‘Collateral damage’: Wait times, cancellations hit health care outside of COVID-19

The coronavirus outbreak in Canada has led to an all-hands-on-deck scenario in health care, leaving some doctors worried about those who need other kinds of care.

The World Health Organization made it clear Monday that while COVID-19 has the spotlight, other “essential health services must continue.”

“Babies are still being born. Vaccines must still be delivered. People still need life-saving treatment for a range of other diseases,” the WHO said.

For COVID-19, the directions are clear: Canadians should stay home, self-monitor for symptoms, and self-isolate for 14 days if they’ve travelled outside of the country.

The measures are meant to mitigate the spread of COVID-19 and keep unnecessary pressure off an already overburdened health system.

But for those with health issues unrelated to COVID-19, it creates a complicated grey area.

“I would say there’s a surge of people not seeking care because they think they can wait or they’re not sure. They’re being less likely to seek care for an issue that may end up being something serious,” said Ritika Goel, a family physician in Toronto.

“People are going to change their behaviour because of their fears around going into the health care system or not wanting to go to the emergency room. For some people, that will be the appropriate decision, but for other people that might be an inappropriate decision.”

General care and chronic pain

The barriers to care patients are facing right now are extensive, Goel explained, and have the capacity to create “unintended consequences” for many people, particularly the most vulnerable.

Those barriers can further disenfranchise the homeless or those who use drugs and require specific care. But it also has a cascading effect on treatment for common illnesses.

It’s forcing health care providers to be more creative — and to go increasingly digital.

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Keeping with global physical distancing measures, many physicians and specialists are turning to phone and video appointments. While the teleconferences are effective for some people, it’s insufficient for others, said Goel.

She used chronic pain as an example of where this doesn’t work.

“We have services like physiotherapy, chiropractic, massage therapy, which are considered non-urgent but very hands-on. They’re generally being put on hold. Those things are understandable, it’s just that they also have these unintended consequences,” she said.

“I’ve seen the term ‘collateral damage’ used, and that’s my concern — the collateral damage on people with mental health issues, chronic pain, even people with a cancer diagnosis are having their treatments delayed.”

The WHO has published guidelines to help countries balance the demands of responding to COVID-19 while maintaining other essential health services.

It lays out recommendations for how to reorganize and maintain access to services, provide treatment for other illnesses and mental health conditions, rapidly redistribute health care workers, and maintain essential equipment and supplies.

Sexual and reproductive health

Adapting to changes under COVID-19 has been half the battle for Dr. Dustin Costescu, an OB/GYN at Hamilton Health Sciences, and a professor and family planning specialist at McMaster University.

“We’re seeing the highest risk patients and we’re deferring the low-risk patients. But that dovetails into who decides which issues can wait and who decides what a negative outcome is?” he said.

“Physicians and specialists are resource managers. We’re used to rationing care in the sense that, for each referral we get, we decide whether they need to be seen urgently, not urgently, or by someone else.

“What’s different is that we believe a person should be seen, and now we don’t have the capacity to see them. That’s the hard part.”

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The answer isn’t always obvious either, he said — especially now. Access to contraception and health care for transgender Canadians are two things he worries may get sidelined as physicians try to find a balance.

“Unintended pregnancy isn’t risk-free. Birth control needs historically tend to go up in a period of crisis. If on top of a pandemic we have a baby boom, that will also put pressure on the system. But the system might not see that as a top priority right now,” he said.

“For trans care, there are people who are on medications that have been shown to reduce suicide risk and improve quality of life. If those resources dry up, there could devastating negative consequences for patients.

“It might seem like a simple thing, but an injection does have life-saving properties to it for other reasons.”

Costescu, like many other specialists, is having to defer certain appointments. He says it normally takes one to two years from being referred to his office to get an appointment.

As cases of COVID-19 continue to rise in Canada, he fears it will only get worse.

“It hurts my heart knowing that patients that have already been asked to wait two years now may be waiting 30 months to be seen,” he said.

Cardiac and transplants

The need to find a balance is also being felt in the way hospitals are scheduling and managing vital surgeries.

Beate Sander, the research chair in the economics of infectious diseases at the University Health Network, and her colleagues are researching how redeploying hospital beds and equipment for COVID-19 patients is impacting other fields of care.

They’ve so far highlighted transplant patients and cardiac care as part of that possible “collateral damage.” She said aside from urgent cases, many of these procedures have been delayed.

While she says it’s “not rocket science” that reducing clinical services — especially for an extended period of time — will impact non-COVID-19 patients, physicians are increasingly facing complex scenarios that ride on their decision-making.

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“Transplant patients need intense immunosuppression after they get a transplant, which makes them very vulnerable for COVID-19… In cardiac care, they’re also among the high-risk groups for COVID-19, but they’re also at risk for deteriorating while waiting,” she said.

“Most of those procedures require hospital stay or ICU stay. So if they go and get the procedure, they could be exposed, but if they don’t go, they may deteriorate and then require hospitalization, which can have even worse outcomes and a higher probability of death.”

While more complicated, one thing is clear: “Healthcare is available,” Goel said.

“Don’t assume you can’t get care. Make sure you’re getting the right information and speaking to the right professionals to determine the urgency of your issue. We should be meeting people’s general needs and not just their COVID-related needs right now.”

“Patients need to know that we are still working and we’re still here for you,” Costescu added.

“So reach out to your doctor if you have questions, because that five minutes to reassure you over the phone may be all you need.”