America has banded together to flatten the curve of Covid -19 infections and hospitalizations. Obscured by this achievement — though the battle is far from won — is the mounting suffering of vulnerable patients with chronic disease. It’s now time to address this next curve: “collateral damage” in the form of preventable disease progression and death for chronically ill patients whose care has been disrupted by the Covid-19 crisis.
This collateral damage is a result of missed or delayed visits, treatments, and procedures for patients with chronic disease unable to access healthcare facilities in some cases because Covid-19 consumes their capacity or they are closed. In other cases, patients haven’t shown up because of stay-at-home orders, fear of virus exposure, or emerging economic hardship.
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Recent reports paint a dire picture of a U.S. healthcare system, repurposed for Covid-19 patients, that is unable to treat the normal flow of chronic disease patients. Evidence is mounting that chronically ill patients are delaying requisite care, such as filling prescriptions or receiving life-saving procedures deemed “elective.” And now we’ve learned that almost one in three Americans have put off needed healthcare. These facts represent an alarming trend of mounting chronic disease exacerbation and death in the home.
Consider, for example, Aortic Valve Replacement (AVR) procedures for certain heart failure patients. As operating rooms and cardiac catheterization labs closed and both visits and referrals dried up, large numbers of patients are no longer receiving nor being evaluated for AVR. Yet the mortality rate for patients waiting for AVR at six months is 23%, and it continues to rise the longer intervention is delayed.
Other examples abound. Consider patients with type 2 Diabetes Mellitus with elevated A1C levels or high blood pressure who face barriers obtaining the medications they need or adjusting their mix of medications for evolving symptoms. These unmet needs represent a grave risk for our society’s most socially and clinically vulnerable, who are now bearing the brunt of the pandemic with high rates of Covid or non-Covid related death.
Not all chronically ill patients face the same level of risk
Patients with a chronic disease are not a uniform group. Focusing first on those at greatest risk is imperative, taking into consideration both socioeconomic and clinical factors.
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Socioeconomic Factors: Social determinants have been highlighted as a key Covid-19 risk factor; our healthcare system suffers from inequities in care quality, and Covid-19 has shed even greater light on these unconscionable disparities. Before the pandemic shook our economy, a Federal Reserve report showed that 40% of Americans don’t have $400 in the bank to cover emergency expenses. It becomes even more difficult to fill prescriptions and pay out-of-pocket costs when economic hardships such as illness, furloughs or layoffs hit households simultaneously.
Clinical Factors: Some patients’ disease profiles or severity carries a higher risk of adverse outcomes. Further, patients who are well managed with efficacious therapies that mitigate these risks face lower risk than those who are not. It’s hard to imagine that the poorly managed diabetic or hypertensive patient won’t do worse with Covid-19 than the patient who despite being labeled with these diseases, has normal glucose and blood pressure numbers.
Minimally, optimal chronic disease management will mitigate the known clinical risks of these conditions and lessen the collateral damage we are seeing during the pandemic. Ideally, optimal clinical management will translate into better outcomes and fewer hospitalizations for those who are infected.
A wave of unmanaged, chronically ill patients could further overwhelm our ailing healthcare system. It’s our responsibility to continually and consistently identify those at highest risk, deploy guideline-based care virtually, and triage and prepare patients for procedures as hospitals reopen. Ultimately, these steps will help keep vulnerable patients healthy, safe, and out of the hospital.
Here’s how we save the most lives
A new normal will emerge from the tragedy of the pandemic. Proactive, virtual outreach to provide patients at greatest risk of death with guideline-directed care is imperative to minimize Covid-19’s collateral damage and support health system recovery.
The first step is leveraging advanced clinical analytics and artificial intelligence to create medically-informed patient risk stratification considering both socioeconomic and clinical factors. We won’t be able to treat everyone at once, so it’s paramount to focus our limited resources and capacity. The most critical clinical cohort includes the highest-risk patients with chronic disease who have either not received guideline-directed care or whose care has been disrupted by the crisis. These patients are at the greatest risk of hospitalization and death related to Covid-19 or their chronic disease(s).
The next step is guideline-directed care recommendations for these patients delivered proactively via telehealth and virtual care visits. For example, patient symptoms may be evaluated remotely and medication regimens may be adjusted. In some cases, new methods of prescription delivery or remote monitoring may be deployed to keep patients safe, healthy and isolated.
These steps will also be crucial in accelerating health system recovery from the Covid-19 crisis. Some of these patients will need in-person care, such as those requiring diagnostic tests or procedures. Completing the requisite precursor steps virtually will make all the difference. Guiding highest-risk patients proactively through new virtual care pathways — such as specialist e-consults, stopping/starting key medications ahead of a procedure, or remotely completing pre-op requirements — will enable health systems to more rapidly reinstate diagnostics and elective procedures.
These technologies and programs can democratize high-quality care in this unprecedented time. For patients not receiving optimal care whose mortality risk increases daily, these measures will save lives. Furthermore, should subsequent Covid-19 waves arise as some predict, these measures will reduce preventable chronic disease admissions, preserving essential hospital capacity throughout the remainder of the crisis.
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