The debate over COVID-19 deaths has been waged since the early days of the pandemic. Some have argued that the methods to tally COVID-19 mortality are not reliable and over-state the numbers.
Ironically, those who argue against the accuracy of the systems that measure the human cost of the pandemic may have a point, but not the one they are trying to make.
The widespread impact of COVID-19 on healthcare systems brought by the pandemic has led to deaths that are not a direct result of infection. A letter published in the journal Circulation explains how COVID-19 can increase the risk of death, even in people who are never infected.
Straight to the Heart
An internationally-based survey published in the journal Circulation sought to determine how the COVID-19 pandemic impacted cardiac surgery units (1). Worldwide, 60 of 61 cardiac surgery units contacted completed the survey, including 7 from Asia; 2 from Australia; 31 from Europe; 16 from North America; and 4 from South America. Overall, cardiac surgery units reported a 50%-75% decrease in cases, with a significant correlation with the amount of COVID-19 cases in the regions of each facility. Two-thirds of the cardiac surgery units reported a 50% decrease in bed availability for patients, and one-third of the centers relocated their personnel, most of whom were sent to Intensive Care Units. The combined loss of beds and healthcare personnel caused most cardiac surgery units to reduce surgeries to emergency cases only, with 5% shutting down cardiac surgery all together.
How does the closure of cardiac surgery units due to COVID-19 stresses increase mortality? Centres that defer cardiac procedures due to limited capacity have an increased mortality rate in patients waitlisted for surgery (2,3). A study from Israel found that in-hospital mortality more than doubled for cardiac surgery patients during the COVID-19 pandemic because of delayed access (4). Although the impact of deferred care on long-term morbidity and mortality won’t be known for sometime, early reports and past studies paint a bleak picture for patients with cardiovascular disease.
The Bigger Picture
In addition to cardiac care, surgeries for a number of specialities declined during the pandemic. A study of robot-assisted surgeries in a Paris hospital showed a decline ranging from 49% in oncology to 81% in gynaecology (5). Northwell Health, the largest healthcare provider in New York state, cancelled all non-emergent care from mid-March to mid-May to accommodate for the COVID-19 surge (6). Despite the best efforts to continue care, 42% of cancer patients in Northwell Health facilities experienced some deviation from normal standards of care. The impact of delays in cancer treatment and surgeries is highly dependent on the type of cancer and stage of disease, but delayed treatment can significantly increase mortality (7).
The impact of COVID-19 on cardiac patients is not a new revelation. In the spring of 2020, the number of people dying of heart attacks outside of hospitals increased dramatically in a number of COVID-19 hotspots. This increase in out-of-hospital mortality was attributed to a fear of seeking care in a high risk environment like hospitals and a lack of healthcare resources, which may have caused some treatable conditions to deteriorate and result in preventable deaths (8).
Cardiovascular injury associated with COVID-19 isn’t confined to the heart: the elevated risk of blood clots increase the risk of stroke. Despite the heightened risk, many studies report a decline in the number of stroke patients. Interestingly, the reduced numbers are seen in the less severely ill groups, suggesting that people experiencing mild strokes may decline to seek care out of fears related to the pandemic (9). The tendency to avoid care out of fear of COVID-19 is supported by the significant delay in stroke patients who do seek care (10). Some have suggested that the respiratory distress experienced by the most severally ill COVID-19 patients may cause minor neurological symptoms indicating stroke to be ignored at triage, leading to an under-diagnosis and under-treatment of stroke (11).
Closing the Pipelines of Care
The survey by Gaudino and colleagues reported that 50% of cardiac surgery units prohibited residents and fellows from participating in cardiac surgeries, and 50% of the units suspended all research activity. If the interruption in training for healthcare professionals – who are already in short-supply – is prolonged, it could negatively impact the number of trained medical personnel available to provide care. Moreover, the disruption to research during a pandemic has significant consequences for the ability to gather crucial information needed to solve problems that are constantly emerging and evolving.
Measuring the impact of COVID-19 by using a single number like the mortality rate ignores the scope of its impact. From long haulers who continue to experience effects well after the virus has been cleared, to the families of those sickened or killed, the effects are real, even if they don’t appear in the daily death counts.
The interruption to cardiac surgery procedures is the tip of the iceberg in healthcare. The stress of COVID-19 flows through the medical system and affects even those who are not infected. While the deaths from COVID-19 grow, the hidden costs continue to mount, and the true impact can’t be captured with any number.
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- Gaudino M et al. Circ. 142: 300-302. 2020. doi: 10.1161/CIRCULATIONAHA.120.047865.
- Malaisrie SC et al. Ann Thorac Surg. 98: 1564-1570. 2014. doi: 10.1016/j.athoracsur.2014.06.040.
- Sobolev BG et al. BMC Health Serv Res. 8: 185. 2008. doi: 10.1186/1472-6963-8-185.
- Keizman E et al. J Cardiothorac Surg. 15: 294. 2020. doi: 10.1186/s13019-020-01342-5.
- Blanc T et al. J Robot Surg. Jan 28: 1-8. 2021. doi: 10.1007/s11701-021-01201-y.
- Teckie S et al. JCO Oncol Pract. Feb 2. OP2000619. 2021. doi: 10.1200/OP.20.00619.
- Russell B et al. Eur Urol Oncol. 3: 239-249. 2020. doi: 10.1016/j.euo.2019.09.008.
- Dhuga G and Pyle WG. COVID-19 Resources Canada, Science Explained. 2020. https://www.covid19resources.ca/2020/10/27/the-e-learning-basics/
- Nogueira R et al. Int J Stroke. Jan 18: 1747493021991652. 2021. doi: 10.1177/1747493021991652.
- Montaner J et al. Stroke. 51: 2307-2314. 2020. doi: 10.1161/STROKEAHA.120.030106.
- Friedlich D et al. J Stroke Cerebrovasc Dis. 30: 105639. 2021. doi: 10.1016/j.jstrokecerebrovasdis.2021.105639