Hospitals struggle to woo patients to reschedule care
Jim Johnson was elated when his hip replacement, canceled in March along with other elective surgeries, finally was performed in May. For months, his pain had been "God-awful," he said - so severe he couldn't sleep, golf or do his job as a part-time pallbearer. Just a few weeks after the operation, he tossed his cane away.
Hospitals and doctors practices across the country are hoping there are a lot more Jim Johnsons out there - patients willing to shake off fears about the coronavirus and come back for tests and treatments put on hold early in the pandemic.
Yet persuading them to return for non-emergency care is a tricky message right now, with the virus slamming the South and West. In parts of Texas, Arizona, Florida and other states, elective procedures have been halted again. For some patients, the spike in infections is reigniting fears about catching the virus in a hospital or a doctor's office. Doctors worry that could undermine their efforts to win people back, and lead to more lives being lost from other, often preventable causes, such as cancer and heart disease.
"Some patients are afraid to come in," said Peter Shields, deputy director of Ohio State University Comprehensive Cancer Center. He said the hospital is running at less than full capacity and recently ran advertisements designed to reassure patients it was safe to get treatment.
The virus's refusal to go quietly is the latest challenge for medical facilities grappling with new safety protocols, huge backlogs and public anxieties surging along with the virus. Doctors say "elective procedures," including for cancer, can't be delayed indefinitely without ill effects. Hospitals, meanwhile, see orthopedic, cardiac and cancer surgeries as their key to survival after losing billions of dollars on the shutdown of lucrative procedures.
Providers are making some progress luring patients back. Screening tests for breast, colon and cervical cancer, which plunged by 86 to 94% early in the pandemic, were running just 20 to 30% below normal as of mid-June, according to Epic, the electronic health records company.
But many consumers are still hesitant about getting treatment, prompting facilities outside the infection hot spots to highlight new safeguards. The result of this re-engineering is often a more streamlined, less personal patient experience - think "contactless care" - that has its own pluses and minuses.
Johnson's experience, for instance, was drastically different than it would have been just two months earlier. The day before his operation, the 70-year-old Long Island resident went to a drive-through facility at Syosset Hospital to be tested for coronavirus. He was grilled about recent travel, suspicious symptoms and told to self-quarantine that night.
When he returned to the hospital the next day, everyone wore masks and squirted hand sanitizer, and the lobby was eerily empty, a sign of new policies that enforce social distancing. New carpeting and curtains had been installed as part of a deep cleaning that followed the discharge in the spring of the last patient with COVID-19, the disease caused by the coronavirus. Everything around Johnson was wiped down frequently, including his call button. "They couldn't do enough disinfecting," Johnson said.
At the beginning of the outbreak, "the last place you wanted to be was in the hospital," said Stephen Bello, senior vice president and eastern region executive director for Northwell Health, a large health-care system that has cared for more than 17,000 COVID-19 patients and includes Syosset Hospital. "But we understand the virus better and have adapted. Now it's safer to be in our hospitals than in a restaurant or grocery store."
He stressed the importance of personal protective equipment for staff and of separating covid-19 patients from other patients.
Some people are not reassured. Rochelle Sallad was supposed to have bariatric surgery in late March at Henry Ford Hospital in Detroit. After the operation was canceled, the hospital offered her a slot in June but she turned it down. "I want them to do some other surgeries to make sure it's safe for me and going smoothly," said Sallad, 52. She plans to have the operation in August.
But it can also be unsafe to delay necessary care. A Washington Post analysis of federal data found thousands more people died in March, April and May of heart disease and a handful of other diseases than would have been expected.
Now the health-care industry is worried that could happen again, especially in hot spots like Texas.
If the situation "continues to spiral, then people, seeing the news, could decide not to go in when they think they are having a heart attack or stroke," said Tom Banning, chief executive of the Austin-based Texas Academy of Family Physicians.
Much of the concern is focused on cancer patients. People who have cancer - or have had it - are at higher risk from coronavirus, partly because of compromised immune systems. Many doctors urged a delay in care early in the pandemic, but now experts are warning that skipping treatment and screening tests carries its own risks and could lead to thousands of avoidable deaths.
"Cancer is going to kill a lot more people this year than covid-19 - by a lot," said Benjamin Neel, director of the Perlmutter Cancer Center at NYU Langone Health. "You'd have to be crazy not to go see your doctor." More than 600,000 people in the United States are expected to die of cancer this year, and almost 650,000 from heart disease. By comparison, more than 130,000 have died of covid-19.
Doctors already are seeing patients whose cancers have gotten much worse because of delays in care. "Instead of presenting with nausea and a five- to 10-pound weight loss, they are presenting with a 35-pound weight loss and a softball-size tumor in their head," said Debra Patt, an oncologist and executive vice president of Texas Oncology.
Such warnings don't sway some patients, partly because of what they see going on outside of hospitals.
Tomika Bryant, a 47-year-old breast cancer survivor, was supposed to have a mammogram in March, but delayed it when the pandemic hit. Two weeks ago, her doctor called and said, " 'You should go. Things are opening,' " said Bryant, a mother of two who lives in suburban Philadelphia.
For now, she has said no. She said she fears contact with other people who she believes are being careless. When she recently went to a Wawa to pick up a takeout order, she said, the convenience store was packed with people without masks. "I canceled my order," she said. "I don't want to bring anything home to my family."
Anne Marie Mercurio, who had breast cancer and a double mastectomy in 2006, feels the same way. In fall, she had her breast implants replaced because the type she used had been linked to a rare lymphoma. Although she needs additional plastic surgery, she has decided to cancel her August follow-up appointment. She doesn't want to travel from her home on Long Island to Memorial Sloan Kettering Cancer Center in Manhattan.
"There are too many people who are cavalier, walking around without masks on. They are all thinking, 'It's not going to get me.' "
But other patients have headed back to hospitals and clinics, happy to cross delayed treatment and tests off their "to do" lists. They are finding a new world that sometimes feels off-kilter.
When Laurel Pointer arrived for her annual mammogram in June, two months after it was originally scheduled, she followed taped arrows at a Dallas medical facility that showed her where to walk and stand, just like in the grocery store. She had her temperature taken, talked to the receptionist through a plexiglass shield and donned a mask.
"Mammograms are odd enough already," said Pointer, 51, who works at Susan G. Komen, a breast cancer charity. "You are dropping your robe and letting someone put your breast in a machine. But to do it when you are wearing a mask and the technician is wearing a mask - well, that's surreal."
Hugs and handshakes between patients and their longtime providers now are rare. "I tend to touch my patients a lot and there is none of that," said Patt, the Texas oncologist. "That has been difficult." Many facilities are still restricting visitors.
Health care is less personal in other ways as well. When Joni Westawski tore her anterior cruciate ligament, or ACL, she got surgery at UPMC Montefiore Hospital and was "fully confident," she said, about its safety measures. But she never saw the full face of her mask-wearing surgeon, who had occasionally been a lecturer for her undergraduate sports medicine classes at the University of Pittsburgh.
In many hospitals and clinics, crowded waiting rooms are gone; chairs have been removed and the remaining ones are spaced several feet apart. Often, patients are asked to remain in their cars until they receive a text that an examination room is ready.
Before the pandemic, Henry Ford Health System asked patients to arrive early for appointments to answer any outstanding insurance questions. Now it has implemented a "just-in-time" system, with paperwork completed online or in exam rooms. "We don't put anyone in waiting rooms," said Steven Kalkanis, chief executive of the Henry Ford Medical Group.
Few patients were as eager to have treatment as 40-year-old David Ruppel, who was born with a severe heart defect and had heart and liver failure. Recently, he had so little stamina that he had trouble keeping up with his energetic 3-year-old niece.
In March, he was scheduled to go to Ronald Reagan UCLA Medical Center for a final procedure before being put on the heart transplant list. But when the pandemic hit, organ transplants plummeted at the medical center and across the country. Ruppel was in "semi-urgent condition," but doctors didn't want to bring him into the hospital in March or April, said his transplant surgeon, Ali Nsair, so they postponed his appointment.
When Ruppel finally flew to Los Angeles in May, his parents chartered a jet to reduce his chances of contracting the coronavirus. So he was shocked when he tested positive once he got there. He called his father in the middle of the night, distraught.
"I thought I had lost my chance at a transplant," Ruppel said. After spending two weeks at a UCLA Health guesthouse and never developing symptoms, he had two negative coronavirus tests and was readmitted to the hospital. On June 21, he had a heart transplant.
Patients are gradually returning to hospitals and doctors offices. Visits to physicians' offices, which declined 60% from mid-March to mid-April, now are running 20 to 30% below pre-pandemic levels, according to a report by the Commonwealth Fund.
Chris Mast, vice president of clinical informatics at Epic estimated that hospital volume based on revenue is back to 80 to 90%, though several individual hospitals contacted by The Washington Post said their numbers were well below that.
And with elective procedures and screening tests canceled from March until May or June, many hospitals have huge backlogs of patient appointments they are trying to work through, even as they try to see new patients.
Intermountain Healthcare's Breast Care Center in Murray, Utah, canceled 15,000 screening mammograms - used for women without symptoms - when the pandemic hit, then began to perform them again in May. Brett Parkinson, medical director of the center, said an estimated 5 out of 1,000 women who have mammograms will be diagnosed with breast cancer, and hospital officials didn't want to postpone screenings any further.
But even as Parkinson tries to reschedule thousands of tests, the breast care center is operating at two-thirds capacity at most, because of time-consuming cleanings between patients.
"We wipe down everything," said Parkinson. "The mammography paddles, the door handles and the face shields, everything." He's adding night and weekend hours. "Nobody is taking vacation this summer," he said.
Henry Ford, like many health systems, has created a priority system to try to determine which patients need to be brought back first. Patients who need chemotherapy or have heart blockages, for example, get top priority. Someone who needs a knee replacement may be asked to wait a few more months, said Kalkanis.
"The patients with more severe conditions are eager to come back," he said. But about 15 to 20% want to delay. "They are saying, 'I'll wait until August - or next spring - to do my shoulder.' "
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