U.S. and U.K. researchers report dip in services, including TIA admissions

Since the Covid-19 pandemic got underway, there has been a significant decline in U.S. stroke and transient ischemic attack (TIA) admissions, as well as across-the-board reductions in all sections of U.K. cardiology services, researchers reported.

In the U.S. study, there was a decline in TIA/stroke admissions between Dec. 30, 2019 and April 19, 2020 (P<0.001 for trend) versus Dec. 31, 2018 to April 21, 2019, according Hugo J. Aparicio, MD, MPH, of Boston University School of Medicine and co-authors.

That drop coincided with the declaration of COVID-19 pandemic stay-at-home recommendations in New York, Washington, Massachusetts and Rhode Island, they stated in a brief report in Stroke & Vascular Neurology.

Across the pond and during the first month of lockdown, there was a “marked reduction in chest pain/breathlessness presentations with a 53% reduction in cardiology ward and coronary care unit (CCU) admissions,” stated Omar Fersia, MD, of Dumfries and Galloway Royal Infirmary in Cargenbridge, Scotland.

Additionally, there was a 40% drop in the number of patients diagnosed with myocardial infarction (MI), they stated in Open Heart.

However, telephone and video consultation services implemented during lockdown brought face-to-face clinic visits down by 93%, although there may be a silver lining to the former.

“While labor-intensive at this point of entry into secondary care, [virtual visits during the pandemic] has to be a template for future outpatient practice, which will yield dividends in reduced clinic waiting times once the ’new normal’ becomes established,” Fersia’s group noted.

The pandemic has driven the restructuring of healthcare worldwide to cope with increased demand, pressure, and prioritization of services, both groups of authors noted, and as resources are diverted to address the crisis, other areas of medicine are beginning to show its effects.

Fersia’s group assessed performance indicators of cardiology services at a district general hospital serving a population of 149,000 in the periods prior to and during the Covid-19 lockdown.

They compared four 1-month time intervals: January-February 2020 (baseline); February-March 2020 (transition period); March-April 2020, and April-May 2020 (lockdown periods).

Changes in service provision and clinical activity during lockdown were compared with the baseline interval.

The analysis revealed a 46% reduction in cardiac troponin T (cTnT) blood tests and an 87% reduction in 12-lead electrocardiograms (ECGs). There also was a 44% reduction in inpatient ECGs, and 75% fewer N-terminal-pro B-type natriuretic peptide (NT-proBNP) blood tests performed both in primary and secondary care, indicating a reduction in patients presenting with symptoms and signs of heart failure, according to the authors.

“Overall, the number of patients referred from primary care to cardiology outpatient clinics dropped by 80%,” they wrote.

Fersia and co-authors stressed that lockdown virtual visits were far from ideal, and actually highlighted the need to develop a communication infrastructure to ensure these services can be delivered to all parts of the community.

They noted that the U.K.’s second lockdown period showed a gradual increase in patient referral to cardiology as well as a rise in MI investigation and diagnoses. The authors pointed out that patients’ cardiology needs don’t disappear during a pandemic lockdown, but presentation for care is postponed.

“There is therefore an expectation of a rebound surge of increased workload on cardiology services, which need to restructure in preparation for this scenario,” they suggested.

Unlike many other cardiology services, deferral of stroke and TIA care is not advisable, as “Acute stroke therapies are time-sensitive, so decreased healthcare access or utilization may lead to more disabling or fatal strokes, or more severe non-neurological complications related to stroke” stated Aparicio’s group.

They conducted a retrospective analysis of hospital admissions for stroke and TIA from December 2018 to April 2019 and December 2019 to April 2020 at five tertiary academic comprehensive stroke centers in Boston, New York City, Seattle, and Providence, R.I.

Hospital capacities ranged from 413 to 719 beds and served a total catchment population of approximately 4 million people. Hospital admissions for the study included ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage, or TIA, including transfers.

Data on baseline stroke severity utilized the National Institutes of Health Stroke Scale (NIHSS) and data on time from symptom onset to hospital arrival for patients with ischemic and hemorrhagic stroke. Patients with TIA and those presenting over 24 hours after symptom onset were excluded.

The authors reported the greatest decline in stroke and TIA admissions between March 23, 2020 and April 19, 2020, with a total of 281 admissions versus 410 in the same period the prior year, representing a 31% downturn.

Stroke alerts — stroke team notification of an emergency department (ED) patient with stroke-like symptoms within 24 hours of presentation — happened 46% less often in late March and April 2020 versus 2019.

But stroke severity increased, with a median NIHSS of 10 for all centers between March and April 2020 was 10 versus 7 for the corresponding weeks in 2019.

Median time from symptom onset to hospital arrival saw a slight decrease during pandemic stay-at-home recommendations, from 7.6 hours in March to April 2019 to 6.9 hours in March to April 2020.

“Patients with stroke may be reluctant to activate emergency services or present to hospitals for fear of exposure to COVID-19,” the authors suggested. “They may be underestimating their risk of death or disability due to stroke and avoiding hospital and emergency systems which they assume are under stress.”

Other factors that may have led to the dip in admissions were stay-at-home and social distancing practices; cancellation of outpatient clinic in-person visits; and urban flight from metropolitan areas, they noted.

A study limitation was that the findings may not be representative of community or rural hospitals, the authors acknowledged, but stressed that “Public health officials, hospital systems and healthcare providers must continue to encourage patients with stroke to seek acute care during this crisis.”

  1. There was a more than 50% drop in patients presenting for cardiology services during the Covid-19 lockdown at one center based in Scotland.

  2. There was a 31% decline in stroke and transient ischemic attack (TIA) admissions from late-March to mid-April 2020 in a multicenter U.S. study.

Shalmali Pal, Contributing Writer, BreakingMED™

The study by Arparicio’s group was supported by the NIH. Aparicio reported support from the Boston University Aram V. Chobanian Assistant Professorship.

Fersia and co-authors reported no relationships relevant to the contents of this paper to disclose.

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