[co-author: Pamela Koenig]

Photo by Hush Naidoo on Unsplash

During the 2020 COVID-19 pandemic, statistics have shown a significant decline in emergency room and hospital admissions for multiple conditions, including acute coronary syndrome (ACS) (-40–50%), stroke (-30–40%), and cancer (-~13%), as well as acute surgical admissions (-25%) compared to 2019.

Hospital admissions fell ~30% in April. Although the specific reasons for the reductions in admissions are not clear, most studies attribute the decline to COVID-19 related factors, such as patient fears of contracting COVID-19 or restrictions to access to healthcare. Some studies examining acute cardiovascular admissions during the pandemic suggest that patients with mild-moderate symptoms may not seek health care, and these patients are responsible for the reduction in number of admissions. On the other hand, patients with severe disease are the ones who are seeking treatment and are being admitted. This scenario may also be true for other conditions.

There is an important question that needs to be addressed regarding the decline in admissions. Namely, what has been the impact on health outcomes and mortality of patients who are not presenting timely for treatment? Have there been excess deaths due to cardiovascular disease? To COVID-19?

There are no easy answers. Muddying the water is the fact that since the pandemic began, criteria for records of death associated with a COVID-19 diagnosis have been inconsistent among institutions.

COVID-19 has been associated with a variety of cardiovascular complications. For example, COVID-19 may cause thrombotic and thromboembolic complications in 20‐50% of patients. Stroke has been described in COVID patients, with rates ranging up to 20% of hospitalized patients. However, after emergency room or hospital admission, COVID-19 testing results may not be available for several days. Consequently, excess deaths attributed to causes other than COVID-19, such as cardiovascular diseases, could reflect deaths from unrecognized or undocumented COVID-19 infection complications.

On the other hand, many people whose deaths have been attributed to COVID-19 have comorbid health conditions, such as cardiovascular disease, which put them at higher risk of mortality. Could it be that some deaths from comorbid conditions are being incorrectly attributed to COVID-19? For example, CDC data shows a range of 0–12% increase in excess non-COVID-19-related deaths in the weeks from March 21-November 28, 2020. A recent analysis of this same CDC data (Wolf et al., 2020) found a 20% overall increase over expected number of deaths from COVID-19 and other causes. The numbers of excess death were based on a predicted or expected number of deaths calculated from yearly mortality data since 2013. Of the excess deaths, 67% were attributed to COVID-19. So, 13% of the 20% overall excess deaths were a result of COVID-19 and 7% from other causes. Other causes included Alzheimer’s disease, heart disease, and 10 other grouped causes. This study data supports the 0–12% range of increase in non-COVID-19 deaths depicted in the CDC graph. Could this reported increase in deaths be due to patients not seeking timely treatment?

To add to the confusion, the CDC’s own numbers call into question whether there has been any increase in deaths this year. When the actual number of deaths from all causes are compared between 2018 and 2020, the number of deaths are very similar. For 2018, the final number of deaths was 2,839,205 and the provisional number of deaths [based on death certificates data received and coded] for 2020 was 2,788,849 [Last updated 12/17]. The similarity in number of deaths between 2018 and 2020 would lead one to ask questions: Have there really been excess deaths from any cause in 2020? Could it be that people with comorbid conditions may have died anyway this year, regardless of COVID-19? The questions regarding the decline in admissions and impact on the health outcomes and mortality of patients who are not presenting for timely treatment remains unanswered.

The one thing that can be concluded is that there has been a considerable decline in the number of emergency room and hospital admissions for multiple conditions during COVID-19 compared to pre-COVID. In regards to some diseases, it could be that patients with mild-moderate disease not presenting for admissions are surviving (at least for now) but will ultimately influence emergency room and hospital admission rates at a future date. The true impact of the decline in emergency room and hospital admissions during the COVID-19 pandemic on patient health outcomes/mortality remains to be seen.

What will be the legal fallout of fewer ER visits and the confusion as to whether there has been an increase in deaths this year, and if, so, what is causing them? That too remains to be seen. Some questions to consider:

· Will there be future increases in personal injury / wrongful death cases for patients whose care / treatment was delayed due to COVID-19?

o If so, will doctors be able to defend on the ground that the plaintiff died of a COVID-19 complication and not a delay in care?

· What about patients who could not be seen in person and had only telephone calls or video calls with their physicians?

o Can a physician adequately examine a patient remotely?

o Will there be a different standard of care for telephone or video appointments than there is for in- person appointments?

o Should more patients have been admitted into ERs for immediate care?

· Will doctors who get sued be able to successfully claim that patients were negligent for waiting to seek care until their situations became dire?

Whatever the future lawsuits hold, it will be important to parse carefully which factors actually caused patients’ injuries and/or deaths.

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