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How to Capture and Code COVID-19 Correctly
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The unintended mortality brought about by the coronavirus pandemic.
The exact number of deaths from COVID-19 is an area of uncertainty. In the midst of a pandemic, data reporting is likely far down on the list of crucial activities. It remains unclear how to count the death of a patient who dies with evidence of infection by coronavirus, but was never diagnosed with COVID-19. Many people are recovering from COVID-19, and only time will tell if there will be long-term residual organ damage.
Those numbers fail to consider another phenomenon: the number of patients who died or suffered adverse health effects because they did not seek medical care during the public health emergency. From the beginning of the pandemic, doctors have noticed that the volume of patients presenting to the emergency department was lower than normal. Of course, one explanation is that those who used the emergency department for minor issues are seeking care elsewhere. However, there are indications that more serious illnesses are also diminishing in number.
On Twitter, one nurse (@dianajean87) noted that while they normally receive several stroke cases a day being flown into her facility for intervention, she could not recall the last one. And while this is only anecdotal, we are also beginning to see more data. On April 10, the Journal of the American College of Cardiology released a pre-print article titled “Reduction in ST-Segment Elevation Cardiac Catheterization Laboratory Activations in the United States during COVID-19 Pandemic.” This study compared the number of cardiac catheterization lab activations for myocardial infarctions in 2019 to 2020 at nine large academic medical centers from coast to coast and found that there were 38 percent fewer activations in March 2020 (on average, 15.3 per month) compared to the monthly average before the pandemic (23.8 per month).
Explanations for this remain elusive. Could it be that for some, the reduced stress of having to travel to the office every day made a positive difference? Could more people be eating healthier, since they cannot go out to eat? Could an increase in exercise contribute? All of these are possible, but it does not seem likely that a couple of weeks of better diet or exercise could make such a difference.
Another theory is that patients continue to have serious health issues, including heart attacks, strokes, exacerbations of heart failure and COPD, but choose to remain at home, afraid to call 911 and be taken to the hospital. Could they be afraid of catching COVID-19? Could they be concerned about diverting necessary medical personnel away from COVID-19 patients to care for them?
And this is not limited to adult medicine. A pediatrician on Twitter (@racheldawkinsmd) reported that she received a call from the mother of a newborn who was concerned that her 2-day-old baby was “super yellow.” It took the pediatrician 30 minutes to convince the mother to take the baby to the hospital. On arrival, the baby’s bilirubin was 25 (normal is less than 5). If this mother did not seek care, the end result would have been a lifelong disability.
The cause of death for patients who die at home is often elusive, especially in a pandemic. If the patient’s physician feels that his or her chronic illnesses may have led to death, the death certificate is often completed with that information. But there is no way to know if it was treatable. In many cases, though, heart attacks and exacerbations of chronic illnesses are survivable, even without medical care. A patient who has a heart attack but does not seek care could survive, but their heart function will be diminished, depending on how much of his or her heart is damaged. A patient may not present until weeks or months later, with shortness of breath or fatigue, and evaluation revealing the damage. An exacerbation of a chronic disease may resolve, but there may be tissue damage to the brain, heart, or kidneys, manifesting later.
It seems that as we all talk about social distancing, flattening the curve, and the amazing heroics of the many professionals in healthcare, perhaps hospitals need to remind their communities that they are still there to care for all health needs and that patients will be cared for safely and efficiently. None of us want to see an epidemic of preventable morbidity and mortality that should not have occurred.
Programming Note: Dr. Hirsch is a permanent panelist on Monitor Mondays. Listen to his live reporting this coming Monday during a special 60-minute townhall edition of Monitor Mondays, 10 -11 a.m. EST.