When the COVID-19 pandemic struck and the U.S. essentially shut down, many people put off medical procedures as facilities didn’t have the capacity to see them and patients didn’t want to potentially expose themselves to COVID. A report from the IQVIA Institute for Human Data Science released in May 2020 examined the pandemic’s impact on the U.S. health care system, including huge drops in diagnostic screenings for cancer (SMA 6/1/20, p. 1). Now, more than a year later, data from the institute are showing that while numbers have improved, they have not returned to normal.
“Disruptions from the pandemic that we’ve been experiencing, both the initial shock disruptions last spring and the sustained impact over the entire year, affecting both logistical visits, procedures, diagnostics, but also engagement with preventive screenings and the concern just generally about engagement in health care with potential long-term risks,” still continue, according to Michael Kleinrock, senior director of research development at the IQVIA Institute for Human Data Science.
“There were about 1 billion fewer diagnosis visits in the country in 2020 compared to what we would have expected without COVID,” as well as a drop of around 21% in expected diagnosis visits in 2020, he explained during a recent webinar. “It does vary quite a bit by therapy area and specialty as well, and you would consider perhaps that the missed visits might be more asymptomatic as opposed to a symptomatic patient, who might be more engaged or more motivated, more actually visiting either an emergency or primary care physician or someone else.”
The top impacted specialty-by-diagnosis-visits gap has been oncology, followed by gastroenterology, dermatology, ophthalmology and anesthesiology. “In this context of diagnosis visits, if you imagine you visit your doctor, and they diagnose you with three things, that’s three diagnosis visits,” explained Kleinrock.
“We also have done a little bit of a projection forward through this year, though the mid-year, summer, and it’s down less in some sense, partly because we don’t have the crater in the spring in the dynamics,” he said. “We have, as a country, begun to better adapt to what’s going on with COVID. But this widening gap between the expected and the actual is something concerning.” Total diagnosis visits are down 12% in 2021 compared with baseline, and the total projected number for this year is 288.3 million. “That’s something that we’re watching very carefully as we go forward. It does seem like there’s a sustained sort of disengagement that’s worrying.
“What’s interesting,” he continued, “and we measure this a lot, is whether those missed diagnosis visits translate into less action at the other end of the treatment journey, which sometimes ends up in prescription medicines.” Researchers found that the total projected loss of prescriptions through June 2021 is 111 million. The percent of projected prescriptions lost through June 2021 is 3.8%. Cardiology is expected to be most affected, as well as primary care, dermatology, oncology and pediatrics.
“In this case, we are seeing an impact on prescription medicines, but only down much lower, 3.8%,” he stated. “And if you consider that there are certain acute, episodic events which might result in a prescription that definitively haven’t happened during this COVID period, you would think there’s lots of extra things, but in reality, we’ve hardly had a…flu season in the fall 2020 into 2021. Back in the spring of 2020, there was a significantly lower amount of acute usage of various things — antibiotics and pain medications — potentially linked to elected procedures. So definitely less impact from those [missed] diagnosis visits but still an impact.”
As far as how this translates into prescription usage, Kleinrock explained that the company examines new-to-brand and continuing prescriptions. New-to-brand prescriptions are when a patient is new on that medicine and hasn’t been on it for the last year. They can switch from another product but cannot refill. Continuing prescriptions are when patients are refilling a script. The company uses “calibrated” data “where we create a virtual clean version of 2020 to help us with the analysis without the shark bite taken out” in spring 2020, he said. “The new patients are the ones who have had the problem in terms of this gap vs. what was expected,” down almost 40% at a few points during the pandemic, he observed. “The continuing patients have actually been remarkably resilient” and “are staying engaged, being adherent, but those new ones are missing, and some of that is worrying.”
Not surprisingly, telehealth use has risen during the pandemic. The IQVIA Institute found that “there was a big drop in these diagnosis visits, and they replaced about 10% or 11% of it with telehealth for a variety of things,” said Kleinrock. “Prior to this pandemic, telehealth was much hyped, much vaunted, but not actually something people used a whole lot, but now it’s become a very solid piece of the system, and that’s very helpful. What it has done, though, is you’ve seen that the office visits are down a bit from where they were, and that collective total is still below that 100% basis that we’re seeing, so that’s one of the things we’ve been watching.”
The institute also found that “essentially the early-
peak COVID states [such as] New York, Louisiana and Michigan are now using telehealth much less. They used it in the peak to get around some of our logistical hurdles; it’s declined quite a lot since. The sustained use of this engagement tool will be an interesting question for the new normal going forward.”
With institutional and office medical claims, “the things that I notice and am sort of heartened by is we’re still tracking a little bit below the baseline of the calibrated view,…but the gap is getting narrower,” stated Kleinrock. Institutional medical claims were down 49% at one point in 2020 and down 25% in February 2021, while office medical claims were down as much as 68% in 2020 and down 14% in February 2021. “So there is a little bit of comeback, [but] there may be some system capacity issues, as well as patient engagement issues that are hampering our recovery here.”
Elective procedures were down as much as 86% in 2020 and down 2% in late February. “On the one hand, obviously the patients who had that procedure planned had it scheduled differently, maybe just a time displacement of two or three months,” he noted. “Some of them may have just been canceled, and that’s a concern. So when we’re tracking cumulatively below about 20% — and that’s a quarter of the year, maybe less — that’s not bad. We’ve gotten some of the way back. But there is definitely a concern, and within elective procedures, we have a whole bunch of things that are elective — and ‘elective’ is sort of a loaded term, meaning that they can be scheduled at any time, but you still need them — so when we don’t have them, it could be a problem. It also becomes a problem for the economics of running our whole health system. For provider systems, it also ends up being a question about what the next step is for that patient: If they needed that surgery, if they needed a biopsy, and they couldn’t get it, [over] time, what does that mean? Is it delayed, or is it canceled? And those are things that we keep looking at very closely.”
In hematology/oncology, total claims were down 21% at one point in 2020, rose in November and have stayed above the zero baseline since, most recently up 7% in late March. Cumulative growth, however, is at zero. In hematology/oncology, newly diagnosed claims were down almost 25% for weeks 14 through 23 in 2020 and up 14% in late March of this year. But cumulatively, they are down 2% now.
“If we look at the total claims, there’s definitely a recovery back to essentially normal,” he pointed out. “The newly diagnosed patients are really my worry, and if we think about delayed diagnosis and delayed treatment, we are seeing that gap, and it’s still a couple of percentage points. The worry is the longer that you have that gap, the worse the potential escalation of that tumor could be and the worse the outcomes, so definitely an interesting thing to watch here.”
Oncologic sales year-over-year growth of oral drugs was 21% at the end of March 2020 and at 1% in late March 2021. Sales of intravenous (IV) cancer drugs were down as much as 6% in April 2020, down 9% in early 2021, up 4% in March and then back down 2% and 3%.
“There’s definitely been this sort of scheduling gap” for administration of IV therapies, which have had negative cumulative growth, “and this suggests to me that the immediate drop last spring was the key issue. That recovery has been stable, but obviously we’re not catching up yet. We want to cross over the zero axis, and it’s not happened yet.”
“As we look at the cancer backlog and what we’ve been seeing with claims data and what we’ve been seeing across the experience, I want to point two things out,” said Jon Morris, M.D., vice president and general manager of US Healthcare Solutions at IQVIA, during the webinar. “If you go back to the diagnosis visit, the 1 billion diagnosis visits that did not occur in 2020, the leading specialty in terms of the decreased diagnosis visits per provider is oncology. Smaller numbers certainly with primary care practitioners, pediatricians and others, but the leading specialty by diagnosis visit gap per specialty is oncology. And that’s even more than anesthesia and others where we saw significant disruption in the procedure volumes,…so I think that’s a really important thing as we think about the lens here coming into the oncology community, the oncology backlog.”
Second, as far as the prescription impact, “the oncology prescribing impact is still not back to 100% of baseline, so at 70% of what we would be expecting at this point in time, we have a cumulative diagnosis visit gap from 2020, and we’re seeing fewer prescriptions, fewer new prescriptions in the patient population. We have to look at what that means and how we think about this across the community.”
Researchers found that providers’:
- Average number of cancer patients before the COVID-19 outbreak was 94.
- Average number of cancer patients per week during April 2020 (Wave 1) was 46.
- Average number of cancer patients per week during June 2020 (Wave 2) was 62.
- Average number of cancer patients per week during October 2020 (Wave 3) was 72.
- Average number of cancer patients per week during February 2021 (Wave 4) was 70.
So, notes Morris, face-to-face oncologist visits are still down 70% to 75% since the start of the pandemic. “So we’re not back, and if you think about the diagnosis visit gap, this is what we’re seeing on the survey when we engage with the providers themselves, as well as this slow return, and we’re still not back to 100%.”
During waves 3 and 4, oncologists spent similar amounts of time discussing COVID-19 during patient consultations: 16% during Wave 3 and 18% during Wave 4. The time spent discussing cancer treatment didn’t change, and neither did demand for patient support services. “We’ve seen continuously about 15% to 20% of time being spent with patients being spent on the oncology-focused impacts of and talking about COVID, the impact of COVID as it relates to that individual patient,” he explained. “Coming into October of last year and into February of this year, [there has been] an awful lot of patient-support activity.”
Oncologist surveys found the following information about remote consultations:
- Average patient proportion prior to the outbreak was 5%.
- Average patient proportion during lockdown was 46%.
- Average patient proportion post-lockdown in June 2020 was 31%.
- Average patient proportion in October 2020 was 29%.
- Average patient proportion in February 2021 was 26%.
- Average patient proportion when COVID-19 won’t exist is 20%.
“Most of the oncologists are saying now that as we get into Wave 4, we’re still at 20% to 25% in remote consultations,” said Morris. “These are established patients, and these are patients that didn’t necessarily miss that diagnosis gap visit. These are the ones who are in the system, the ones who are actively engaged in care, so we are seeing utilization of…remote engagement continuing for this population.”
When oncologists were asked what kind of care they are willing to deliver remotely to their cancer patients, findings revealed:
- Discussion of report/test/examinations done: 84%.
- Follow-up consultation: 83%.
- Easy consultation for patients with stable medical conditions: 67%.
- Control/monitoring of adverse events/toxicity/side effects: 67%.
- Discuss the changes in treatment plan/assistance on prescription of any drug: 51%.
- Patients taking simpler chemotherapeutic options can be consulted remotely: 40%.
The institute has seen telehealth claims “dropping off significantly during the past six weeks,” said Morris. “This precipitous drop in telehealth may be a harbinger of things to come as we get back into our face-to-face and our engagement models.”
Delays in surgeries have remained consistently above 70% through all four waves of the pandemic. Fewer diagnoses being conducted have dropped from 55% in Wave 1 to 44% in Wave 4. Delayed chemotherapy visits have remained slightly below 50% through all four waves, and changes in treatment protocol to introduce oral cancer medications whenever possible have risen from 33% in Wave 2 to 43% in Wave 4.
“We are seeing over 70% of the oncologists that we’ve surveyed said that they are still seeing delays, still experiencing delays, and whether that’s a facility logistic challenge, whether it’s patient-specific or” whether it’s due to labs not being able to be done as quickly as they had been before the pandemic, “we’re seeing significant barriers still in access to the procedures themselves,” he noted.
Fewer diagnoses are being conducted when compared to the time before the pandemic: 57% down in Wave 3 and 55% down in Wave 4. Screening for early disease was down more than 80% in both waves, and postponing of biopsies was down more than 70%. Delays in imaging were down 71% in Wave 3 and 64% in Wave 4.
The top three cancer types have been breast, colorectal and lung cancer. “Think about how we get there: From mammographies, colonoscopies, CT scans, the overall decrease in the procedure volume, the decrease in diagnosis-related visits upstream are translating into risk here,” Morris pointed out.
Screenings Are Still Down
Screenings remain down compared with baseline. Mammograms were down 87% on April 10, 2020, down 50% through quarter-two (Q2) and down 20% through Q4 2020. Pap smears had declined 83% as of April 10, 2020, 43% through Q2 2020 and 14% through Q4 2020. Colonoscopies had dropped 90% as of April 10, 2020, 55% through Q2 2020 and 23% through Q4 2020. CT scan decreased by 53% as of April 10, 2020, then 27% though Q2 2020 and 11% through Q4 2020. Prostate-specific antigen (PSA) tests were down 60% as of April 10, 2020, 32% through Q2 2020 and 11% through Q4 2020.
From early March 2020 to early January 2021, “diagnostics used to screen and monitor cancer dropped dramatically and recovered, though an 11% to 23% deficit remains,” Morris observed. Researchers saw “blips” around the Fourth of July and Labor Day “but saw things tailing off” as 2020 came to a close.
Based on positive cancer diagnosis per test and the modeled impact of reduced screening tests through 2020, “nearly 22 million screening tests for five common tumors may be disrupted, risking delayed or missed diagnoses for almost 90,000 patients,” he said. That number breaks down as follows:
- 41,500 breast cancer patients,
- 2,097 cervical cancer patients,
- 24,000 colorectal cancer patients, and
- 678 lung cancer patients.
There are three significant concerns affecting cancer patient engagement, leading to reduced screening and testing, diagnoses and treatment.
“We can talk about supply and access and availability of clinic visits to practitioners, we can talk about telehealth, [but] there is an element of patient reticence to engage right now,” asserted Morris. “We’ve seen it — we’ve seen it across health systems, locations, geographies. In the setting of COVID and the pandemic, the challenge of getting patients to engage I think is a real one for us to be thinking about.”
“The second thing is just the reality of reduced system capacity,” he continued. “Staffing adjustments, having to change the workflow, adjusting the scheduling frequency, cleaning the rooms and wiping rooms down after patients, all of that has rolled together both on risk mitigation, as well as some of the standard social distancing measures that have been implemented from a public health standpoint.”
The third factor is “health service disruptions, procedure-related disruptions. When all of our anesthesiologists and our nurse anesthetists and our intensivists were focusing on all of the patients in the ICU, that redeployment of resources, that reprioritization of services has had an effect on the ability of cancer patients to get in to have these initial diagnosis visits and to be able to go through the appropriate screening.”
IQVIA has found that a variety of stakeholders — not only hospitals and providers but entities such as patient-advocacy groups and pharmacists — are taking actions to address the cancer diagnosis backlog, including reprioritizing health services activities, developing new protocols, restructuring workflows, using pharmacists more effectively and developing patient communication and awareness programs.
“Getting patients back in the flow is a critical thing for us,” maintained Morris. “We’ve got a structural systemic problem that we need to be thinking about.”