How COVID-19 created a healthcare backlog

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At the start of the coronavirus pandemic, hospitals and healthcare facilities across the country halted non-essential and elective procedures to mitigate the spread of the disease. While it may have been the right call to help flatten the curve, the decision also delayed millions of women from having routine mammograms to detect breast cancer. Scientists from across Penn worked together on a study with Independence Blue Cross, using the company’s insurance data to quantify the effect of the pandemic on screening and diagnostic mammograms. The study, titled “Disruptions in Preventive Care: Mammograms during the COVID-19 Pandemic,” was recently published in the journal Health Services Research. Hummy Song, professor of operations, information and decisions at Wharton, and Aaron Smith-McLallen, director of data science and healthcare analytics for Independence Blue Cross, are two of the co-authors. They joined [email protected] to share the results of the study.

Listen to the podcast at the top of this page or read an edited transcript of the conversation below.

[email protected]: Professor Song, can you tell us what the main conclusions of your study are?

Hummus song: First of all, we found that in the 20 weeks from mid-March 2020, when it all kind of fell apart, to the end of July, the volume of routine screening mammograms dropped by 58 %. If you just focus on the first four weeks of that timeframe, we see a 99% drop, so it’s completely dropped.

You might think that with routine screening mammograms, it’s okay to skip a year or delay them, because it’s just preventative. But we also looked at what happened to diagnostic mammograms – these are the types that are done when breast cancer is actually suspected. We have also seen very significant drops in the volume of these. In the first four weeks these dropped by 74%, then over the 20 weeks of our study they dropped by 38%.

[email protected]: It’s amazing. But your data showed that the number of tests rebounded in the summer months, after those early months of COVID. Doesn’t that mean there is no longer a problem?

Song: I would say there is both good news and bad news. The good news is that yes, volumes started to rebound in mid-May in terms of diagnostic mammograms. By the end of our study period in July, diagnostic mammograms had recovered to levels similar to previous years. But for screening mammograms – the routine ones – at the end of July, they were still about 14% lower than what we expected them to be.

“In the worst case, we see that this backlog is going to continue to grow.” –Hummy song

Even though volumes have largely recovered for many of them, especially for diagnostic mammograms which are really important, the bad news is that there have been a lot of mammograms that have not been done during this time. intermediate. This is what we will call missed mammograms. In the document, we did some calculations to predict how long it would take to clear that whole queue of missed mammograms that had built up over those months. Best case scenario, it will take at least 22 weeks, and that takes into account all the things you have to think about in terms of reducing capacity so that we can have more space in the waiting room, and have longer hours so that we can accommodate patients maybe evenings or weekends, just to get those numbers back.

In the worst case, we find that this backlog will continue to grow. This means women won’t be able to catch up on missed mammograms.

[email protected]: Dr. Smith-McLallen, can you tell us about the data you used in this study? Your company, Independence Blue Cross, was instrumental in this research, right?

Smith-McLallen: That’s right. Independence Blue Cross and Penn, especially Wharton, have a very strong research collaboration on many fronts. In this case, we used anonymized medical claims from 2018 through July 2020. We identified the diagnostic and screening mammograms Hummy just described, using the Healthcare Common Procedure Coding System (HCPCS) codes on those claims. The data represents both our commercial policyholders and our Medicare members – women over 40 who are eligible. This is the age when mammograms begin to be recommended. The data comes primarily from women who live in the Philadelphia Five Counties area, which is our primary service area, and historically represents 240,000 screening mammograms and approximately 66,000 diagnostic mammograms included in the study.

We can see what happened in the early years and then compare it to what happened more recently, which makes it more compelling to attribute mammogram declines to the onset of COVID, because we can see previous trends of previous years.

[email protected]: These numbers represent real people and real cases, don’t they?

Smith-McLallen: Absoutely. It’s at the heart of it. These are not only interesting graphs and statistics, but these are real women who were unable to get the screenings and care they needed at that exact moment. We may have real implications that we are trying to circumvent.

[email protected]: What are the data gaps?

Smith-McLallen: Our data typically represents about 50% of the commercially insured population in the Philadelphia Five Counties area. Independence has a strong imprint in this area, but we do not have data for a significant number of women eligible for screening. So if they are not insured or covered by a different commercial plan or by a traditional Medicare or Medicaid plan, those are obviously not represented in our data. We have a little blind spot there. Our data tells the story of a considerable portion of the women in our communities, but certainly not all of them. There are people we missed.

“These are real women who weren’t able to get the testing and care they needed.” –Aaron Smith-McLallen

Interestingly, however, we know that compliance is generally higher for commercially insured women. The results we have may not be representative of all members of our population, but I think the declines we see relate to those who may have been most likely to get tested. In other populations, the story might even be a little worse, unfortunately.

[email protected]: In your brief, you wrote that health care systems need to find a way to optimize care for all patients during the pandemic because preventative screening like mammograms will catch problems early. We are now in the second year of the pandemic, and there are strain variants of the virus. What are the researchers’ concerns?

Song: One thing to note [regarding] that best case scenario I told you about earlier [is that] we are already far beyond the point where we can even dream of achieving it. As we both mentioned, the study ended with data collected through the end of July. You can imagine that other cases of missed mammograms have since piled up. The pandemic is ongoing and the number of cases is still incredibly high. There will be additional unperformed mammograms that you can consider as essentially adding to this queue of missed mammograms.

But I want to say something positive here as well, which is that the environment we find ourselves in now in terms of health care delivery systems is really different from what we saw in March and April 2020. Many of these health systems, rather than closing completely for all types of elective care and non-urgent care, now remain open. As a patient with a non-urgent or elective need, you can come in and be seen for any care issues you may have. It means more people come in. They get their diagnostic mammograms done, often even their screening mammograms, whether they were carried over from last year or are due next.

“Go get your breast cancer screening. Don’t neglect other preventative care. –Hummy song

Smith-McLallen: We are concerned that people are forgoing the care they need that can identify the disease. Not just mammograms and breast cancers that we’re talking about here, but there are other cancer screenings and chronic disease screenings that people may not get. Early detection of the disease is essential to help delay the onset and manage the disease and even cure it. So we are really concerned about the progression of the disease and the increase in morbidity that results from the delay or abandonment of care. It may be out of fear of going to the doctor or the hospital, or [difficulty] get appointments as providers try to manage patient flows. And certainly, it is for the sake of safety to go to the hospital or to the point of care.

At Independence, we work closely with our vendors to support telemedicine services. I know it’s not particularly helpful with mammograms, but in other cases it’s really helpful in facilitating clearances and really trying to partner with our providers to make things easier and care more available .

[email protected]: What would you say to women who are still reluctant to schedule their mammograms for fear of contracting COVID?

Smith-McLallen: In our study, we estimate that between March and July 2020, there were approximately 39,000 missed screening mammograms. Statistically, this translates to between 200 and 320 women who experienced a delay in breast cancer diagnosis. So I think it’s really important that they continue to get tested. We’ve come a long way in treating breast cancer, and early detection is key to achieving a positive outcome. Although the percentages may seem low, it affects a substantial number of women, and getting this early detection is extremely important.

Song: Go get your breast cancer screening. Don’t overlook other preventive care for which you should also consult your provider and get checked out. Providers really pay attention to the kinds of safety measures they implement — not just for their patients, but for themselves as well. We also need our providers to stay healthy.

If you are concerned, call your provider’s office. Ask them to explain what your visit will be like and what kind of safety protocols they have in place. I hope this will make you more comfortable with your routine care.

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