Reductions in US life expectancy during the COVID-19 pandemic by race and ethnicity: Is 2021 a repetition of 2020?

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Abstract

COVID-19 had a huge mortality impact in the US in 2020 and accounted for most of the overall reduction in 2020 life expectancy at birth. There were also extensive racial/ethnic disparities in the mortality impact of COVID-19 in 2020, with the Black and Latino populations experiencing reductions in life expectancy at birth over twice as large as that of the White population. Despite continued vulnerability of these populations, the hope was that widespread distribution of effective vaccines would mitigate the overall mortality impact and reduce racial/ethnic disparities in 2021. In this study, we quantify the mortality impact of the COVID-19 pandemic on 2021 US period life expectancy by race and ethnicity and compare these impacts to those estimated for 2020. Our estimates indicate that racial/ethnic disparities have persisted, and that the US population experienced a decline in life expectancy at birth in 2021 of 2.2 years from 2019, 0.6 years more than estimated for 2020. The corresponding reductions estimated for the Black and Latino populations are slightly below twice that for Whites, suggesting smaller disparities than those in 2020. However, all groups experienced additional reductions in life expectancy at birth relative to 2020, and this apparent narrowing of disparities is primarily the result of Whites experiencing proportionately greater increases in mortality in 2021 compared with the corresponding increases in mortality for the Black and Latino populations in 2021. Estimated declines in life expectancy at age 65 increased slightly for Whites between 2020 and 2021 but decreased for both the Black and Latino populations, resulting in the same overall reduction (0.8 years) estimated for 2020 and 2021.

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Critical Supply Shortages — The Need for Ventilators and Personal Protective Equipment during the Covid-19 Pandemic

Megan Ranney, Valerie Griffeth, Ashish Jha (2020)

New England Journal of Medicine

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High-dimensional characterization of post-acute sequalae of COVID-19

Ziyad Al-Aly, Yan Xie, Benjamin Bowe (2021)

The acute clinical manifestations of COVID-19 have been well characterized1,2, but the post-acute sequelae of this disease have not been comprehensively described. Here we use the national healthcare databases of the US Department of Veterans Affairs to systematically and comprehensively identify 6-month incident sequelae-including diagnoses, medication use and laboratory abnormalities-in patients with COVID-19 who survived for at least 30 days after diagnosis. We show that beyond the first 30 days of illness, people with COVID-19 exhibit a higher risk of death and use of health resources. Our high-dimensional approach identifies incident sequelae in the respiratory system, as well as several other sequelae that include nervous system and neurocognitive disorders, mental health disorders, metabolic disorders, cardiovascular disorders, gastrointestinal disorders, malaise, fatigue, musculoskeletal pain and anaemia. We show increased incident use of several therapeutic agents-including pain medications (opioids and non-opioids) as well as antidepressant, anxiolytic, antihypertensive and oral hypoglycaemic agents-as well as evidence of laboratory abnormalities in several organ systems. Our analysis of an array of prespecified outcomes reveals a risk gradient that increases according to the severity of the acute COVID-19 infection (that is, whether patients were not hospitalized, hospitalized or admitted to intensive care). Our findings show that a substantial burden of health loss that spans pulmonary and several extrapulmonary organ systems is experienced by patients who survive after the acute phase of COVID-19. These results will help to inform health system planning and the development of multidisciplinary care strategies to reduce chronic health loss among individuals with COVID-19.

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Delay or Avoidance of Medical Care Because of COVID-19–Related Concerns — United States, June 2020

Mark Czeisler, Kristy Marynak, Kristie Clarke … (2020)

Temporary disruptions in routine and nonemergency medical care access and delivery have been observed during periods of considerable community transmission of SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19) ( 1 ). However, medical care delay or avoidance might increase morbidity and mortality risk associated with treatable and preventable health conditions and might contribute to reported excess deaths directly or indirectly related to COVID-19 ( 2 ). To assess delay or avoidance of urgent or emergency and routine medical care because of concerns about COVID-19, a web-based survey was administered by Qualtrics, LLC, during June 24–30, 2020, to a nationwide representative sample of U.S. adults aged ≥18 years. Overall, an estimated 40.9% of U.S. adults have avoided medical care during the pandemic because of concerns about COVID-19, including 12.0% who avoided urgent or emergency care and 31.5% who avoided routine care. The estimated prevalence of urgent or emergency care avoidance was significantly higher among the following groups: unpaid caregivers for adults* versus noncaregivers (adjusted prevalence ratio [aPR] = 2.9); persons with two or more selected underlying medical conditions † versus those without those conditions (aPR = 1.9); persons with health insurance versus those without health insurance (aPR = 1.8); non-Hispanic Black (Black) adults (aPR = 1.6) and Hispanic or Latino (Hispanic) adults (aPR = 1.5) versus non-Hispanic White (White) adults; young adults aged 18–24 years versus adults aged 25–44 years (aPR = 1.5); and persons with disabilities § versus those without disabilities (aPR = 1.3). Given this widespread reporting of medical care avoidance because of COVID-19 concerns, especially among persons at increased risk for severe COVID-19, urgent efforts are warranted to ensure delivery of services that, if deferred, could result in patient harm. Even during the COVID-19 pandemic, persons experiencing a medical emergency should seek and be provided care without delay ( 3 ). During June 24–30, 2020, a total of 5,412 (54.7%) of 9,896 eligible adults ¶ completed web-based COVID-19 Outbreak Public Evaluation Initiative surveys administered by Qualtrics, LLC.** The Human Research Ethics Committee of Monash University (Melbourne, Australia) reviewed and approved the study protocol on human subjects research. This activity was also reviewed by CDC and was conducted consistent with applicable federal law and CDC policy. †† Respondents were informed of the study purposes and provided electronic consent before commencement, and investigators received anonymized responses. The 5,412 participants included 3,683 (68.1%) first-time respondents and 1,729 (31.9%) persons who had completed a related survey §§ during April 2–8, 2020. Among the 5,412 participants, 4,975 (91.9%) provided complete data for all variables in this analysis. Quota sampling and survey weighting ¶¶ were employed to improve cohort representativeness of the U.S. population by gender, age, and race/ethnicity. Respondents were asked “Have you delayed or avoided medical care due to concerns related to COVID-19?” Delay or avoidance was evaluated for emergency (e.g., care for immediate life-threatening conditions), urgent (e.g., care for immediate non–life-threatening conditions), and routine (e.g., annual check-ups) medical care. Given the potential for variation in interpretation of whether conditions were life-threatening, responses for urgent and emergency care delay or avoidance were combined for analysis. Covariates included gender; age; race/ethnicity; disability status; presence of one or more selected underlying medical conditions known to increase risk for severe COVID-19; education; essential worker status***; unpaid adult caregiver status; U.S. census region; urban/rural classification ††† ; health insurance status; whether respondents knew someone who had received a positive SARS-CoV-2 test result or had died from COVID-19; and whether the respondents believed they were at high risk for severe COVID-19. Comparisons within all these subgroups were evaluated using multivariable Poisson regression models §§§ with robust standard errors to estimate prevalence ratios adjusted for all covariates, 95% confidence intervals, and p-values to evaluate statistical significance (α = 0.05) using the R survey package (version 3.29) and R software (version 4.0.2; The R Foundation). As of June 30, 2020, among 4,975 U.S. adult respondents, 40.9% reported having delayed or avoided any medical care, including urgent or emergency care (12.0%) and routine care (31.5%), because of concerns about COVID-19 (Table 1). Groups of persons among whom urgent or emergency care avoidance exceeded 20% and among whom any care avoidance exceeded 50% included adults aged 18–24 years (30.9% for urgent or emergency care; 57.2% for any care), unpaid caregivers for adults (29.8%; 64.3%), Hispanic adults (24.6%; 55.5%), persons with disabilities (22.8%; 60.3%), persons with two or more selected underlying medical conditions (22.7%; 54.7%), and students (22.7%; 50.3%). One in four unpaid caregivers reported caring for adults who were at increased risk for severe COVID-19. TABLE 1 Estimated prevalence of delay or avoidance of medical care because of concerns related to COVID-19, by type of care and respondent characteristics — United States, June 30, 2020 Characteristic No. (%)† Type of medical care delayed or avoided* Urgent or emergency Routine Any %† P-value§ %† P-value§ %† P-value§ All respondents 4,975 (100) 12.0 — 31.5 — 40.9 — Gender Female 2,528 (50.8) 11.7 0.598 35.8 <0.001 44.9 <0.001 Male 2,447 (49.2) 12.3 27.0 36.7 Age group, yrs 18–24 650 (13.1) 30.9 <0.001 29.6 0.072 57.2 <0.001 25–44 1,740 (35.0) 14.9 34.2 44.8 45–64 1,727 (34.7) 5.7 30.0 34.5 ≥65 858 (17.3) 4.4 30.3 33.5 Race/Ethnicity White, non-Hispanic 3,168 (63.7) 6.7 <0.001 30.9 0.020 36.2 <0.001 Black, non-Hispanic 607 (12.2) 23.3 29.7 48.1 Asian, non-Hispanic 238 (4.8) 8.6 31.3 37.7 Other race or multiple races, non-Hispanic¶ 150 (3.0) 15.5 23.9 37.3 Hispanic, any race or races 813 (16.3) 24.6 36.4 55.5 Disability** Yes 1,108 (22.3) 22.8 <0.001 42.9 <0.001 60.3 <0.001 No 3,867 (77.7) 8.9 28.2 35.3 Underlying medical condition†† No 2,537 (51.0) 8.2 <0.001 27.9 <0.001 34.7 <0.001 One 1,328 (26.7) 10.4 33.0 41.2 Two or more 1,110 (22.3) 22.7 37.7 54.7 2019 household income, USD <25,000 665 (13.4) 13.9 0.416 31.2 0.554 42.8 0.454 25,000–49,999 1,038 (20.9) 11.1 30.9 38.6 50,000–99,999 1,720 (34.6) 12.5 30.5 41.1 ≥100,000 1,552 (31.2) 11.2 33.0 41.4 Education Less than high school diploma 65 (1.3) 15.6 0.442 24.7 0.019 37.9 0.170 High school diploma 833 (16.7) 12.3 28.1 38.1 Some college 1,302 (26.2) 13.6 29.7 40.3 Bachelor's degree 1,755 (35.3) 11.2 34.8 43.6 Professional degree 1,020 (20.5) 10.9 31.2 39.5 Employment status Employed 3,049 (61.3) 14.6 <0.001 31.5 0.407 43.3 <0.001 Unemployed 630 (12.7) 8.7 34.4 39.5 Retired 1,129 (22.7) 5.3 29.9 33.8 Student 166 (3.3) 22.7 30.5 50.3 Essential worker status§§ Essential worker 1,707 (34.3) 19.5 <0.001 32.4 0.293 48.0 <0.001 Nonessential worker 1,342 (27.0) 8.4 30.3 37.3 Unpaid caregiver status¶¶ Unpaid caregiver for adults 1,344 (27.0) 29.8 <0.001 41.0 <0.001 64.3 <0.001 Not unpaid caregiver for adults 3,631 (73.0) 5.4 27.9 32.2 U.S. Census region*** Northeast 1,122 (22.6) 11.0 0.008 33.9 0.203 42.5 0.460 Midwest 936 (18.8) 8.5 32.0 38.7 South 1,736 (34.9) 13.9 29.6 40.7 West 1,181 (23.7) 13.0 31.5 41.5 Rural/Urban classification††† Urban 4,411 (88.7) 12.3 0.103 31.5 0.763 41.2 0.216 Rural 564 (11.3) 9.4 30.9 38.2 Health insurance status Yes 4,577 (92.0) 12.4 0.036 32.6 <0.001 42.3 <0.001 No 398 (8.0) 7.8 18.4 24.8 Know someone with positive test results for SARS-CoV-2§§§ Yes 989 (19.9) 8.8 0.004 40.7 <0.001 46.6 <0.001 No 3,986 (80.1) 12.8 29.2 39.5 Knew someone who died from COVID-19 Yes 364 (7.3) 10.1 0.348 41.4 <0.001 46.3 0.048 No 4,611 (92.7) 12.2 30.7 40.5 Believed to be in group at high risk for severe COVID-19 Yes 981 (19.7) 10.0 0.050 42.5 <0.001 49.4 <0.001 No 3,994 (80.3) 12.5 28.8 38.8 Abbreviations: CI = confidence interval; COVID-19 = coronavirus disease 2019; USD = U.S. dollars. * The types of medical care avoidance are not mutually exclusive; respondents had the option to indicate that they had delayed or avoided more than one type of medical care (i.e., routine medical care and urgent/emergency medical care). † Statistical raking and weight trimming were employed to improve the cross-sectional June cohort representativeness of the U.S. population by gender, age, and race/ethnicity according to the 2010 U.S. Census. § The Rao-Scott adjusted Pearson chi-squared test was used to test for differences in observed and expected frequencies among groups by characteristic for avoidance of each type of medical care (e.g., whether avoidance of routine medical care differs significantly by gender). Statistical significance was evaluated at a threshold of α = 0.05. ¶ “Other” race includes American Indian or Alaska Native, Native Hawaiian or Pacific Islander, or Other. ** Persons who had a disability were defined as such based on a qualifying response to either one of two questions: “Are you limited in any way in any activities because of physical, mental, or emotional condition?” and “Do you have any health conditions that require you to use special equipment, such as a cane, wheelchair, special bed, or special telephone?” https://www.cdc.gov/brfss/questionnaires/pdf-ques/2015-brfss-questionnaire-12-29-14.pdf. †† Selected underlying medical conditions known to increase the risk for severe COVID-19 included in this analysis were obesity, diabetes, high blood pressure, cardiovascular disease, and any type of cancer. Obesity is defined as body mass index ≥30 kg/m2 and was calculated from self-reported height and weight (https://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/index.html). The remaining conditions were assessed using the question “Have you ever been diagnosed with any of the following conditions?” with response options of 1) “Never”; 2) “Yes, I have in the past, but don’t have it now”; 3) “Yes I have, but I do not regularly take medications or receive treatment”; and 4) “Yes I have, and I am regularly taking medications or receiving treatment.” Respondents who answered that they have been diagnosed and chose either response 3 or 4 were considered as having the specified medical condition. §§ Essential worker status was self-reported. ¶¶ Unpaid caregiver status was self-reported. Unpaid caregivers for adults were defined as having provided unpaid care to a relative or friend aged ≥18 years at any time in the last 3 months. Examples provided to survey respondents included helping with personal needs, household chores, health care tasks, managing a person’s finances, taking them to a doctor’s appointment, arranging for outside services, and visiting regularly to see how they are doing. *** Region classification was determined by using the U.S. Census Bureau’s Census Regions and Divisions. https://www2.census.gov/geo/pdfs/maps-data/maps/reference/us_regdiv.pdf. ††† Rural-urban classification was determined by using self-reported ZIP codes according to the Federal Office of Rural Health Policy definition of rurality. https://www.hrsa.gov/rural-health/about-us/definition/datafiles.html. §§§ For this question, respondents were asked to select the following statement, if applicable: “I know someone who has tested positive for COVID-19.” In the multivariable Poisson regression models, differences within groups were observed for urgent or emergency care avoidance (Figure) and any care avoidance (Table 2). Adjusted prevalence of urgent or emergency care avoidance was significantly higher among unpaid caregivers for adults versus noncaregivers (2.9; 2.3–3.6); persons with two or more selected underlying medical conditions versus those without those conditions (1.9; 1.5–2.4); persons with health insurance versus those without health insurance (1.8; 1.2–2.8); Black adults (1.6; 1.3–2.1) and Hispanic adults (1.5; 1.2–2.0) versus White adults; young adults aged 18–24 years versus adults aged 25–44 years (1.5; 1.2–1.8); and persons with disabilities versus those without disabilities (1.3; 1.1–1.5). Avoidance of urgent or emergency care was significantly lower among adults aged ≥45 years than among younger adults. FIGURE Adjusted prevalence ratios* , † for characteristics § , ¶ , ** , †† associated with delay or avoidance of urgent or emergency medical care because of concerns related to COVID-19 — United States, June 30, 2020 Abbreviation: COVID-19 = coronavirus disease 2019. * Comparisons within subgroups were evaluated using Poisson regressions used to calculate a prevalence ratio adjusted for all characteristics shown in figure. † 95% confidence intervals indicated with error bars. § “Other” race includes American Indian or Alaska Native, Native Hawaiian or Pacific Islander, or Other. ¶ Selected underlying medical conditions known to increase the risk for severe COVID-19 were obesity, diabetes, high blood pressure, cardiovascular disease, and any type of cancer. Obesity is defined as body mass index ≥30 kg/m2 and was calculated from self-reported height and weight (https://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/index.html). The remaining conditions were assessed using the question “Have you ever been diagnosed with any of the following conditions?” with response options of 1) “Never”; 2) “Yes, I have in the past, but don’t have it now”; 3) “Yes I have, but I do not regularly take medications or receive treatment”; and 4) “Yes I have, and I am regularly taking medications or receiving treatment.” Respondents who answered that they have been diagnosed and chose either response 3 or 4 were considered as having the specified medical condition. ** Essential worker status was self-reported. For the adjusted prevalence ratios, essential workers were compared with all other respondents (including those who were nonessential workers, retired, unemployed, and students). †† Unpaid caregiver status was self-reported. Unpaid caregivers for adults were defined as having provided unpaid care to a relative or friend aged ≥18 years to help them take care of themselves at any time in the last 3 months. The figure is a forest plot showing the adjusted prevalence ratios for characteristics associated with delay or avoidance of urgent or emergency medical care because of concerns related to COVID-19, in the United States, as of June 30, 2020. TABLE 2 Characteristics associated with delay or avoidance of any medical care because of concerns related to COVID-19 — United States, June 30, 2020 Characteristic Weighted* no. Avoided or delayed any medical care aPR† (95% CI†) P-value† All respondents 4,975 — — — Gender Female 2,528 Referent — — Male 2,447 0.81 (0.75–0.87)§ <0.001 Age group, yrs 18–24 650 1.12 (1.01–1.25)§ 0.035 25–44 1,740 Referent — — 45–64 1,727 0.80 (0.72–0.88)§ <0.001 ≥65 858 0.72 (0.64–0.81)§ <0.001 Race/Ethnicity White, non-Hispanic 3,168 Referent — — Black, non-Hispanic 607 1.07 (0.96–1.19) 0.235 Asian, non-Hispanic 238 1.04 (0.91–1.18) 0.567 Other race or multiple races, non-Hispanic¶ 150 0.87 (0.71–1.07) 0.196 Hispanic, any race or races 813 1.15 (1.03–1.27)§ 0.012 Disability** Yes 1,108 1.33 (1.23–1.43)§ <0.001 No 3,867 Referent — — Underlying medical condition†† No 2,537 Referent — — One 1,328 1.15 (1.05–1.25)§ 0.004 Two or more 1,110 1.31 (1.20–1.42)§ <0.001 Education Less than high school diploma 65 0.72 (0.53–0.98)§ 0.037 High school diploma 833 0.79 (0.71–0.89)§ <0.001 Some college 1,302 0.85 (0.78–0.93)§ 0.001 Bachelor's degree 1,755 Referent — — Professional degree 1,020 0.90 (0.82–0.98)§ 0.019 Essential workers vs others§§ Essential workers 1,707 1.00 (0.92–1.09) 0.960 Other respondents (nonessential workers, retired persons, unemployed persons, and students) 3,268 Referent — — Unpaid caregiver status¶¶ Unpaid caregiver for adults 1,344 1.64 (1.52–1.78)§ <0.001 Not unpaid caregiver for adults 3,631 Referent — — U.S. Census region*** Northeast 1,122 Referent — — Midwest 936 0.93 (0.83–1.04) 0.214 South 1,736 0.90 (0.82–0.99)§ 0.028 West 1,181 0.99 (0.89–1.09) 0.808 Rural/Urban classification††† Urban 4,411 1.00 (0.89–1.12) 0.993 Rural 564 Referent — — Health insurance status Yes 4,577 1.61 (1.31–1.98)§ <0.001 No 398 Referent — — Know someone with positive test results for SARS-CoV-2§§§ Yes 989 1.22 (1.12–1.33)§ <0.001 No 3,986 Referent — — Knew someone who died from COVID-19 Yes 364 0.99 (0.88–1.12) 0.860 No 4,611 Referent — — Believed to be in a group at high risk for severe COVID-19 Yes 981 1.33 (1.23–1.44)§ <0.001 No 3,994 Referent — — Abbreviations: aPR = adjusted prevalence ratio; CI = confidence interval; COVID-19 = coronavirus disease 2019. * Statistical raking and weight trimming were employed to improve the cross-sectional June cohort representativeness of the U.S. population by gender, age, and race/ethnicity according to the 2010 U.S. Census. † Comparisons within subgroups were evaluated using Poisson regressions used to calculate a prevalence ratio adjusted for all characteristics listed, as well as a 95% CI and p-value. Statistical significance was evaluated at a threshold of α = 0.05. § P-value calculated using Poisson regression among respondents within a characteristic is statistically significant at levels of p<0.05. ¶ “Other” race includes American Indian or Alaska Native, Native Hawaiian or Pacific Islander, or Other. ** Persons who had a disability were defined based on a qualifying response to either one of two questions: “Are you limited in any way in any activities because of physical, mental, or emotional condition?” and “Do you have any health conditions that require you to use special equipment, such as a cane, wheelchair, special bed, or special telephone?” https://www.cdc.gov/brfss/questionnaires/pdf-ques/2015-brfss-questionnaire-12-29-14.pdf. †† Selected underlying medical conditions known to increase the risk for severe COVID-19 were obesity, diabetes, high blood pressure, cardiovascular disease, and any type of cancer. Obesity is defined as body mass index ≥30 kg/m2 and was calculated from self-reported height and weight (https://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/index.html). The remaining conditions were assessed using the question “Have you ever been diagnosed with any of the following conditions?” with response options of 1) “Never”; 2) “Yes, I have in the past, but don’t have it now”; 3) “Yes I have, but I do not regularly take medications or receive treatment”; and 4) “Yes I have, and I am regularly taking medications or receiving treatment.” Respondents who answered that they have been diagnosed and chose either response 3 or 4 were considered as having the specified medical condition. §§ Essential worker status was self-reported. For the adjusted prevalence ratios, essential workers were compared with all other respondents (including those who were nonessential workers, retired, unemployed, and students). ¶¶ Unpaid caregiver status was self-reported. Unpaid caregivers for adults were defined as having provided unpaid care to a relative or friend aged ≥18 years at any time in the last 3 months. Examples provided to survey respondents included helping with personal needs, household chores, health care tasks, managing a person’s finances, taking them to a doctor’s appointment, arranging for outside services, and visiting regularly to see how they are doing. *** Region classification was determined by using the U.S. Census Bureau’s Census Regions and Divisions. https://www2.census.gov/geo/pdfs/maps-data/maps/reference/us_regdiv.pdf. ††† Rural/urban classification was determined by using self-reported ZIP codes according to the Federal Office of Rural Health Policy definition of rurality. https://www.hrsa.gov/rural-health/about-us/definition/datafiles.html. §§§ For this question, respondents were asked to select the following statement, if applicable: “I know someone who has tested positive for COVID-19.” Discussion As of June 30, 2020, an estimated 41% of U.S. adults reported having delayed or avoided medical care during the pandemic because of concerns about COVID-19, including 12% who reported having avoided urgent or emergency care. These findings align with recent reports that hospital admissions, overall emergency department (ED) visits, and the number of ED visits for heart attack, stroke, and hyperglycemic crisis have declined since the start of the pandemic ( 3 – 5 ), and that excess deaths directly or indirectly related to COVID-19 have increased in 2020 versus prior years ( 2 ). Nearly one third of adult respondents reported having delayed or avoided routine medical care, which might reflect adherence to community mitigation efforts such as stay-at-home orders, temporary closures of health facilities, or additional factors. However, if routine care avoidance were to be sustained, adults could miss opportunities for management of chronic conditions, receipt of routine vaccinations, or early detection of new conditions, which might worsen outcomes. Avoidance of both urgent or emergency and routine medical care because of COVID-19 concerns was highly prevalent among unpaid caregivers for adults, respondents with two or more underlying medical conditions, and persons with disabilities. For caregivers who reported caring for adults at increased risk for severe COVID-19, concern about exposure of care recipients might contribute to care avoidance. Persons with underlying medical conditions that increase their risk for severe COVID-19 ( 6 ) are more likely to require care to monitor and treat these conditions, potentially contributing to their more frequent report of avoidance. Moreover, persons at increased risk for severe COVID-19 might have avoided health care facilities because of perceived or actual increased risk of exposure to SARS-CoV-2, particularly at the onset of the pandemic. However, health care facilities are implementing important safety precautions to reduce the risk of SARS-CoV-2 infection among patients and personnel. In contrast, delay or avoidance of care might increase risk for life-threatening medical emergencies. In a recent study, states with large numbers of COVID-19–associated deaths also experienced large proportional increases in deaths from other underlying causes, including diabetes and cardiovascular disease ( 7 ). For persons with disabilities, accessing medical services might be challenging because of disruptions in essential support services, which can result in adverse health outcomes. Medical services for persons with disabilities might also be disrupted because of reduced availability of accessible transportation, reduced communication in accessible formats, perceptions of SARS-CoV-2 exposure risk, and specialized needs that are difficult to address with routine telehealth delivery during the pandemic response. Increasing accessibility of medical and telehealth services ¶¶¶ might help prevent delay of needed care. Increased prevalences of reported urgent or emergency care avoidance among Black adults and Hispanic adults compared with White adults are especially concerning given increased COVID-19-associated mortality among Black adults and Hispanic adults ( 8 ). In the United States, the age-adjusted COVID-19 hospitalization rates are approximately five times higher among Black persons and four times higher among Hispanic persons than are those among White persons ( 9 ). Factors contributing to racial and ethnic disparities in SARS-CoV-2 exposure, illness, and mortality might include long-standing structural inequities that influence life expectancy, including prevalence and underlying medical conditions, health insurance status, and health care access and utilization, as well as work and living circumstances, including use of public transportation and essential worker status. Communities, health care systems, and public health agencies can foster equity by working together to ensure access to information, testing, and care to assure maintenance and management of physical and mental health. The higher prevalence of medical care delay or avoidance among respondents with health insurance versus those without insurance might reflect differences in medical care-seeking behaviors. Before the pandemic, persons without insurance sought medical care much less frequently than did those with insurance ( 10 ), resulting in fewer opportunities for medical care delay or avoidance. The findings in this report are subject to at least five limitations. First, self-reported data are subject to recall, response, and social desirability biases. Second, the survey did not assess reasons for COVID-19–associated care avoidance, such as adherence to public health recommendations; closure of health care provider facilities; reduced availability of public transportation; fear of exposure to infection with SARS-CoV-2; or availability, accessibility, and acceptance or recognition of telemedicine as a means of providing care in lieu of in-person services. Third, the survey did not assess baseline patterns of care-seeking or timing or duration of care avoidance. Fourth, perceptions of whether a condition was life-threatening might vary among respondents. Finally, although quota sampling methods and survey weighting were employed to improve cohort representativeness, this web-based survey might not be fully representative of the U.S. population for income, educational attainment, and access to technology. However, the findings are consistent with reported declines in hospital admissions and ED visits during the pandemic ( 3 – 5 ). CDC has issued guidance to assist persons at increased risk for severe COVID-19 in staying healthy and safely following treatment plans**** and to prepare health care facilities to safely deliver care during the pandemic. †††† Additional public outreach in accessible formats tailored for diverse audiences might encourage these persons to seek necessary care. Messages could highlight the risks of delaying needed care, especially among persons with underlying medical conditions, and the importance of timely emergency care. Patient concerns related to potential exposure to SARS-CoV-2 in health care settings could be addressed by describing facilities’ precautions to reduce exposure risk. Further exploration of underlying reasons for medical care avoidance is needed, including among persons with disabilities, persons with underlying health conditions, unpaid caregivers for adults, and those who face structural inequities. If care were avoided because of concern about SARS-CoV-2 exposure or if there were closures or limited options for in-person services, providing accessible telehealth or in-home health care could address some care needs. Even during the COVID-19 pandemic, persons experiencing a medical emergency should seek and be provided care without delay ( 3 ). Summary What is already known about this topic? Delayed or avoided medical care might increase morbidity and mortality associated with both chronic and acute health conditions. What is added by this report? By June 30, 2020, because of concerns about COVID-19, an estimated 41% of U.S. adults had delayed or avoided medical care including urgent or emergency care (12%) and routine care (32%). Avoidance of urgent or emergency care was more prevalent among unpaid caregivers for adults, persons with underlying medical conditions, Black adults, Hispanic adults, young adults, and persons with disabilities. What are the implications for public health practice? Understanding factors associated with medical care avoidance can inform targeted care delivery approaches and communication efforts encouraging persons to safely seek timely routine, urgent, and emergency care.

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Author and article information

Contributors

Theresa Andrasfay:

ORCID: https://orcid.org/0000-0003-3885-8718

Role: ConceptualizationRole: Formal analysisRole: InvestigationRole: MethodologyRole: VisualizationRole: Writing – original draftRole: Writing – review & editing

Noreen Goldman:

ORCID: https://orcid.org/0000-0003-2865-9491

Role: ConceptualizationRole: InvestigationRole: MethodologyRole: VisualizationRole: Writing – original draftRole: Writing – review & editing

Anselm J. M. Hennis: Role: Editor

Journal

Journal ID (nlm-ta): PLoS One

Journal ID (iso-abbrev): PLoS One

Journal ID (publisher-id): plos

Title: PLoS ONE

Publisher: Public Library of Science (San Francisco, CA USA )

ISSN (Electronic): 1932-6203

Publication date (Electronic): 31 August 2022

Publication date Collection: 2022

Publication date PMC-release: 31 August 2022

Volume: 17

Issue: 8

Electronic Location Identifier: e0272973

Affiliations

[1 ] Leonard Davis School of Gerontology, University of Southern California, Los Angeles, California, United States of America

[2 ] Office of Population Research, School of Public and International Affairs, Princeton University, Princeton, New Jersey, United States of America

PAHO/WHO, UNITED STATES

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Competing Interests: The authors have declared that no competing interests exist.

* E-mail: andrasfa@ 123456usc.edu

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Theresa Andrasfay https://orcid.org/0000-0003-3885-8718

Noreen Goldman https://orcid.org/0000-0003-2865-9491

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Publisher ID: PONE-D-22-10701

DOI: 10.1371/journal.pone.0272973

PMC ID: 9432732

PubMed ID: 36044413

SO-VID: 2998c41e-3d8b-4e1a-b35d-a6c98562ac41

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This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

History

Date received : 11 April 2022

Date accepted : 30 July 2022

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Figures: 4, Tables: 1, Pages: 12

Funding

Funded by: funder-id http://dx.doi.org/10.13039/100000049, National Institute on Aging;

Award ID: T32AG000037

Award Recipient :

ORCID: https://orcid.org/0000-0003-3885-8718

Theresa Andrasfay

Research reported in this publication was partly supported by the National Institute on Aging under Award Number T32AG000037 (TA). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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Data Availability All data used in this analysis are publicly available. Data on mortality rates from all causes and from COVID-19 are available from CDC WONDER: https://wonder.cdc.gov/mcd.html.

Outbreaks COVID-19

ScienceOpen disciplines: Uncategorized

Data availability:

ScienceOpen disciplines: Uncategorized

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