June
2, 2021 Matthew D. Solomon, MD,
PhD1; Mai Nguyen-Huynh, MD2; Thomas K. Leong, MPH3; et
alJanet Alexander, MSPH3; Jamal S. Rana, MD, PhD1; Jeffrey Klingman, MD2; Alan S. Go, MD3
Author
Affiliations Article Information JAMA. 2021;326(1):82-84. doi:10.1001/jama.2021.8414
Early
during the COVID-19 pandemic, marked declines in patients presenting with acute
cardiovascular conditions were observed,1,2 whereas mortality attributed to
cardiovascular causes increased.3 This raised concerns that patient
reluctance to seek emergency care contributed to preventable complications and
excess deaths, and public health campaigns sought to reassure patients that
hospitals were safe and to encourage seeking care when needed. As COVID-19
resurged in late 2020, rates of infections, hospitalizations, and deaths exceeded
those of previous surges. Many countries reimplemented lockdowns, and recent UK
data indicate that presentations for emergent cardiovascular conditions again
declined.4 We evaluated changes in rates of
acute myocardial infarction (AMI) hospitalizations and suspected ischemic
stroke as measures of patient willingness to seek emergency care during the
most recent COVID-19 surges in the US.
Methods
We
examined data from Kaiser Permanente Northern California (KPNC), a large,
integrated health care delivery system with 21 medical centers and 255 clinics,
providing comprehensive care for more than 4.5 million persons throughout
Northern California. Its membership is highly representative of the local and
statewide population regarding age, sex, race and ethnicity, and socioeconomic
status.5
We
examined weekly incidence rates for adult members hospitalized for AMI or
suspected acute ischemic stroke (ie, “stroke alerts”) who presented to KPNC
facilities from January 22, 2019, to January 18, 2021. Acute MI was identified
with a combination of discharge diagnosis codes and positive values of serum
cardiac troponin I.1 Stroke alerts are tracked through
a comprehensive stroke program at 21 Joint Commission stroke-certified KPNC
facilities that includes immediate consultation by neurologists for evaluation
and treatment for all suspected ischemic strokes.2,6 We excluded patients younger than
18 years, with unknown sex, or with lack of active health plan membership in
each weekly cohort.
Weekly
incidence rates of events per 100 000 person-weeks and 95% CIs for AMI and
stroke alerts during COVID-19 periods (January 21, 2020, to January 18, 2021)
and pre–COVID-19 periods (January 22, 2019, to January 20, 2020) were
calculated. Incidence rates across 3 COVID-19 surge periods (spring, weeks
8-15; summer, weeks 23-30; and winter, weeks 42-52 of 2020) were compared with
the same weeks during the pre–COVID-19 period by using incidence rate ratios
(IRRs), with 2-sided P < .05 considered statistically
significant. We also plotted the weekly incidence of COVID-19 hospitalizations.
Analyses were conducted with R version 4.0.2. The study was approved by the
KPNC institutional review board with a waiver of informed consent.
Results
During
183 928 759 person-weeks from January 21, 2020, to January 18, 2021, weekly AMI
hospitalization rates declined up to 41% (ie, incidence rate per 100 000
person-weeks, 1.66 vs 2.82; 95% CI, 1.29-2.14 vs 2.32-3.44; P = .001
for week 11, 2020 vs 2019) during the spring COVID-19 surge (IRR, 0.66; 95% CI,
0.59-0.74; P < .001 for weeks 8 to 15) but recovered to 2019
rates in weeks 16 to 19 (IRR, 0.87; 95% CI, 0.75-1.01; P = .07) (Figure, A). Similarly, weekly rates of stroke
alerts declined during the spring surge (IRR, 0.72; 95% CI, 0.65-0.79; P < .001)
but recovered in weeks 16 to 19 (IRR, 0.89; 95% CI, 0.78-1.02; P = .10)
(Figure, B). Despite larger increases in COVID-19
hospitalizations (Figure, C), no significant declines in AMI were
observed during the summer COVID-19 surge (IRR, 0.99; 95% CI, 0.89-1.10; P = .65)
or the winter surge (IRR, 0.94; 95% CI, 0.86-1.03; P = .20). A
statistically significant decline in stroke alerts was observed during the
summer COVID-19 surge (IRR, 0.87; 95% CI, 0.79-0.96; P = .006),
whereas no significant decline in stroke alerts was observed during the winter
surge (IRR, 1.08; 95% CI, 0.99-1.17; P = .07).
Discussion
In
contrast to the initial COVID-19 surge during March to April 2020 in the US and
to recent data from the UK, no significant declines in AMI hospitalization or
stroke alerts were observed during the largest and most recent surge during
October 2020 to January 2021 in KPNC. A modest decline was observed for stroke
alerts during the summer COVID-19 surge but quickly rebounded. Study
limitations include an inability to delineate specific reasons for observed
declines in AMI and stroke alerts and potential lack of generalizability to
other regions or systems. These patterns may reflect changing patient attitudes
during the COVID-19 pandemic or the success of health system and public health
campaigns to reassure patients about the safety of seeking emergency care when
needed.
Section
Editor: Jody W. Zylke,
MD, Deputy Editor.
Article Information
Corresponding Author: Matthew D. Solomon, MD, PhD, Department
of Cardiology, Oakland Medical Center, Kaiser Permanente Northern California,
3600 Broadway, Oakland, CA 94611 (matthew.d.solomon@kp.org).
Accepted for Publication: May 10, 2021.
Published Online: June 2, 2021. doi:10.1001/jama.2021.8414
Author Contributions: Dr Solomon had full access to all the
data in the study and takes responsibility for the integrity of the data and
the accuracy of the data analysis.
Concept and design: Solomon, Nguyen-Huynh, Rana, Klingman,
Go.
Acquisition, analysis, or interpretation of
data: All authors.
Drafting of the manuscript: Solomon, Nguyen-Huynh, Leong, Go.
Critical revision of the manuscript for
important intellectual content: All authors.
Statistical analysis: Solomon, Leong, Alexander.
Obtained funding: Solomon.
Administrative, technical, or material
support: Solomon,
Nguyen-Huynh, Leong.
Supervision: Solomon, Nguyen-Huynh, Go.
Conflict of Interest Disclosures: Dr Solomon reported receiving grants
from The Permanente Medical Group and the Kaiser Permanente Garfield Memorial
Fund during the conduct of the study. Dr Nguyen-Huynh reported receiving grants
from The Permanente Medical Group and the Kaiser Permanente Garfield Memorial
Fund during the conduct of the study. Dr Go reported receiving grants from The
Permanente Medical Group and the Garfield Memorial Fund during the conduct of
the study. No other disclosures were reported.
Funding/Support: This study was sponsored by grants from
the Kaiser Permanente Garfield Memorial Fund and The Permanente Medical Group
Delivery Sciences and Applied Research Program.
Role of the Funder/Sponsor: The sponsor had no role in the design
and conduct of the study; collection, management, analysis, and interpretation
of the data; preparation, review, or approval of the manuscript; or decision to
submit the manuscript for publication.
Additional Contributions: We acknowledge additional persons who
contributed to the work, including Edward J. McNulty, MD (Department of
Cardiology, Kaiser Permanente Northern California), for contributions to
concept and design and analysis and interpretation of the data, and Sue Hee
Sung, MPH (Division of Research, Kaiser Permanente Northern California), for
contributions to supervision and administrative, technical, and material
support. No one received financial compensation for their contributions.
References
Solomon MD, McNulty EJ, Rana JS, et al. The Covid-19 pandemic and
the incidence of acute myocardial infarction. N Engl J Med. 2020;383(7):691-693. doi:10.1056/NEJMc2015630PubMedGoogle ScholarCrossref
2. Nguyen-Huynh MN, Tang XN, Vinson DR, et al. Acute stroke presentation, care, and
outcomes in community hospitals in Northern California during the COVID-19
pandemic. Stroke.
2020;51(10):2918-2924. doi:10.1161/STROKEAHA.120.031099PubMedGoogle ScholarCrossref
3. Wadhera RK, Shen C, Gondi S, Chen S, Kazi DS, Yeh RW. Cardiovascular
deaths during the COVID-19 pandemic in the United States. J Am Coll Cardiol. 2021;77(2):159-169. doi:10.1016/j.jacc.2020.10.055PubMedGoogle ScholarCrossref
4. Wu J, Mamas MA, de Belder MA, Deanfield JE, Gale CP. Second decline in admissions with
heart failure and myocardial infarction during the COVID-19 pandemic. J Am Coll Cardiol. 2021;77(8):1141-1143. doi:10.1016/j.jacc.2020.12.039PubMedGoogle ScholarCrossref
5. Gordon N, Lin T. The Kaiser Permanente Northern
California adult member health survey. Perm J.
2016;20(4):15-225. doi:10.7812/TPP/15-225PubMedGoogle Scholar
6. Nguyen-Huynh MN, Klingman JG, Avins AL, et al; KPNC Stroke FORCE Team. Novel telestroke
program improves thrombolysis for acute stroke across 21 hospitals of an
integrated healthcare system. Stroke.
2018;49(1):133-139. doi:10.1161/STROKEAHA.117.018413PubMedGoogle ScholarCrossref
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