The Veriblog

Diagnosis in the age of COVID-19

To provide these insights, Verilogue engaged in voice-enabled pulse surveys with healthcare professionals and analyzed 54 responses collected July 30 – August 3, 2020

Verilogue is chronicling the impact of COVID-19 across the care continuum, focusing on the shared experiences of healthcare providers and their patients.  To further understand the impact of COVID-19 at the beginning of the patient journey, Verilogue raised the following question to Specialists (Allergists, Cardiologists, Dermatologists, Gastroenterologists, Nephrologists, Infectious Disease Specialists, Oncologists, Neurologists, Rheumatologists, and Endocrinologists):

“How, if at all, is the COVID-19 pandemic affecting the diagnosis of new conditions in your practice at this point in time?”

These physicians share a range of experiences pertaining to the impact of COVID-19 on diagnosis, and view this experience through their own unique lens.  While these experiences vary by individual, most agree that COVID-19 is negatively impacting the diagnosis process, though this reasoning is nuanced, and varies by situation.

Multiple delays outside of the specialist’s office impact time-to-diagnosis, with many characterizing the root cause of the delay in diagnosis as “patient fear”.  This indicates that patients continue to be afraid to come into the office, despite additional public information and initiatives emphasizing safety, thus resulting in reduced patient volumes and subsequent delays in diagnosis.  Indeed, most HCPs continue to report lower in-office patient volumes compared to pre-COVID levels, though this has been increasing in frequency over the past several weeks/months.

“Yes. [COVID-19] is affecting a lot. Uh, patients are, um, scared. They are staying at home, so they are not coming, um, to the clinic. Um, they’re not getting blood work done. So, yes, it is affecting the practice a lot.” – Endocrinologist

“Because of COVID-19, uh, patients are not, not coming. They are delaying visits to the office. Even those who are, uh, needing treatment are delaying, uh, visits to the office.” – Infectious Disease Specialist

When patients ultimately prioritize seeking medical attention over concerns of exposure to COVID-19, they may present to their HCP with greater disease severity.

“I think I have seen a few patients who presented with disease that was more advanced than where we should have diagnosed them, and that was probably a direct, um, attribute to, to delays incurred during the COVID pandemic.” – HEM/ONC

COVID-19 has had a significant effect on the ability to diagnose patients. With diabetes, patients have not been going for blood tests. So, in many cases they have developed symptoms of polyuria, polydipsia… And in some cases, it was new onset diabetes.” – Endocrinologist

An additional stated reason behind the decrease in specialist office visits is due to perceived PCP ‘bottlenecks’ which are limiting new patient referrals.  Despite specialists reporting that they are able to maintain an adequate level of existing patient care, reduced staffing and availability at Primary Care practices, combined with ‘patient fear’ of attending an in-office visit, are leading to fewer referrals to specialists, which leads to delays in diagnosis when the referral ultimately occurs.

“There’s been some delay in the referral process. So, I think there’s been a delay in the diagnosis because they’re not coming to the office as quickly. But when they come to the office, my diagnosis would take about the same amount of time. But I would say some of these patients have had symptoms for two or three months and just haven’t gone to the doctor and have not been referred until now.” – Neurologist

When the new patient referral occurs, specialists often rely on testing to support the diagnosis process, of which telemedicine does not currently provide a suitable alternative.  Therefore, some physicians are utilizing messaging to drive urgency around the importance of a proper in-person consultation, and are emphasizing safety to provide assurance.

“COVID-19, um, has not allowed patients to come in as freely to the clinic to get, um, to get examined and have the, uh, history and physical taken. Uh, during the height of the pandemic… we were doing a lot of telemedicine visits. Now that our regional numbers have decreased, we are encouraging patients to come in over the summer so that we can do an examination and a proper office visit, uh, informing the patients that they are coming in for, due to regional numbers being low. And it is good to have a full exam just in case the fall numbers show an uptick of COVID-19 and patients are, and the stay at home order goes back into effect.” – Nephrologist

“We do some telemedicine, very little, actually. I’d say it’s, uh, one percent of less of my visits. Um, I’ve literally done it about three or four times. Um, the problem is our patients need labs, they need to be examined and, um, rather than send them to a commercial lab and then come, and then do a telemedicine, uh, I think it’s safer to come here and, um, than it is to go to a commercial lab. So, we encourage our patients to come here, do their labs, get examined, have face to face, um, but with, you know, masking and distancing, etc.” – HEM/ONC

Allergists and Endocrinologists are particularly impacted by new testing protocols, as some report that they are unable to utilize spirometry, FeNO testing, blood tests, or food challenges to aid in their diagnosis due to safety concerns.  Restrictions around use of nebulizer treatment and immunosuppressive medications are also presenting challenges at the time of treatment. 

“It’s been a problem. I cannot use spirometry. I cannot do, uh, FeNO and I also cannot do food challenges safely. It’s been a problem with both diagnosis and treatment. Additionally there has been no nebulizer treatments allowed.” – Allergist

“I’m having major problem in making diagnoses of asthma and also patients who have allergic rhinitis and underlying environmental allergy or food allergy because these patients are not able to come to the office, and they are not able to get the breathing test done. These are patients who are not able to get allergy skin testing done, so I’m struggling to make a diagnosis.” – Allergist

Additionally, delays in getting scans, biopsies or tests because of hospital restrictions and new protocols are also noted as factors in delaying diagnosis.  Some practices require a negative COVID-19 test prior to the in-office consultation, which further adds to the timeline.

“…We have several diagnostic facilities in and around the cancer center, such as, um, hospitals, biopsies are delayed. Um, elective surgeries for, um, oncologic procedures have, um, been delayed. Primary care offices, um, are operating at less than full capacity and, and the new referrals have been delayed, um, or less than what it usually used to be. Um, that has affected, uh, uh, patient volumes that, uh, comes to our cancer center.” – Oncologist

“And once I have a suspicion that the patient has any problems, then I send the patient to have any tests. I would require to have a COVID test prior to the test. So, that usually take one or two days. And, um, amount of the tests that we do per day seems to decrease due to the staffing is not up to the maximum.” – Cardiologist

Some note that as the pandemic goes on, more patients are losing insurance, causing further diagnostic and treatment delays.

“We are finding that a lot of patients have lost their insurance or have increased enrollment in Medicaid. So, we are having certain delays in getting patients scans scheduled and also confirming their insurance before proceeding with, uh, seeing the patient and ordering the appropriate test. The, uh, second thing is that, uh, we have had to make some, uh, adjustments to chemotherapy protocols and or delay, uh, chemotherapy, uh, in patients, uh, who are on palliative treatment.” – HEM/ONC

Delays are occurring at the point of diagnosis, due to both direct and indirect effects of COVID-19.  Despite recent improvement, physicians continue to see reduced in-person patient volumes due to patient fears of contracting the virus.  PCPs ‘bottlenecks’ are limiting new patient referrals to specialists, and when patients ultimately prioritize seeking treatment over their virus fears, they may present with greater disease severity.  Testing delays are widespread due to logistical issues (e.g. reduced staffing/backlog of tests at testing centers), and this compounds the diagnosis process for specialists who rely on tests which need to be performed in-person (e.g. biopsies, spirometry, FeNO, allergy tests, etc.)

However, despite these current concerns at the point of diagnosis, and the looming uncertainty of what the fall and the next few months will bring, there are signs of hope.  Patient volumes are increasing, and some HCPs express optimism about the future for telemedicine due to the massive and rapid increases in adoption that were driven by the pandemic.  To quote the words of one physician:

“All this will hopefully lead to potential regulatory and reimbursement and restructuring and I’m optimistic that the volumes will return close to baseline albeit gradually. And that, and you have widespread telemedicine updates will revolutionize the field of healthcare as really it was grotesquely underutilized prior to this pandemic.” – Endocrinologist

Best of health,

-Verilogue

The insights presented in this content piece were developed through a collaborative effort across Verilogue’s research team

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