The Wider Mortality & Morbidity Impact of COVID-19 – A Discussion

Since early April 2020, COVID-19 disease (virus ‘SARS-CoV-2’) has become the leading cause of death in the United States, outpacing cancer and cardiovascular disease in daily mortality.

Critically important containment measures have been shown to ‘flatten the curve’ of new SARS-CoV-2 infections, save lives and ease the pressure on healthcare systems and medical supplies. At the same time, there are indications that these and other COVID-19 related measures will, depending on their extent and duration, also impact on the future mortality and morbidity trends of other areas of disease and health. This wider impact is the focus of this discussion piece, though it must be stressed that observations are at this stage limited and trends assumed; supporting data is not yet available and the opinions expressed are solely those of the author.

Wider health consequences of epidemic containment

Social distancing and stress and isolation relating to the pandemic are increasing the incidence and severity of psychiatric disease. Beyond this often-reported outcome, there has also been a wider reduction in access to medical care, with potentially significant negative impacts on current and future health. To summarize:

• Many states have ordered the suspension of elective surgery and invasive procedures.
• Many primary care physicians have reduced office staff and limited their office hours and services. This could lead to delayed diagnoses and treatments, increased rates of preventable, serious infectious disease and treatable problems evolving into more complex medical issues:
  • Reduced access to preventative, well-care exams
  • Increased waiting times for appointments
  • Reduced common office screenings for chronic diseases such as hypertension, diabetes, hypercholesterolemia and prostate cancer
  • Children falling behind on routine immunizations
  • Less access to mental health providers.
• Reduced availability of healthcare providers for the management of chronic disease will negatively impact patients now and in the long-term.
• Reduced access to mental health providers and community support networks will have a serious impact on vulnerable persons.
• Reduced preventive dental care could lead to more serious dental issues evolving, as well as having a direct, negative effect on cardiovascular health.
• Reduced podiatry care could lead to significant problems in subsets of patients with diabetes and peripheral vascular disease.

We now expand on issues relating to the suspension of elective surgery and invasive procedures, reduced access to emergency care and impacts on behavioral health.

Elective and invasive procedures

While some procedures are completely elective (cosmetic surgery, for example), most fall into a gray area. A procedure that is scheduled in the future may not be truly elective. A biopsy of a suspicious skin lesion or of a prostate in someone with elevated PSA may not be emergent but is medically necessary. Delayed diagnosis of skin and prostate cancers will increase mortality related to these diseases. Postponement of upper endoscopy and cholangiography will miss significant treatable conditions, such as Barrett’s esophagus, peptic ulcer disease, gallbladder and pancreatic disease, as well as cancers.

Hip and knee replacements are elective but are only done after a period of failed conservative treatment. Impaired mobility and increasing pain often push a patient to joint replacement. When these procedures are done, they have met stringent criteria for medical necessity. Delay will increase disability and worsen outcomes, as patients with significant deconditioning and loss of strength and range of motion have more complications.

Similarly, some types of organ transplantation have been put on hold in some regions of the country. This is due to limited hospital space and the desire not to start a prolonged inpatient stay and an intense immunosuppressive regime when bed space and resources are scarce, compounded by the high risk of hospital-acquired SARS-CoV-2 infection. Prolonging the need for dialysis has an effect on mortality, and liver transplantation is the only hope for those in the final stages of liver failure.

Reduced rates of critical cancer screenings will also have an impact. There are over 33 million screening mammograms in the US each year, 0.5% of which find cancer. If these tests are delayed for six months, over 80,000 cancers could have delayed diagnosis. Similarly, 15 million surveillance colonoscopies are done each year, finding about 100,000 colorectal cancers. Surveillance colonoscopy has been shown to decrease the incidence of colorectal cancer by 40% and decrease mortality by 50%. Undoubtedly, the suspension of these ‘elective’ procedures will have a negative effect on cancer mortality.

Management of chronic disease

Diabetes, hypertension, chronic kidney disease, chronic lung disease (chronic obstructive pulmonary disease, asthma) and cardiovascular disease need regular monitoring via physical exam and laboratory testing. Such care allows for treatment regime modifications to optimize outcomes and reduce mortality. Complications such as infections and disease flares, which would previously have been easily treated on an outpatient basis, now risk going undiagnosed and progressing to more serious issues. This is likely to lead to more emergency department visits and hospitalization. Telehealth, video visits and email or app communications are poor substitutions for traditional medical care, and many elderly people may not be able to effectively utilize these types of service.

Pharmacy access is also critical in the management of most of these patients. Any reduction/elimination of home delivery services and fear of going to the pharmacy will impact mortality in many of these vulnerable populations.

Persons undergoing chemotherapy regimens face additional hurdles. Not only does the resulting immunosuppression increase the risk of SARS-CoV-2 infection and mortality, but social distancing practices limit the availability of these treatments. Many hospital infusion centers are being converted into patient wards. Those that are still open have reduced capacity due to reassignment of staff and the necessary increase in physical spacing between patients. This has resulted in missed infusions and less frequent treatments. There are also reports of delay in the initiation of care for new chemotherapy treatment. The impact of decreased chemotherapy treatment availability and delay in initiation of treatment for newly diagnosed cancers will not be known for several years, but it will likely decrease overall cancer survival.

Emergency care

The strain that COVID-19 has put on emergency departments (EDs), providers and staff, impacts all types of emergency care. Most urgent care centers, like many primary care offices, are closed, so many patients with acute illness and minor trauma are forced to use EDs. Many patients will delay or avoid care, perhaps increasing the risk of worsening illness and complications. Untreated lacerations can lead to skin and joint infections. Minor upper respiratory infections, if left untreated, especially in those with asthma or chronic obstructive pulmonary disease, can lead to pneumonia and respiratory failure. Untreated urinary tract infections develop into pyelonephritis and sepsis. Persons suffering major trauma, heart attack and stroke will need emergency department care, placing additional burdens on already overtaxed ED facilities and staff. It is not hard to imagine that care may be delayed or negatively impacted by an over-stretched staff. In some cases, mortality and morbidity will increase.

Behavioral health

Lastly, it is well documented that the stress of social distancing, job loss, and uncertainty about the future of one’s health and that of others, is having a negative impact on psychological health. Social isolation is likely to lead to increased rates of suicidal ideation and, coupled with decreased availability of access to providers and support groups, is expected to lead to more suicide deaths. Increased consumption of drugs and alcohol, which has been well documented, will likely exacerbate depression and other forms of mental health issues, as well as lead to increased rates of overdose. Medicare and commercial insurers are now allowing behavioral health therapy via videoconference or tele-health providers. While not optimal, this type of connection to mental health providers may be lifesaving.

Conclusions for insurers

Although data is not yet available, the reduction in preventive medicine and access to maintenance and acute medical care will likely have a measurable effect on mortality. Many cities have already reported an increased number of people dying at home, some of which would have sought medical care and survived in pre-COVID-19 times. As some states have started relaxing social distancing rules, and increasing access to routine medical care, the effect will not be uniform in all parts of the country.

As insurers, we must understand that this period has created a new mortality risk factor, and that only time will tell as to the long-term effects on non-COVID-19 related mortality and morbidity. Current underwriting guidelines may become less useful as we assess new applicants, since many will not have the usual follow-up healthcare visits which we would normally expect. Severity and complications of known chronic disease will be difficult, if not impossible, to determine without current medical records. We must remain diligent, considerate and consistent as we enter the post-COVID-19 era.

Contact us

If you found this overview interesting, and/or have related findings or opinions to share, please contact us. We look forward to hearing from you.

Cristina Downey
Chief Underwriting Officer US, North America Life

Contributor

Dr. Robert Profumo, MD, PartnerRe
robert.profumo@partnerre.com

This article is for general information, education and discussion purposes only. It does not constitute legal or professional advice; and does not necessarily reflect, in whole or in part, any corporate position, opinion or view of PartnerRe or its affiliates.