Missed screenings in 2020 could impact women’s health

Many women skipped important preventive health care appointments in 2020 due to the COVID-19 pandemic, especially if they were from lower-income and minority communities, according to a study published in JAMA Health Forum.

While the effect of these missed appointments depends on the patient, they could have long-term consequences on overall health, said author Nora V. Becker, MD, PhD, a primary care doctor with Michigan Medicine.

“If missed appointments for nonurgent routine screenings are rescheduled relatively quickly, on the order of months, it could have very little impact,” Becker told Healio. “On the other hand, if the patient was overdue for screening before, or if they never reschedule their routine care, it could have a much larger impact across a range of women’s health outcomes.”

The University of Michigan Institute for Healthcare Policy and Innovation examined medical and pharmacy claims data from Blue Cross Blue Shield of Michigan’s commercial health maintenance organization plan involving 685,373 women between the ages of 18 and 74 years from January 2019 through January 2021.

The study focused on breast and cervical cancer screenings, screenings for STDs, insertions of long-acting reversible contraceptives (LARCs), and pharmacy-obtained hormonal contraception, which Becker called the most important and common services that women receive.

Each of these services saw sharp declines in utilization during the first half of 2020, except for pharmacy-obtained contraception, compared to 2019. April 2020 saw the lowest rates of the use of preventive health services, but the rates recovered by July 2020.

Breast and cervical cancer screenings showed the biggest decreases, dropping by 96.6% and 90.5%, respectively, in April 2020 compared with April 2019. These screenings require in-person visits and cannot be managed by phone or video, Becker noted.

Also, STD testing and LARC insertions declined by 63.5% and 71.6%, respectively, in April 2020.

Meanwhile, claims for pharmacy-obtained contraceptives were consistently 15% to 30% lower in 2020 compared to 2019 without the temporal variation the other services experienced.

Nora V. Becker

“Even during the period when almost all in-person visits were cancelled, contraceptive prescriptions could still be easily written and sent to pharmacies by doctors,” Becker said.

“So, we don’t see the same drop and then recovery correlated with the timing of the state-level care shutdowns that we see with services that required an in-person visit,” she continued.

During the second half of 2020, breast cancer screenings surpassed the 2019 baseline (P < .001), whereas the other services remained slightly lower than their 2019 levels or were not significantly different.

Overall, however, women were 20% to 30% less likely to receive these services in 2020 than they were in 2019. And once clinics reopened, there was no corresponding increase in services indicating that patients were making up for lost time.

Patients who were up to date on their prior cancer screenings and who rescheduled missed screenings within a year or so probably saw very little impact on their health, Becker said.

“But for patients who were already behind on recommended screenings, or who didn’t reschedule their missed screenings in a timely fashion, it could result in later cancer diagnoses and potentially increased morbidity from breast and cervical cancer screenings,” Becker said.

Meanwhile, delays in contraception services could result in increased rates of unintended pregnancies, Becker added.

Declines in the utilization of preventive health services were even greater in zip codes with lower average income levels, more non-white residents, or more nonproficient English speakers, which all already saw disparities in care before the pandemic, the researchers said.

For example, women receiving cervical cancer and STD screenings and pharmacy-provided contraception during the post-pandemic period were more likely to live in zip codes with higher per-capita income.

Also, women receiving breast cancer and STD screenings during the post-pandemic period were more likely to live in zip codes with lower percentages of non-English-proficient speakers and non-white residents.

“Underserved populations, including racial minorities, low-income people and people who don’t speak English well, face enormous structural barriers to easily accessing medical care, including problems with health insurance coverage, affordability of care, and structural racism,” said Becker.

“The results of our study raise the concern that the pandemic may have worsened access for these populations, but our ability to study this in our data was limited, so more work is needed in this area,” she said.

The researchers noted that their data came from a commercial health plan in Michigan, so the study findings may not be generalizable to other states or plans such as Medicaid, Medicare or ACA Marketplace plans. Also, the study did not account for women who lost their health insurance during the pandemic.

Covariates such as income, race/ethnicity and language spoken also were not available, prompting the use of zip codes as proxies as well. Moreover, the data only describe the use of preventive health services through December 2020, meaning there may be additional variations in reporting.

“The next step is to look to other data sources, like survey data, to identify which patients are most behind on screening and to better understand what barriers exist to them accessing it,” Becker said. “And in the longer term, it will be important to track outcomes like cancer diagnoses and unintended pregnancies to see what happens and if they change as a result of the pandemic.”

Becker advised health care providers and systems to identify patients who are not just a little behind on routine screenings but very behind and who would therefore benefit the most from receiving them.

“But realistically, this will be a hard thing for lots of systems to do, both because there are data limitations that can make it difficult to identify these patients and because some providers and health care systems lack the resources or manpower to devote staff to these efforts,” she said.

Reference:

Becker NV, et al. JAMA Health Forum. 2021;doi:10.1001/jamahealthforum.2021.1408.

For more information:

Nora V. Becker, MD, PhD, can be reached at beckernv@umich.com.