Americans Who Delayed or Avoided Medical Care Over COVID-19 Fears, June 2020

During periods of heavy COVID-19 transmission, routine and nonemergency medical care was disrupted. But putting off care can raise the risk of illness and death from treatable and preventable conditions, and may have contributed to excess deaths linked directly or indirectly to COVID-19. To measure how many people avoided care out of concern about the virus, a web survey was run from June 24 to 30, 2020, among a nationwide representative sample of U.S. adults.

The survey

Qualtrics administered the COVID-19 Outbreak Public Evaluation Initiative survey; 5,412 of 9,896 eligible adults (54.7%) completed it, and 4,975 gave complete data for the analysis. Quota sampling and weighting made the sample representative by gender, age and race and ethnicity. Respondents were asked whether they had delayed or avoided medical care because of COVID-19 concerns, for emergency care (such as immediately life-threatening conditions), urgent care (immediate but not life-threatening) and routine care (such as annual checkups). Because people judge "life-threatening" differently, urgent and emergency care were combined.

What they found

As of June 30, 2020, 40.9% of U.S. adults had delayed or avoided some medical care because of COVID-19 concerns, including 12.0% who avoided urgent or emergency care and 31.5% who avoided routine care.

Some groups reported especially high avoidance:

One in four unpaid caregivers cared for adults at increased risk of severe COVID-19.

After adjusting for other factors, avoidance of urgent or emergency care was significantly higher among:

• unpaid caregivers for adults versus non-caregivers (adjusted prevalence ratio 2.9);
• people with two or more underlying conditions that raise the risk of severe COVID-19 versus those with none (1.9);
• people with health insurance versus those without (1.8);
• Black adults (1.6) and Hispanic adults (1.5) versus White adults;
• adults aged 18–24 versus 25–44 (1.5);
• people with disabilities versus those without (1.3).

It was significantly lower among adults 45 and older than among younger adults.

Adjusted prevalence ratios for avoiding urgent or emergency care, by characteristic. CDC.

Why it matters

The findings match reports that hospital admissions and emergency department visits — including visits for heart attack, stroke and hyperglycemic crisis — fell after the pandemic began, while excess deaths rose. Avoiding routine care may partly reflect stay-at-home orders and closed facilities, but if it continued, people could miss chronic disease management, vaccinations and early detection of new illness.

• Caregivers, people with underlying conditions and people with disabilities avoided both kinds of care most. Caregivers may worry about exposing the vulnerable people they look after; people with underlying conditions need more care and may fear exposure in health facilities. States with many COVID-19 deaths also saw large proportional rises in deaths from other causes such as diabetes and heart disease. People with disabilities may face disrupted support services, less accessible transport and communication, and needs that telehealth handles poorly.
• Black and Hispanic adults' higher avoidance of urgent and emergency care is especially worrying because COVID-19 death rates are higher among them, and age-adjusted hospitalization rates were about five times higher for Black and four times higher for Hispanic people than for White people. Long-standing structural inequities in health, insurance, access to care, work and living conditions likely contribute.
• Insured people may have reported more avoidance simply because, before the pandemic, uninsured people sought care much less often and so had fewer visits to put off.

Health facilities were taking precautions against infection, and delaying care can itself lead to life-threatening emergencies. The authors call for accessible, tailored outreach explaining the risks of delay and facilities' safety measures, accessible telehealth or home care where in-person options are limited, and — above all — that anyone having a medical emergency seek and receive care without delay.

Limits

Self-reports are open to recall and other biases; the survey did not ask why people avoided care, their usual care patterns, or when and for how long they avoided it; people judge what is life-threatening differently; and a web survey may not represent the population fully by income, education and internet access — though the results match the observed drops in admissions and emergency visits.

Sources

Based on Czeisler MÉ, Marynak K, Clarke KEN, et al., "Delay or Avoidance of Medical Care Because of COVID-19–Related Concerns — United States, June 2020," MMWR Vol. 69, No. 36, CDC; a work of the United States government in the public domain. Its social-media graphic is not reproduced.