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Delaying Care: The Flip Side of COVID-19 in Westchester

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While Westchester focused on getting the coronavirus under control this spring, residents who were worried about contracting it sometimes put their own healthcare on hold. Here’s what the impact of that looks like now.

The Flip Side of COVID-19

Vanessa Solomon did what many people were told to do once stay-at-home orders went into effect in Westchester and across the state in March: She found a way to release her stress and keep her activity level up. The Irvington resident says that when gyms closed, she began doing home workouts and running about three miles as often as four times a week, “because CrossFit is a huge part of my life, so I was looking for a way to stay active, fit, and keep sane.” And then hip pain set in.

“I had had some muscle pains in the past, but this was much more acute, and I realized it was making it difficult for me to sit for long periods of time, which was problematic, since I was remote teaching all day,” says Solomon, a learning specialist at Ethical Culture Fieldston School in the Bronx. She kept working out, and the pain didn’t subside.

Ultimately, Solomon waited about a month before seeking care. “I was definitely afraid of COVID and thought the chiropractic care or caring for my muscles and body were not as important as staying COVID-free; additionally, my doctor was not seeing patients,” she explains. But after being notified that her chiropractor had limited hours and learning about the practice’s safety measures, she finally decided to go.

She’s not the only one. At the start of quarantine, writer Nancy Claus noticed a strange-looking pimple on her face. At first, she figured it would simply go away. “Six weeks later, when it grew to the size of a pencil eraser, I started to worry,” she says, and scheduled a telehealth appointment with her internist.

“She immediately made an appointment with my dermatologist, who removed it and had it biopsied,” says the Waccabuc resident. Claus was diagnosed with squamous cell carcinoma, a common type of skin cancer that is usually not serious but can turn that way if untreated. Shortly thereafter, she had Moh’s surgery to have it removed.

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A Pattern of Procrastination

Solomon and Claus are just two of many examples of people who put off seeking care, particularly during the early months of the pandemic, when many doctor’s offices were closed or running minimal hours, and when elective surgeries were halted throughout the state and the majority of Westchester residents were leaving their homes only to buy groceries. That’s been the trend around the country: A recent CDC report found that nationwide, about four out of 10 Americans had put off care during the pandemic because they were worried about the virus.

Dr. A. Garvey Rene, a clinical and interventional cardiologist at CareMount Medical in Mount Kisco and Fishkill, and the associate director of the cardiac catheterization lab at Northern Westchester Hospital, estimates that from April through about mid-May, in-office volume was less than 40% of the practice’s usual amount. “People were scared,” says Rene.

That fear of contracting COVID-19, whether at the hospital or through an office visit, was at the core of why many people delayed care for both the minor and more acute issues they were experiencing. 

A separate CDC report, released in June, found that from the end of March through the end of April, emergency department visits nationwide were down 42% — with the number in the Northeast closer to 50% — when compared with the same time period in 2019. And while visits for infectious-disease-related reasons skyrocketed to four times the amount from the previous year, visits for things like abdominal pain, muscle pain, chest pain, and strains and sprains, among other issues, all saw significant declines.

In fact, the CDC reported that from March 15 through May 23, across the country, emergency department visits for heart attack were down 23%; visits for stroke were down 20%; and hyperglycemic crisis visits were down 10%. 

As with other stroke centers, the Comprehensive Stroke Center Program at Westchester Medical Center in Valhalla maintains a stroke registry. “We track all of our stroke admissions, and there certainly was a reduction starting in February and March,” says Dr. Ramandeep Sahni, a neurologist who is the head of WMC’s stroke center program. “Now we see that volumes are going back to our normal range.”

That fear of contracting COVID-19, whether at the hospital or through an office visit, was at the core of why many people delayed care for both the minor and more acute issues they were experiencing.

Sahni adds that they’ve done education regionally on the importance of getting to the hospital ASAP after spotting signs of a stroke — particularly since certain treatments are most effective when administered immediately — but found that patients sometimes hesitated if they felt their symptoms were mild. They thought if it was a minor stroke, an outpatient visit would be preferable to the possibility of contracting COVID in the hospital, she says. “Or, they would call the outpatient office, asking, ‘Oh, should I really come to the hospital?’ instead of coming directly to the ER, as they would normally,” Sahni explains. “There [were] a number of patients whom I told, ‘No, you need immediate medical attention. I will meet you in the ER. I assure you that we’ll take all the precautions.”

To that end, WMC created new stroke protocols for patients during this period, including screening and testing for the virus and administering chest X-rays. “All of these things were not normally part of the acute stroke evaluation in the ED,” says Sahni. “But we made a protocol process to assure patient safety and to minimize delays in identifying the patients who need emergent stroke therapy.”

There were additional issues to contend with throughout the height of the pandemic in Westchester, such as deciding how long to postpone an elective surgery or when to proceed with cancer care. This was particularly an issue when elective surgeries — which can range from having a pacemaker put in to doing a joint replacement — were put on hold in March.

“There was a lot of anxiety among our patients,” says Dr. James Peacock, a cardiac electrophysiologist at White Plains Hospital, of patients who needed to have an elective procedure. “I think that it is the conflict of whether is it riskier to have the procedure done during COVID and take the risk of possible exposure or not having the procedure done. That was a fine line we were managing with a number of our patients.” That’s where he says telehealth visits and remote monitoring became crucial. “If I’m asking them to wait weeks to months, I have to follow them much more closely, to see if they hit that emergent category,” Peacock explains.

Dr. Ahmad Raza, director of the Cheryl R. Lindenbaum Comprehensive Cancer Center at NewYork-Presbyterian Hudson Valley Hospital in Cortlandt Manor, and Dr. Stephanie Smith-Marrone, director of NewYork-Presbyterian Lawrence Hospital Cancer Center in Bronxville, offer a similar take. “As an oncology community, we discussed a lot and thought a lot about how we could tailor care and regimens to be safer,” says Smith-Marrone. “That could mean altering the schedule of treatment a little bit, so patients didn’t have to come in as frequently, using telehealth or switching to oral therapies, if possible. And there was a lot done in terms of physical space and screening of patients to help reduce exposure risk for patients and staff.” 

Pause and Effect    

So, what has the outcome of these changes and delays been? While many of the physicians we spoke with said that the data isn’t there yet (it may take another year to get a full picture), there are some preliminary signs of what the impact has been.

For some patients, waiting even just a few hours to seek care made a difference. Rene tells the story of a patient in his early 50s who started having heart attack symptoms at home but was terrified of contracting COVID and waited before coming to the hospital. Even though he survived the heart attack, he did develop congestive heart failure, says Rene. “I think if he had come sooner, especially if he had come in at least within the first few hours, at the onset of symptoms, there’s a strong chance that we could have done more at that time,” he adds.    

For other patients, the effects are more apparent now that scans, screenings, and elective surgeries have resumed.

“Over the summer, I certainly can count more than a handful of patients who presented with more advanced disease” than their initial, pre-pandemic scans showed, says Dr. Ulrich Hermanto, medical director at Montefiore Yonkers Radiation Oncology and assistant professor at the Albert Einstein College of Medicine. Likewise, Raza found that some patients newly diagnosed with cancer “seem to be at quite a higher state, and they were very sick because they were living with the symptoms,” he says, though he and Smith-Marrone caution that it’s hard to predict now what the outcomes will be.

Most physicians’ offices, outpatient clinics, and hospitals are back to seeing patients and performing elective surgeries, albeit with a roster of new safety precautions.

Dr. Susan Haas, an internist at Westmed Medical Group in White Plains, says that she’s had some patients with newly diagnosed breast cancer who might have been diagnosed earlier had not the pandemic forced them to postpone their mammograms, but “I still think they will have great outcomes,” she says.

“I have many patients who delayed their care for one reason or another,” explains Haas. “Every patient I’ve seen is under a tremendous amount of stress, due to social isolation, the loss of family and friends from COVID-19, job loss, financial stress, managing home schooling, caring for elderly parents, and even teachers worried about returning to the classroom. There is a general fear of the unknown and frustration over not being able to plan for much more than next week when it comes to COVID-19.

“These stressors have affected many of my patients’ underlying medical problems,” Haas continues. “I can’t tell you the number of patients I’ve seen whose blood pressure, diabetes, and cholesterol have worsened, and because of this, there are many more people worried about heart disease and stroke. I am also seeing many more patients with back and neck pain and carpal tunnel syndrome. Anxiety, depression, and sleep issues are becoming more commonplace. Unfortunately, some people are coping through increased alcohol intake and restarting smoking. I acknowledge the stress we have all been through; however, we want to get to the finish line with our health intact.”

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The Institutional Impact

As we head into winter, and with Westchester largely reopened, most physicians’ offices, outpatient clinics, and hospitals are back to seeing patients and performing elective surgeries, albeit with a roster of new safety precautions — from symptom screenings and temperature checks to socially distanced waiting rooms and mandatory masks. But they all encourage making those appointments. “In many ways, I feel safer here [at the hospital] than I do at the grocery store, to be honest,” says Smith-Marrone.

Interestingly, the pandemic has produced some unexpected upsides in patient care, particularly with regard to telehealth. Pre-pandemic, only about 11% of people had done a telehealth visit, compared with 46% these days, according to one survey. And more than half of providers surveyed look positively on the practice now, compared with how they felt pre-pandemic.   

Physicians point to their ability to monitor patients more closely and stay in touch should their conditions suddenly worsen. “In some ways, it made the doctor-patient relationship much closer, even though we were virtual,” says WPH’s Peacock, “because there was a reliance upon frequent communication between the physician and the patient, to ensure they were getting their treatment or properly postponing it.” And the communication was more in-depth, too. “Most of the telemedicine visits were very long visits: Usually, they’re scheduled for 10 to 15 minutes, but they wind up being an hour or so,” says Montefiore’s Hermanto.

“I didn’t realize how powerful it was to see patients’ homes,” adds Peacock. With televisits, he could see the flight of stairs a patient had to ascend or how their kitchen was arranged. “Being able to see those things really has opened my eyes to the way patients were handling some of their symptoms at home.”

In what seems like a total reversal, some patients are now seeking care earlier. Peacock has found that new patients “seem to be coming in earlier than I would have expected them to back in February or March,” he says. “For some of these patients, we’re actually catching them earlier in their disease progressions than we may have pre-COVID.” For example, a patient with a history of heart palpitations may have noticed them getting worse because of COVID-related anxiety. In the past, he adds, the patient may not have come in until they passed out at work, but now they’re taking steps to be seen sooner.

“The pandemic has definitely gotten people a lot more health-conscious,” says Rene of CareMount, adding that some patients have an understanding that certain conditions, like high blood pressure, may result in a worse outcome should they actually get COVID. “I’m seeing a lot of patients who are being more proactive about their care, which I think is one of the silver linings of this pandemic.”


Marisa Iallonardo is a freelance writer and editor who often writes about health and wellness. She lives in White Plains with her husband and two young kids.