread of Covid-19,” wrote Darryl P. Leong, MBBS, PhD, of McMaster University in Canada, and co-authors in an accompanying editorial.

“These include physical distancing, hand washing, masks, and avoiding large gatherings in closed settings,” they said. “Such a strategy may allow the economy, schools, and less urgent but important health services, including selective cardiac diagnostic tests, to be provided to a limited extent.”

If a system is overwhelmed by a flood of patients with Covid-19, “it will be appropriate for non-urgent diagnostic procedures to be restricted, so that resources and personnel can be diverted to the care of hospitalized patients with Covid-19,” they added.

Infectious disease-related deaths account for some but not all of the excess deaths seen over the last year. Approximately 1.9 million global deaths related to Covid-19 in 2020 compare with the approximately 17.9 million deaths yearly due to cardiovascular disease, the leading cause of global mortality.

“Between March 1 and Aug. 1, 2020, the mortality rate from all causes in the United States was 20% higher than historical mortality rates from 2014 to 2020,” Leong and co-authors pointed out. “Of these excess deaths, 65% were directly attributed to Covid-19 and 35% to other causes.”

Decreases in cardiac tests in any one area or system are likely multifactorial, including resources available at baseline, resources diverted for reasons related to the pandemic, and changes in patterns of seeking care among those with both acute and chronic issues.

Einstein and colleagues’ survey characterized use of PPE and strategic plans for re-opening in addition to changes in volume for procedures including transthoracic and transesophageal echocardiography, cardiac magnetic resonance, stress testing (multiple modality), PET infection studies, coronary artery calcium scanning, and invasive or CT angiography.

Each responding facility provided data for three months, with March 2019 as the baseline, and March and April 2020 for comparison. “Countries contributing data had a combined population of 6.7 billion, and over 3.2 million cases of Covid-19, constituting 99% of the world’s reported cases, as of the end of the study period,” the researchers noted.

At all facilities during these three months, 1.3 million cardiac diagnostic procedures were done. Most (83%) outpatient centers cancelled at least some activities, and all activities were cancelled some time during the year by 45%.

“We observed a significant difference in procedure reduction between economically challenged and wealthier countries,” the researchers said. Important differences were seen in three areas:

  • Reduction in cardiac diagnostic procedures was more prominent for the world’s economically challenged.
  • Shortages of PPE in a higher proportion of low- and lower–middle-income countries than in higher income countries: surgical masks 28% versus 21%; high-filtration masks 50% versus 64%; gloves 7% versus 13%; gowns 45% versus 25%; and eye shielding 60% versus 37%.
  • Telehealth had been implemented in 60% of centers in high-income countries, about half of centers in both upper–middle-income and lower–middle-income countries, and none of the four centers in low-income countries.

“Access to telehealth was lower in low-income countries than that in higher-income countries, which might contribute to greater vulnerability to excess non–Covid-19 mortality in low-income settings,” the editorialists observed. “This calls for more emphasis on developing efficient systems of telehealth, especially in poorer countries or in remote settings in all countries. Such transformative health systems can provide sustainable low-cost care, even after the epidemic has receded.”

“It may also stimulate reconsideration of whether the current levels of diagnostic testing in some countries are appropriate and may lead to more selective use,” they added.

Limitations include data acquisition at fixed times when changes related to peak Covid-19 burden differed in different areas. Nevertheless, “Covid-19–related changes in practice likely preceded this peak in many centers,” the researchers noted.

  1. Cardiovascular testing fell early in the Covid-19 pandemic, survey data showed.
  2. Overall diagnostic procedure volumes were 42% less in March 2020 and 64% less in April 2020 than they were in March 2019.

Paul Smyth, MD, Contributing Writer, BreakingMED™

Einstein has received consulting fees from W.L. Gore and Associates, institutional grant support from Canon Medical Systems, GE Healthcare, Roche Medical Systems, W.L. Gore and Associates, and XyloCor Therapeutics, and travel/accommodations/meeting expenses from HeartFlow.

Leong reported no relationships relevant to the contents of this paper.


Cat ID: 914

Topic ID: 74,914,730,933,914,190,926,192,927,925,934