Throughout the pandemic, thousands of Americans have had to make difficult decisions about the value and safety of minor procedures, annual checkups and preventative care measures such as colonoscopies and mammograms. The question of whether medical appointments are worth the risk of contracting Covid-19 in a doctor’s office has created a dangerous culture in which each visit requires an impossible risk-benefit analysis . Data from the Health Cost Institute demonstrated that, by mid-April of 2020, childhood immunizations were down by 59%, mammograms were down by 76% and colonoscopies were down by 88%, as compared to data from April of 2019 . While many of these services have had a substantial rebound to pre-pandemic numbers in recent months, the impact of foregoing preventative care measures, specifically those related to early detection of cancer, may not be known for years to come.
According to Dr. Alon Bergman, a researcher at the Leonard Davis Institute of Health Economics, the decline in routine screening mammograms and diagnostic mammograms has led to a backlog, which will only continue to grow as people feel more comfortable going to clinics and hospitals for the procedure . Many patients who are due for preventative care procedures and checkups are not able to schedule appointments due to this backlog. Bergman’s analysis of mammogram trends showed that even patients with prior breast cancer diagnoses had a 40% reduction in screening mammograms and 30% decrease in diagnostic mammograms between March and July of 2020 . Of the pool of data Bergman analysed, the percentage of missed screening mammograms translated to approximately 200-320 cases of delayed breast cancer diagnoses, of which 130-200 would be cases of invasive cancers . The Breast Cancer Now charity predicted that almost 9,000 women in the UK who missed mammograms due to the pandemic are living with undetected breast cancer . When discussing the health implications of the pandemic, not many people think about the impact of reduced diagnostic and preventative care measures. These statistics demonstrate the shocking and pervasive impacts of lost appointments on people’s health.
However, hope is not lost. Hospitals and clinics are finding new ways to meet the shifting demands related to preventative care during the pandemic era. In a September 2020 interview, Dr. Alexander Ding described how advancements related to telemedicine have introduced several options for select preventative care measures, such as colorectal cancer screenings . Patients are briefed in a virtual visit, and then a test kit is sent to their home. These at-home resources are helpful for mitigating anxiety associated with deciding whether to go for in-person appointments. Moreover, telehealth and at-home screenings are not only safer options for patients, but also protect healthcare workers by minimizing contact.
While there is certainly value in the expansion of telemedicine usage, it also presents several difficulties. In order to effectively participate in telemedicine, you must have a secure internet connection and access to a computer or device in a private location, a “luxury” that not all patients enjoy. Moreover, only 26 states require private insurers to cover healthcare services delivered through telemedicine . These financial and sociological considerations illustrate how telemedicine is a service catered towards a wealthier demographic and cannot completely alleviate the growing need for routine screening.
In addition to the increased usage of telemedicine, the pandemic has uncovered other questions about the efficacy of existing health structures as they relate to preventative care. In particular, the concept of the ‘routine annual exam’ is being scrutinized. Physicians Daniel Horn and Jennifer Haas at Massachusetts General Hospital argue that the US healthcare system should embrace this moment of readjustment in the delivery of preventative care to shift from face-to-face annual exams to focusing on population health and community based initiatives . Named strategies would include “clinical registries that readily identify all preventive services for which a patient is due; annual prevention kits for patients that facilitate widespread deployment of home-based testing, shared decision making, and self-scheduling of preventive screening tests and procedures in more convenient and approachable community settings; and robust community-based strategies involving navigators to overcome health disparities in underserved populations” .
As we think creatively about how to increase health equity for people of all races, socioeconomic groups, gender identities and geographic locations, it is important to recognize that annual physical exams are far more common among white, wealthy populations . Therefore, passively continuing to rely on annual exams as the main form of preventative care will not effectively address existing disparities in health. These are the same disparities which have been highlighted by the progression of the pandemic in which we see Black, Indigenous and People of Color (BIPOC) being hospitalized due to Covid-19 at far greater rates than white people. Horn and Haas argue that we must shift our focus towards a population-based prevention strategy in order to both improve health outcomes as a whole as well as create a more racially and culturally competent preventative health system .
While the impact of missed mammograms, colonoscopies and immunization appointments cannot be known for years to come, Covid-19 has presented us with a watershed moment to creatively reassess how we deliver and access preventative care in ways which will reduce health disparities and promote equity.
Edited by: Julia Bulova
Illustrated by: Noor Ghanam