Introduction
Recently, a friend of mine talked about his 92-year-old mother who lived in a home
for the elderly, which was locked down four months ago to prevent COVID-19 infections.
During the lockdown, she was moved from her small apartment into a psychogeriatric
care ward. Both her sons were not involved in the decision-making process, as they
were not allowed to visit her. She changed from being a reasonably autonomous person
into a depressed, incontinent and dependant person, without much hope for recovery.
A colleague told me about a 48-year-old man who visited his practice after several
days of worsening eye pain and visual deterioration. The diagnosis was quite straightforward:
keratitis. Subsequent consultation with an ophthalmologist confirmed the feared sequelae:
the cornea was lost. When the patient was asked why he had waited so long before visiting,
he answered that he had not wanted to bother his doctor, who was so busy in these
times of COVID.
Worldwide, the COVID-19 pandemic continues to grow. On 1 July, the virus reached a
sad milestone, with mortality exceeding half a million people. The USA, South America
and the Middle East are now leading in (registered) mortality [1]. With the European
COVID-19 pandemic receding, we can start to ‘calculate the bill’. This evaluation
is necessary, because ‘winter is coming’ – to quote a well-known television series,
and fear exists for a second wave of the pandemic. The medical ingredients for this
bill are significant, including not only the effects of the pandemic and the costs
of measures taken but also the unintended consequences of these actions and the sequelae
arising from postponed care. We will have to learn lessons from the past months.
Policy against COVID-19 and unwanted side effects
In daily healthcare, measures including social distancing and the use of facemasks
and eye-protection seem reasonably effective, with a relative risk of transmission
of the virus of between 0.2 and 0.4 [2]. However, problems of a lack of personal protective
equipment (PPE) and inadequate distribution to the health care facilities caused significant
concerns. Intensive care units (ICU), hospital wards and emergency care facilities
were prioritised in many countries. Primary care, social care providers, retirement
homes, and nursing homes were typically at the end of the queue despite their overwhelming
needs. The virus struck hard in these settings, including residential home care and
care facilities for the elderly. Many older people died, and facilities were completely
locked down: no visitors were allowed for many months. At this moment, it is difficult
to judge the results of that policy, but social isolation and segregation from beloved
ones certainly are not salutary for our elderly. Unfortunately, my friend’s story
was no rarity.
The impact of lockdown measures on patients with chronic illnesses is yet to be assessed.
Limited data from Greece indicate an increase in distress and somatisation – but not
in anxiety and depression, yet – during quarantine among patients with a chronic illness
[3].
Because of fear for overcrowded ICU’s, hospitals partly closed down and reallocated
their facilities and personnel to critical care settings to prepare for an invasion
of acutely ill patients, who would require long-term therapy. Although about one-third
of the ICU patients with COVID-19 die, this strategy proved reasonably successful
and probably saved thousands of lives, at least in the short term.
In primary care, with a shortage of PPE, social distancing was recommended, and GPs
(i.e. general practitioners, family physicians) started rationalising physical entrance
to the practice, expanded telephone and email communications and quickly introduced
video consultations [4]. As a result, patients were sometimes hesitant to ‘trouble’
their GP or postponed a visit because of fear of catching the virus. Even more worrying,
the rationalisation of hospital services delayed diagnostic testing and evaluation
of referred patients. GPs found it challenging to refer patients – which often failed.
Missed care
This combination of measures culminated in an unprecedented decrease in health care
services delivered. The WHO reported that in 92% out of 155 responding countries,
staff was reassigned from non-COVID to COVID related services. That shift mainly affected
rehabilitation and chronic care, but cancer treatment and acute cardiovascular care
were also often involved [5]. Two examples illustrate this ‘hidden pandemic’. In Spain,
the number of invasive procedures for acute myocardial infarction at the onset of
the pandemic decreased by 40%, which not only resulted in death but also increased
survivors’ disability [6]. In Greece, strict lockdown measures were implemented from
mid-March, and the number of patients consulting with chest pain, dyspnoea or palpitations
who visited a cardiology emergency centre decreased sharply. Although the fraction
of consulting patients, admitted to the hospital increased, the absolute number of
myocardial infarction patients sharply decreased [7]. Until now, there is no explanation
for this hidden morbidity and – probably – mortality. Additional research is needed
to explain the impact of the decrease in the use of emergency department services
during the pandemic.
Although the provision of acute care might look impressive, other services, including
oncology, may suffer. In Europe, every year, almost 4 million people are diagnosed
with invasive cancer, more than 350,000 patients each month [8]. In the Netherlands,
during the first three months of the epidemic, diagnosed cancer was about 75% of usual;
and a month after the alleviation of the epidemic measures, it did not reach at the
expected number. For skin cancer (excluding basal cell carcinoma), the reduction was
50% [9]. For some cancers, it might be less troublesome to be discovered a few months
later, e.g. cancers diagnosed by population screening. However, in many cancers, timely
detection should not be postponed too long in order to prevent diagnosis at a more
advanced stage. Catching up, however, is a tremendous job, for which facilities are
lacking. A reasonable estimation of postponed care is about 5000 new cancers not diagnosed
(yet) compared to the previous year in the Netherlands. If the numbers in the Netherlands
equal those in Europe, we are 245,000 cancers behind [10].
Moreover, as far as oncology is concerned, it is not only about new diagnoses. Postponed
care for prevalent cancer will have serious consequences as well. In oncology, often
operation and post- or preoperative treatment is involved. Operations have been postponed
due to a reduction in surgery capacity in hospitals, and chemotherapy has been postponed
because of its immunosuppressive side effects. Furthermore, the inclusion of new patents
in trials has often been delayed.
Similar problems may have arisen in other life-threatening or highly debilitating
diseases. In the Netherlands alone, the estimation is that compared to the previous
year, about 2.5 million referrals from primary to secondary care have not been made.
While some claim that this crisis is a welcome opportunity to get rid of unnecessary
health care, it is highly unlikely that this applies to all 2.5 million referrals.
These figures probably contain much hidden morbidity. In primary care, the effects
of postponing care are not as visible yet. However, the decreased number of cancer
diagnoses certainly has a relation with decreased numbers of referrals by GPs, as
well as by postponing diagnostic evaluations in specialised care. Somehow, this ‘missed
care’ will return to the health care system, which is still suffering from COVID-19.
A shortage of anything will be our part if no appropriate action is taken.
What could general practitioners do?
GPs could try to catch up on delayed care, try to keep their practices accessible
during an outbreak or ‘second wave’, act in the chain of testing, tracing and quarantine,
and participate in the evaluation of new technology and health care procedures.
To catch up on delayed care, GPs can draw up a list of patients they have not seen
in a while. They can contact patients with chronic conditions and patients at high-risk
for health problems, e.g. patients with mental illness and patients with difficult
access to health care. The current crisis is adversely affecting the mental health
of the population, and primary care will be the first to notice this. Primary care
teams may identify these issues among their patients and provide appropriate integrated
care.
In addition, GPs can review telemedicine consultations in recent months for possibly
missed clues, overlooked laboratory results or missed referrals. GPs can sift through
referrals and check whether patients have arrived at the right specialist and have
been followed up correctly. In a patient – suspected of cancer or other serious illness
– who is not evaluated appropriately, the GP should take action. These ‘catch-up’
activities may require additional personnel, which should be trained for this task.
To keep general practices accessible, the separation of COVID care from ‘regular’
care may need to be continued. In the event of the ‘second wave’, patients should
not hesitate to consult their GP face-to-face [11]. Therefore, GPs could collaborate
at a district or city level to concentrate COVID care in locations other than their
regular practices. Furthermore, these collaborative organisations would be the appropriate
level to engage with diagnostic services to develop diagnostic protocols (triage,
testing) and to act as distributors for PPE for primary care and home care staff.
Testing, tracing, and quarantine are the essential public health measures in an epidemic.
Germany is an excellent current example. In countries where public health services
are less well developed, GPs might take responsibility for the implementation of this
policy, at least within their practices.
GPs should engage in the evaluation of novel communication technologies like video
consultation and other telemedicine applications, which undoubtedly provide solutions
for a part of the problems, both in acute and in chronic care [12,13]. In this evaluation,
the limitations of these new technologies must be considered. For example, we do not
exactly know which information is lost compared to face-to-face consultations. Evaluation
in terms of increase or decrease of correct diagnostic or prognostic interpretation
is warranted. The sharp decrease in diagnosed malignancies of the skin in the Netherlands
might – at least partly – be caused by the application of video instead of face-to-face
consultations.
Another example is the extent to which telemedicine is an adequate way to provide
health care to patients with mental or social problems. This group of patients may
be most hesitant to visit their GP. Reports from Italy and Spain showed a marked increase
in psychiatric problems like depression, anxiety, somatoform, and alcohol-related
disorders during the last economic crisis [14]. When unemployment strikes, this will
undoubtedly happen again [15].
GPs should also be involved in evaluating newly developed or revitalised diagnostic
and prognostic tests to separate COVID-patients from other patients by telephone and
to triage common symptoms. The second wave of COVID patients would form a threat to
our healthcare systems, and we should better be safe than sorry.
Finally, we need to evaluate whether our policy to prioritise ICU and hospital care
and to isolate our older patients have been the right choices. In the event of a second
wave of the COVID-19 pandemic in Europe, we need to be better informed about the effects
of such prioritisation. In view of their experiences in recent months, GPs and geriatric
specialists are pre-eminently the disciplines that can make an expert contribution
to this policy evaluation.