Quality of care increased, but patients seeking care decreased. Indirect effects of the COVID-19 pandemic and their impact on cardiovascular patients
Understanding how COVID-19 lockdowns may have influenced the health-seeking behaviour of heart patients, as well as delivery of care by specialist services, is vitally important. Leeds Institute for Data Analytics researchers have been at the forefront of an academic collaboration to monitor the impact of COVID-19 on emergency cardiac services, morbidity and mortality rates since 2019. Initially, this collaboration sought to determine whether the first lockdown changed patient response, hospital treatment, and mortality from acute myocardial infarction (AMI). Research continued, offering further insights, not only into the health-seeking behaviour of patients (including during the second lockdown), but also care indicators and a possible link between thromboembolic events and Covid-19.
Prior investigation (link here) by the National Institute for Cardiovascular Outcomes Research was commissioned by the Chief Scientific Advisor to the Government of the United Kingdom, to support the response of the Department of Health to the COVID-19 pandemic in the UK. At the time, the work highlighted the widespread unintended consequences of the pandemic, and sought to minimise them for a potential second wave and beyond. The research found COVID-19 did, in fact, affect care and outcomes of hospitalised AMI. During the first lockdown, government stay-at-home messaging meant patients were wary about attending hospital. Researchers found there was a substantial decline in admissions with AMI. Those who presented to hospital were younger, less comorbid, and had higher 30-day mortality for non-ST-elevation myocardial infarction (NSTEMI).
Current work has involved monitoring progress of AMI patient characteristics, care, and outcomes as the pandemic continues. Access to the datasets required for this study was fast-tracked by adopting a novel collaboration as part of the national drive for research related to COVID-19. Using data from the NHFA (National Heart Failure Audit) and MINAP (Myocardial Ischaemia National Audit Project), the team examined whether the public response to the second UK national lockdown replicated that of the first, using daily incidence data – in the National Institute for Cardiovascular Outcomes Research databank – on admissions with heart failure (HF) and myocardial infarction (MI) among adults, for pre-Covid and post-Covid timeframes.
From March 23, 2020 (first UK lockdown), daily HF and MI hospitalisations decreased by 54%. From the beginning of October 2020, there was a second decline in admissions by 41% for HF and by 34% for MI up to November 17, 2020, compared with the pre–COVID-19 period. In comparison, there was little variation in admissions with HF and MI in the baseline year between 2018 and 2019.
“Last year we saw the impact of Covid-19 and its indirect impact on cardiovascular mortality,” explains Dr Jianhua Wu, associate professor in the Faculty of Medicine and Health at the University of Leeds. “So, we also wanted to look in more detail at cardiovascular care in hospitals during the pandemic. Using the heart failure registry, NICOR data and ONS mortality rates, the team looked at quality of care indicators. We found that during the pandemic quality indicators didn’t get worse, but moderately improved.” This was probably due to fewer cardiovascular patients, with many of them staying at home because of government messaging. The team also looked at a range of conditions, including thromboembolic events and saw these increased with incidence of Covid 19 – indicating there could be a possible link.
With so many different aspects to investigate – including conditions, procedures and outcomes, quality of care, and quality indicators – the interdisciplinary team used the same data as in their original study, but looked at different conditions and different links in the dataset, applying slightly different methodologies compared to before, looking at potential links between Covid-19 infection and outcomes. What they found was surprising. Despite Professor Chris Whitty’s message that, “hospitals are open for business”, a decline in admissions with heart failure and myocardial Infarction (MI) occurred during the second UK lockdown, just like with the first.
The second dip appears of similar magnitude to the first, signalling that the public were fearful of attending hospitals despite having medical emergencies, and that this varies over time – possibly relating to numbers of cases and local mandates. Given that the period cohort for this analysis cannot determine a nadir (lowest possible rate) in admissions, rates of admissions may decline further. Earlier work from the UK described how delays in seeking help were temporally related to an inflation in deaths from a range of acute cardiovascular diseases. Dr Jianhua Wu underscores that this is incredibly important because, “From the initial data outputs, we see a decline in hospital visits for CV patients has a direct impact on mortality outcomes. These are critical, acute conditions. If patients don’t get treatment in time, it has a direct effect on mortality.”
The work has highlighted that clear public messaging is necessary to prevent further unintended consequences resulting from social distancing mandates introduced to reduce the spread of Covid-19. Ongoing work confirms the quality of care in hospital is good, but the message needs to get out to the general public to not delay care and continue attending clinics. Ultimately, this is about saving lives. “When patients attend clinic in time, they have better treatment and better outcomes, including mortality outcomes.” adds Dr Jianhua Wu.
References and further information:
Incidence and mortality due to thromboembolic events during the COVID-19 pandemic: Multi-sourced population-based health records
cohort study (https://doi.org/10.1016/j.thromres.2021.03.006)
Quality of acute myocardial infarction care in England and Wales during the COVID-19 pandemic: linked nationwide cohort study (http://dx.doi.org/10.1136/bmjqs-2021-013040)
Substantial decline in hospital admissions for heart failure accompanied by increased community mortality during COVID-19 pandemic (https://doi.org/10.1093/ehjqcco/qcab040)
Place and Underlying Cause of Death During the COVID-19 Pandemic: Retrospective Cohort Study of 3.5 Million Deaths in England and Wales, 2014 to 2020 (https://doi.org/10.1016/j.mayocp.2021.02.007)
Outcomes of COVID-19-positive acute coronary syndrome patients: A multisource electronic healthcare records study from England (https://doi.org/10.1111/joim.13246)
Second Decline in Admissions With Heart Failure and Myocardial Infarction During the COVID-19 Pandemic (https://doi.org/10.1016/j.jacc.2020.12.039)
For more information on this research contact: J.H.Wu@leeds.ac.uk
Dr. Jianhua Wu