Fear of seeking care
in hospitals overwhelmed by the pandemic may have caused thousands of deaths,
experts say
By Reis Thebault, Lenny Bernstein, Andrew Ba Tran and Youjin Shin
July 2, 2020
The coronavirus
killed tens of thousands in the United States during the pandemic’s first
months, but it also left a lesser-known toll: thousands more deaths than would
have been expected from heart disease and a handful of other medical
conditions, according to an analysis of federal data by The Washington Post.
The analysis suggests
that in five hard-hit states and New York City there were 8,300 more deaths
from heart problems than would have been typical in March, April and May — an
increase of roughly 27 percent over historical averages.
That spike
contributed to Illinois, Massachusetts, Michigan, New Jersey, and New York
state and the city having a combined 75,000 “excess deaths” during that period, 17,000 more than the number
officially attributed to covid-19, the disease the virus causes.
While several experts
said some of the excess deaths in the analysis were almost certainly
unrecognized fatalities from covid-19, the review suggests that many patients
suffering from serious conditions died as a result of delaying or not seeking
care as the outbreak progressed and swamped some hospitals.
Normally, heart
disease is the leading cause of death in the United States. But in the early
months of the pandemic, some hospital departments were nearly devoid of the heart,
cancer, stroke and other patients who populated them before.
Looking at the
analysis, more than 50 patients a day “died excess deaths just from heart
disease, just in New York City,” said John Puskas, chairman of cardiovascular
surgery at Mount Sinai Morningside Hospital in Manhattan. “Frankly, that would
explain where all the patients went.”
The analysis of data
from March 1 to May 30, using a model previously developed by the Yale School
of Public Health, shows heart disease is the major driver of excess deaths,
excluding those officially attributed to covid-19.
As states in the
South and West restart their economies and see new cases surge, the excess
deaths should serve as a cautionary tale, said Nahid Bhadelia, medical director
of Boston University School of Medicine’s Special Pathogens Unit.
“This data underlines
the importance of not letting our health systems get to the point where they
are so overwhelmed that it spills over and affects people with other medical
conditions in our community,” she said.
The number of excess
deaths in the United States during the pandemic far surpasses the number
officially attributed to covid-19, analyses have shown. The official death
counts from the disease are incomplete, according to experts, in part because
it spread for weeks before testing was widely available and because the virus
kills in a variety of ways that were not recognized early on.
But several experts
said the spikes in the causes of death in the new Post analysis suggested a
deadly collateral effect of the pandemic. They said the surge in deaths from
heart disease and several other conditions matches what they saw in clinics and
hospitals and confirms their fears that many patients died after not seeking
care.
“This is in line with
what we were scared of happening: that we were missing people beforehand and
that people were dying of other diseases,” Bhadelia said.
Deaths due to heart disease
Total weekly deaths Expected deaths
Illinois March 1May 305001,0001,500
Massachusetts March 1May 305001,0001,500
Michigan March 1May 305001,0001,500
New Jersey March 1May 305001,0001,500
New York* March 1May 305001,0001,500
New York City March 1May 305001,0001,500
*New York totals do not include New York City,
which is charted separately.
New York City, which
reports its covid-19 statistics separately from the state, quickly became the
epicenter of the pandemic in the United States and saw more than 4,700 excess
deaths from heart disease — more than four times the number of any other jurisdiction
The Post examined.
Puskas said that even
at the height of the outbreak, when his hospital was nearly overwhelmed by the
pandemic response, it didn’t turn away anyone seeking heart care. Yet the
number of cardiovascular patients showing up remained low, he said.
Health-care providers
everywhere are now reckoning with the consequences.
“All those patients
that would typically have been there having cardiovascular care were not
there,” Puskas said. “Those who would’ve had emergency lifesaving care did not
receive that care, and they then became one of the statistics on your chart.”
In many cases,
experts said, patients suffered through cardiac events, strokes, hyperglycemia
and other health difficulties at home, likely fearful of seeking care in
hospitals where large numbers of people suffering from covid-19 were receiving
treatment.
Between March 15 and
May 23, visits to hospital emergency departments declined 23 percent for heart
attacks, 20 percent for strokes and 10 percent for high-blood-sugar crises — a
complication of diabetes — when compared with the previous 10 weeks, according
to a report last month from the Centers for Disease Control
and Prevention. “The striking decline in ED visits for acute life-threatening
conditions might partially explain observed excess mortality not associated
with COVID-19,” the researchers wrote.
Deaths due to diabetes
Total weekly deaths Expected deaths
Illinois March 1May 3050100150
Massachusetts March 1May 3050100150
Michigan March 1May 3050100150
New Jersey March 1May 3050100150
New York* March 1May 3050100150
New York City March 1May 3050100150
*New York totals do not include New York City,
which is charted separately.
And in a separate excess deaths analysis, the CDC estimated that
since Feb. 1, between about 20,000 and 49,000 more people have died of all
non-covid-19 causes than would be expected in a typical year.
On Wednesday, an article published
in the Journal of the American Medical Association bolstered the findings from
the Post and CDC analyses. The paper looked at excess deaths nationwide in
March and April and found that 35 percent were attributed to causes other than
covid-19. The researchers, led by a team at Virginia Commonwealth University,
concluded that those deaths may include unreported, “nonrespiratory
manifestations” of the virus, or they could represent “secondary pandemic
mortality caused by disruptions in society that diminished or delayed access to
health care.”
The emerging
understanding of the collateral toll signals the fallout that America’s new hot spots could face in coming weeks and also
suggests the backlog in health-care problems that hospitals and other
caregivers will face once the pandemic subsides.
“We are waiting for
this cloud of coronavirus to lift more fully so we can see what’s happened to
our patients,” said Gregory Piazza, a cardiovascular specialist at Brigham and
Women’s Hospital in Boston. “Are we going to see a flood of new patients that
have decreased left heart function because they’ve had a missed myocardial
infarction? Are we going to see more patients with heart failure?
“We’re certainly
preparing, in the cardiovascular community, to run double speed to accommodate
all the things we’ve put off, that have been backing up all this time,” he
said.
The head of the
National Cancer Institute, Norman “Ned” Sharpless, predicted on June 18 that delays in cancer screenings,
diagnoses and treatment during the pandemic are likely to result in “thousands”
of excess cancer deaths in years to come.
For its analysis, The
Post selected the five states and New York City because their official covid-19
tolls ranked among the highest in the nation and their death data were among
the most complete. The analysis focused on common causes of death.
The analysis
calculates excess deaths in the United States by estimating the number of
people who would have died absent the pandemic — an estimate that takes into
account population growth and seasonal variations — and subtracting that number
from the overall number of deaths reported by the National Center for Health
Statistics (NCHS).
The great majority of
those excess deaths are counted as covid-19 deaths. In the United States to
date, at least 125,000
deaths are officially attributed to the disease, according to a
Post tally.
Some of the remaining
excess deaths — especially early in the pandemic — were likely caused by
covid-19 but not attributed to the disease when death certificates were filled
out by physicians, coroners or medical examiners.
“Not everyone gets an
autopsy,” said Evert Eriksson, trauma medical director at the Medical
University of South Carolina, one of the physicians who saw empty beds as the
pandemic first hit. “There is some miscoding that goes on in there. That’s why
a lot of this is difficult to tie causation to.”
Increases in deaths
from pneumonia and influenza, for example, point clearly to missed cases of
covid-19, said Dan Weinberger, professor of epidemiology at the Yale School of
Public Health, who led the team that developed the model The Post used in its
analysis and co-wrote the JAMA paper.
The Post found about
2,100 excess deaths from influenza and pneumonia in the six locations it
examined, about 20 percent of them in New York City alone.
Because tracking
efforts showed that influenza fell to “undetectable levels” in March,
Weinberger said, “the excess pneumonia and influenza deaths we’re seeing are
probably covid-19 deaths that are just not being attributed to the virus.”
Variations in the way
underlying causes of death are recorded on some death certificates mean some
covid-19 deaths could be included in the analysis of other causes; however, the
number is small and does not account for the dramatic increase in excess deaths
from heart disease and other causes, said Robert N. Anderson, chief of the
Mortality Statistics Branch of the National Center for Health Statistics.
Piazza said he was
not surprised to see across-the-board increases in diabetes deaths given that
the pandemic has drastically altered routines, making it more difficult for
people to stick to regular diets and exercise crucial for glucose control. Some
diabetics may be reluctant to go to the pharmacy and could be more likely to
run out of medication, he said.
The Post analysis
estimated there were more than 1,300 excess deaths from diabetes.
“Diabetes is the kind
of illness that requires, for good control, a reasonable amount of monitoring
from both patient and provider,” Piazza said.
The Post analysis
also estimated there were 1,300 more deaths attributed to Alzheimer’s disease
than would have been expected, adding to the pandemic’s devastating toll on the
country’s elderly.
The coronavirus has
made nursing homes some of the deadliest places, and responding to the crisis
probably affected care across the board, Bhadelia said. Facilities may also
have been reluctant to send uninfected residents to hospitals for fear of
exposure, she said.
“They just didn’t get
timely care,” Bhadelia said.
And as with other
diseases, experts said, some of those Alzheimer’s deaths may have been missed
cases of covid-19.
Deaths due to Alzheimer’s
Total weekly deaths Expected deaths
Illinois March 1May 3050100150
Massachusetts March 1May 3050100150
Michigan March 1May 3050100150
New Jersey March 1May 3050100150
New York* March 1May 3050100150
New York City March 1May 3050100150
*New York totals do not include New York City,
which is charted separately.
The Post’s analysis
found that cerebrovascular diseases — stroke and other conditions that involve
blood flow to the brain — accounted for more than 170 excess deaths in New York
City and more than 120 in New Jersey.
In New York state and
Illinois, the numbers were smaller, well below 100 each. Massachusetts and
Michigan saw about the same or fewer deaths from strokes than would have been
expected over the same period.
Deaths due to stroke and other cerebrovascular
disease
Total weekly deaths Expected deaths
Illinois March 1May 3050100150
Massachusetts March 1May 3050100150
Michigan March 1May 3050100150
New Jersey March 1May 3050100150
New York* March 1May 3050100150
New York City March 1May 3050100150
*New York totals do not include New York City,
which is charted separately.
Though covid-19 was
originally believed to be primarily a respiratory illness, Eriksson noted its
ability to attack blood vessels and form blood clots. That virus-related
complication could have created stroke symptoms in some patients, he said, but
there also almost certainly were patients who delayed stroke treatment out of
fear of exposure to the virus.
Analyzing deaths by
cause underscores the severity of the pandemic, its cascading effects and the
deadliness of the novel coronavirus, Weinberger said.
“It’s useful to see
the magnitude of those increases in relation to the magnitude of the epidemic
overall,” he said. “It tells us even if there are deaths due to these other
causes, it’s probably much smaller than the deaths we’re seeing due to the
virus.”
Lenny Bronner
contributed to this report.
Methodology
The Washington Post gathered historical data
on select causes of death by state between 2014 and early 2020, published by the National Center for Health Statistics
(NCHS), and used a model previously developed by a research team led by the
Yale School of Public Health to estimate the number of deaths that would
normally be expected each week from March 1 to May 30. The estimate takes into
account seasonal variations as well as year-to-year variations in mortality
levels but did not adjust for the flu. The mortality data are collected from
state health departments, which report deaths at different rates. It usually
takes about three weeks for death data to stabilize, but even then, they are
still not complete. As a result, it is expected that the numbers of deaths in
the period The Post analyzed will increase as states continue reporting
additional data to the NCHS. Details on the team’s statistical approach can be
found on GitHub. The Post has published the data and methodology
on GitHub.
Reis Thebault is a reporter covering national and breaking
news. He has worked on the local desks of the Boston Globe and the Columbus
Dispatch. He joined The Washington Post in June 2018.Follow
Lenny Bernstein covers health and medicine. He started as an
editor on The Washington Post’s National desk in 2000 and has worked in Metro
and Sports.Follow
Andrew Ba Tran is an investigative data reporter. Tran
shared in winning the Pulitzer Prize for Investigative Reporting in 2018.Follow
Youjin Shin
works as graphics reporter at The Washington
Post. Before joining The Post, she worked as multimedia editor at the Wall
Street Journal and a research fellow at the MIT SENSEable city lab.Follow
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