Weathered, wiry and in his early 60s, the man stumbled into clinic, trailing cigarette smoke and clutching his chest. Over the previous week, he had had fleeting episodes of chest pressure but stayed away from the hospital.
“I didn’t want to get the coronavirus,” he gasped as the nurses unbuttoned his shirt to get an EKG. Only when his pain had become relentless did he feel he had no choice but to come in.
In pre-pandemic times, patients like him were routine at my Boston-area hospital; we saw them almost every day. But for much of the spring and summer, the halls and parking lots were eerily empty. I wondered if people were staying home and getting sicker, and I imagined that in a few months’ time these patients, once they became too ill to manage on their own, might flood the emergency rooms, wards and I.C.U.s, in a non-Covid wave.
But more than seven months into the pandemic, there are still no lines of patients in the halls. While my colleagues and I are busier than we were in March, there has been no pent-up overflow of people with crushing chest pain, debilitating shortness of breath or fevers and wet, rattling coughs.
“It’s so weird,” a colleague remarked recently. “It’s like those people have vanished.”
I remembered my colleague’s observation when I read a recent study that suggested why those patients have never returned.
Researchers from Sound Physicians, a national medical group of almost 4,000 doctors specializing in hospital medicine, critical care and emergency medicine, and the Dartmouth Institute for Health Policy and Clinical Practice gathered admissions data from more than 200 hospitals in 36 states and compared differences in patient characteristics, diagnoses and mortality rates between February and July of this year with the same time period last year. The researchers found that by mid-April, non-Covid admissions to hospitals had dropped by almost half.
But surprisingly, even months later, as coronavirus infection rates began falling and hospitals were again offering elective surgery and in-person visits to doctor’s offices, hospital admissions remained almost 20 percent lower than normal.
“We found it staggering that such a high number of patients who might have been hospitalized for serious issues just kind of disappeared,” said Dr. John D. Birkmeyer, lead author of the study, chief clinical officer of Sound Physicians, and adjunct professor of health policy and clinical practice at the Dartmouth Institute for Health Policy and Clinical Practice. “You have to wonder, ‘Where did they all go?’”
Some experts have pointed to patients’ overwhelming fear of contagion as a reason for the drop in the numbers seeking hospital care. But the patients in the study who had the greatest persistent drop in hospitalization were those with acutely worsening asthma or emphysema, pneumonias, sepsis, strokes and even heart attacks, all illnesses where hospitalization is generally not optional.
And those who were hospitalized were not necessarily Covid-19 holdouts, so fearful of contagion that they came only when they were at death’s door. Analyzing hospital mortality rates, Dr. Birkmeyer and his colleagues found that apart from a small bump during the early weeks of the pandemic, hospitalized patients without Covid-19 were not dying more than they were before.
Moreover, as the pandemic wore on, fears of getting infected at the hospital may have begun to dissipate. By June, patients were going back to their doctors’ offices, with some specialists like dermatologists experiencing more demand for in-person visits than previously. “If dermatology visits are higher than pre-Covid levels,” said Jonathan Skinner, senior author of the study and a professor of economics at Dartmouth College, “I can’t imagine people not showing up at a hospital if they are having a stroke.”
The most likely explanation for persistent lower hospitalization rates “may simply be that fewer patients are getting sick in the first place,” Dr. Birkmeyer posited. Statewide stay-at-home orders aimed at curbing the coronavirus resulted in a dramatic drop in human activity and a concomitant improvement in air quality across the country. Poor air quality is linked not only to respiratory diseases like asthma and emphysema but also to other illnesses like strokes and heart attacks. Recent reports from around the world have noted decreases in hospitalizations for heart attacks and non-Covid viral respiratory illnesses like influenza during regional lockdowns and quarantines.
Research over the years has also shown that during recessions and periods of higher unemployment, people may at least temporarily adopt healthier behaviors. Individuals may smoke and drink less, get more exercise, improve their diet, lose weight and have less stress related to work or commuting.
Recent public health efforts to promote wearing masks and frequent hand-washing have also probably lowered the transmission rate of other viruses and bacteria that can be responsible for colds, pneumonias and the life-threatening infections or exacerbations of asthma and emphysema. “People keep saying, ‘Hey, I don’t remember the last time I had a cold,’” Mr. Skinner noted. “It’s because no one is hugging or shaking hands, and everyone is washing their hands.”
The published study followed hospitalization trends only through July, but the researchers have continued to gather data which shows that depressed hospital admission rates are persisting into the fall. While both Dr. Birkmeyer and Mr. Skinner concede that more work needs to be done, their study makes clear that the pandemic has had significant public health and public policy implications beyond those directly related to Covid-19.
“All of the things we are doing to reduce Covid shouldn’t necessarily disappear once we have a vaccine,” Mr. Skinner reflected.
He added: “Someday, when Covid is an answer on ‘Jeopardy!’, I hope that we won’t have forgotten the important beneficial effects of reducing pollution and stress on our health in general.”
Dr. Pauline W. Chen, the author of “Final Exam; A Surgeon’s Reflections on Mortality,” is a physician who practices in Boston.
