Changing patient priorities: Covid-19’s impact on chronic conditions and elective surgeries

In SA, we are dealing with a unique case needing novel solutions. The quadruple disease burden coupled with deep structural societal issues puts our nation in a most vulnerable position. Though Covid-19 is a state of national emergency, how do we balance the treatment of it against other diseases such as HIV/Aids and TB, cancer, and medical emergencies that arise from domestic violence and injuries? It’s no surprise that the issue of patient priorities becomes important. 

As a medical scheme, we see how there is less attention to the latter, while the health sector focuses on the fight against Covid-19. Patient priorities are changing and medical claims for conditions that were previously considered essential have lessened dramatically.

Coronavirus means difficult, life-changing decisions for chronic patients

Many of our scheme members suffer from chronic conditions that need to be carefully monitored, but the pandemic is forcing these patients to make difficult decisions. Cancer patients, for example, have been advised to stay at home if possible, but those under chemotherapy have no option but to visit hospitals for treatment, thus increasing their risk of infection. 

The evidence suggests that people with cancer have a significantly higher risk of severe illness resulting in intensive care admissions or death when infected with Covid-19, particularly if they have recently had chemotherapy or surgery. This means patients and doctors will have to make an informed trade-off about whether to continue a patient’s cancer treatment (which has the potential to stop recurrence in the next five years) vs increasing their chance of survival during the crisis. 

Reducing the risk of a cancer recurrence may be outweighed by the potential for increasing a patient’s risk of death from Covid-19 in the short term. Yet in the long term, more people’s cancer will return if we aren’t able to offer these treatments now. 

Working patterns are already changing and the hospital workforce has shifted focus towards dealing with the pandemic, thus reducing capacity for treatment of other conditions. Though interventions such as increasing phone consultations, minimising routine follow-ups and adding drugs that minimise the risk of complications, are good for the short term, they pose greater problems.

Unfortunately, doctors might start advising against treatments they would normally recommend and no doubt, see some patients die sooner not because of Covid-19, but because they are not able to treat their patients as they normally would.

This is not limited to cancer patients. Those with kidney conditions needing weekly dialysis, HIV/Aids patients needing chronic medication, and other conditions that require routine checks to assist and monitor a patient’s recovery are all affected by the crisis. Has the pandemic taken over patient priorities, as the greater battle is to fight against it at this point and for the foreseeable future?

Are elective surgeries and procedures a luxury?

What about patients needing surgery — how many beds will be available for surgery and intensive care recovery during this crisis? According to the lockdown Regulation 11(B)(a), the movement of people will be restricted unless to obtain an essential good or service, collecting a social grant, or seeking emergency, life-saving or chronic medical attention, and thus surgery will be limited unless it conforms to the aforementioned requirement. 

The issue of elective surgical procedures is an even bigger question. The practicalities of these scenarios are still being worked out by hospitals and surgeons, who will thereafter determine on a case-by-case basis, whether to update or cancel authorisations for the elective surgery. While it may result in inconvenience for elective surgery patients, it is a responsible measure to ensure patient safety, health care security, and maximise the benefits of the national lockdown measures.

The SA Society of Anaesthesiologists (Sasa) recently provided a guidance document for elective procedures: Recommendations for the management of anaesthesia and surgery for elective procedures. Elective procedures are broad in meaning and some have incorrectly interpreted them as “non-essential” or “optional” surgeries but this is not always the case. Sasa has carefully categorised elective and other surgeries as follows:

1. Elective surgery or procedure is one that is scheduled in advance and where its postponement will not result in the patient’s outcome or quality of life being significantly altered with a three-month delay.
2. Semi-elective surgery is one that must be performed to preserve the patient's life or limb or prevent longer-term systemic morbidity, but does not need to be performed immediately.
3. Urgent surgery is one can wait until the patient is medically stable but should generally be done within two days. It also includes surgery for fast-growing malignancies, or where delaying cancer surgery by more than two months may lead to systemic morbidity.
4. Emergency surgery is surgery that must be performed without delay; the patient has no choice other than to undergo immediate surgery if permanent disability or death is to be avoided.

Patient numbers in SA are increasing exponentially, and this categorising gives a good view of how the industry can prioritise procedures of this nature so that our infrastructure can deal with the demand. By prioritising procedures, we also reduce the risk of contracting Covid-19 while recovering from non-essential surgery as this increases their risk of morbidity and mortality.

Technology in health care is the way forward

Though elective surgical procedures have been postponed until the situation improves, we must ensure that we maintain the quality of care given to our patients. The emergence of Covid-19 has given our country a timely opportunity to reflect and evaluate the use of innovation and technology in the workplace. 

In Singapore, technology is being leveraged not only for remote patient monitoring and rehabilitation but also for training of resident doctors who were formally allowed to receive practical training during the recently cancelled elective surgical procedures. 

The adoption of telemedicine initiatives such as these, which allow patients to be reviewed in the comfort of their own homes, will become even more important in the seasons to come and Medshield is proud to have launched Medshield SmartCare — an innovative virtual medical consultation tool — which has paved the way for the adoption of telemedicine in SA.

Since this programme’s launch, it has received very positive feedback, as it is not only convenient, but it puts the trust back into health care and more recently is a way of accessing a GP during the Covid-19 lockdown period.

Technology will continue to play a key role in the delivery of medicine and the management of health care. At Medshield, we have always aimed to stay abreast of potential challenges such as this and as a not-for-profit organisation, we worked hard to ensure that our vision of “Caring about you towards a healthier nation” is fulfilled by being prepared in advance. Our focus has been to unlock three things: increasing access to health care, ensuring quality of care, and making sure it’s affordable.

With a history that dates back over 51 years, the scheme is driven by its mission to provide access to affordable high-quality health care through partnerships at very competitive prices in comparison to the market. Medshield is a transparent and sensible supporter of national initiatives to provide greater access to quality health care for all South Africans, especially during this pandemic. 

We have great trust and confidence in SA’s experienced health care professionals, and they have our full support during this challenging period. We will continuously monitor the Covid-19 situation and communicate as regularly as possible to ensure our members have continued access to affordable quality health care.

This article was paid for by Medshield.