Fear of seeking care in hospitals overwhelmed by coronavirus may have caused thousands of deaths

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 about 27% 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.

More than 50 patients a day "died excess deaths just from heart disease, just in New York City," said John Puskas, a cardiovascular surgeon at Mount Sinai 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 University school of public health, shows that 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 medical school'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.

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, probably 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% for heart attacks, 20% for strokes and 10% 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.

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% 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, Ned Sharpless, predicted on June 18 that delays in cancer screenings, diagnoses and treatment during the pandemic will 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 - probably were 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.

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 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 that 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 that 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.

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.

Although 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.”