Abstract
To curb transmission of SARS-CoV-2 and preserve hospital resources, elective procedures were postponed in the United States, affecting patients previously scheduled for electrophysiology (EP) procedures. We aimed to understand patients’ perceptions related to procedural postponements during the first wave of the SARS-CoV-2 pandemic. We performed a telephone survey between May 1-15 2020, of consecutive patients who experienced procedural postponement from March-April. Of 112 patients, 20% may have been lost to follow up and 12% lost interest in having their procedures done. The level of anxiety related to postponement was moderate to high in more than two thirds of patients.
Introduction
The SARS-CoV-2 pandemic has created unprecedented challenges across medicine, especially in procedural subspecialties such as electrophysiology. As a result of “shelter in place” orders issued during the course of spring 2020, 1 elective procedures in hospitals across much of the United States were postponed. To help electrophysiologists triage pending procedures for postponement, the Heart Rhythm Society (HRS) released guidelines outlining the level of urgency of cardiac electrophysiology (EP) procedures. 2 As procedural wait times may affect patient satisfaction and retention, delays have also created challenges for health care providers, hospitals, and health systems. Given the unequal distribution of vaccines, mutations of the virus, and possible further pandemic waves, we aimed to understand patients’ perceptions and anxiety level related to procedural and admission postponements at an urban center in a city deeply affected by the SARS-CoV-2 pandemic. 3 We hoped to gain insight in understanding our patients’ experience in the event of another unforeseen health catastrophe.
Methods
We identified consecutive patients scheduled for various EP procedures and admissions from March 23rd - April 22nd 2020 who experienced procedural postponement immediately following our regional “shelter in place order” during the first wave of the SARS-CoV-2 pandemic. 1 The elective procedures postponed during that time period followed the HRS prioritization guidelines to minimize peri-procedural SARS-CoV-2 exposure for both patients and providers. 2 Telephone interviews were performed by medical trainees between May 1st and May 15th 2020. Consent was obtained at the beginning of the telephone interview and mailed to participants for their review and signature. Patients were not incentivized to participate in the phone survey. The survey was an original instrument generated by co-authors (ASLR, BK, EC, AB, AV, MBB, JC, IRW). Socio-demographics and SARS-CoV-2 testing history were obtained from patients during the telephone survey. Anxiety was measured by asking patient about their self-perceived level of anxiety on a point-based scale. Exact questions asked as part of the survey are included in the (Supplemental Appendix). Medical history and comorbidities were obtained from the electronic medical record. Patient income was estimated based on zip code from state records. 4 This study was approved by our institutional review board.
Normally distributed continuous variables were compared using the Student’s t-test. Unadjusted analyses of d ichotomous variables were performed using Pearson’s X2 test. Potential associations were determined a priori, namely patient sociodemographic variables and testing history versus response questions regarding perceptions of procedural postponement. P-values < 0.05 were considered significant. Analyses were performed using STATA 15.1 Statistical Software (StataCorp, College Station, Texas).
Results
Of the 112 patients postponed, 77 patients (68%) consented to the study. The remaining 35 patients could not be reached by phone despite ≥ 3 attempts (n = 22, 20%) or did not consent to the study (n = 13, 12%). Baseline characteristics of patients with procedural postponements can be found in Table 1. Atrial fibrillation (AF) was the most common indication for a procedure among those surveyed, followed by heart failure, which was related to 26% of postponed procedures.
Baseline Patient Characteristics.
SD, standard deviation
Self-reported patient characteristics were unable to be obtained for those patients not able to be reached by phone.
Subcutaneous and transvenous defibrillators.
Supraventricular tachycardia ablation, typical atrial flutter ablation, ventricular tachycardia ablation, premature ventricular complexes ablation.
Cardiac implantable electronic device extraction (lead fracture), loop recorder implant and removal, left atrial appendage closure device implant, pacemaker generator change, implantable cardioverter defibrillation generator change, implantable cardioverter defibrillator lead revision.
Among those surveyed, almost half of patients (48%) blamed their procedural postponement on the “lack of safety in the hospital.” The majority of patients self-reported moderate (32%) or high (38%) anxiety related to their procedural postponement. There was no relationship between procedure type (ablation vs. device vs. other) and level of anxiety (p = 0.16). In response to when patients thought their procedure would occur, 35% believed it would occur within 12 weeks of the survey, 17% believed it would occur in more than 12 weeks, and 45% were unsure, while 3% stated their procedure would likely never occur.
Few patients (11%) disagreed with the postponement (Figure 1), and there was no relationship between disagreement with postponement and race (p = 0.77), living in poverty (p = 0.31), level of education (p = 0.28), employment status (p = 0.54), EP diagnosis (p = 0.63), or type of procedure (p = 0.3). A similar proportion of patients (12%, n = 9) reported a change in interest in having their procedure done. However, all the patients who had a change in interest in moving forward with their procedure nonetheless agreed with the postponement. Of patients reconsidering their procedure during the course of the postponement, 22% had AF, all awaiting AF ablation, and 44% had heart failure, all awaiting primary prevention implantable cardioverter-defibrillator (ICD) or cardiac resynchronization therapy defibrillator (CRT-D) implant. The remaining 3 patients reconsidering their procedures were scheduled for loop recorder implant (n = 1) and typical atrial flutter ablation (n = 2). There was no relationship between reconsidering a procedure and race (p = 0.92), level of education (p = 0.28), EP diagnosis (p = 0.55), or type of procedure (p = 0.8). However, all patients with a change in interest in having their procedures done lived in an area with median income above the poverty line (p = 0.04).
Patient Perceptions of Electrophysiology Procedural Postponement during the SARS-CoV-2 Pandemic.
Patients who had undergone SARS-CoV-2 testing (19%, n = 15) were more likely to disagree with postponement than those who had not undergone testing (81%, n = 62) (30% of those tested disagreed vs. 2% of those not tested, p < 0.001). Notably, only 2 patients tested positive for SARS-CoV-2 (Figure 1) and both patients wanted to move forward with having their procedures done.
Discussion
The postponement of elective procedures due to SARS-CoV-2 poses multifaceted challenges for patients, hospitals, and health systems. Given the unequal distribution of vaccines and the mutation of the virus, there remains a potential future need to postpone EP procedures. Therefore, we aimed to understand how EP patients receiving care at an urban center markedly affected by the first wave of the SARS-CoV-2 pandemic perceived these delays and how it may affect patient retention. Nearly half of patients identified the perceived risk of exposure to SARS-CoV-2 in the hospital as the reason for procedural postponement. Although retention was high at our own institution, 12% of patients surveyed still lost interest in rescheduling their procedures after the pandemic, and 20% were not easily reachable and may have been lost to follow-up. This was independent of socio-demographic characteristics such as ethnicity, income or education level, as well as the specific procedure planned. As nearly half of patients were uncertain as to when their procedure would occur and most reported anxiety regarding procedural postponement, these may be important areas of focus regarding patient expectations, education, and communication during such a prolonged delay or potential future postponements.
Our specific study population is representative of many urban communities, with a high proportion of racial and ethnic minorities, prevalent poverty, and a broad range of levels of education. 5 Urban centers and minorities have been disproportionately affected by SARS-CoV-2,6–8 and similarly, historically are disproportionately affected by cardiovascular risk factors and disease.9,10 In Pennsylvania, Philadelphia County had the highest number of SARS-CoV-2 cases per 100,000 during the first pandemic wave and within the county, there was wide hospital and health system variation in regards to number of cases. 3 The perceptions of urban patients and the perceived impact of delays in their healthcare as a result of SARS-CoV-2 is particularly relevant, as they are the patients most likely to be affected by SARS-CoV-2 infection and have a severe course if infected.11,12
The level of anxiety related to postponement was moderate to high in more than two thirds of patients, and while one third of patients surveyed were confident their procedure would occur within 12 weeks of the survey, nearly half were uncertain as to when their procedures would occur. This is important as proceduralists should anticipate and gauge patients’ expectations with regards to rescheduling procedures delayed for several weeks.
A potential hurdle in rescheduling postponed patients or even patients now scheduled during the ongoing pandemic may be the perception that exposure to SARS-CoV-2 in the hospital may occur. In fact, nearly half of our patients cited this as the reason for their procedural postponement, and nearly all patients agreed with postponement. Nonetheless, 12% of patients lost their interest in having their procedure done, perhaps now questioning the necessity of the procedure given that it could be postponed, or questioning the safety of the hospital. In scheduling patients for procedures during the pandemic, having safety measures in place, and communicating these measures to patients may be an important assurance.
Although we serve a diverse and at-risk population, socio-demographic characteristics within our population had no association with reconsidering their procedures, nor did the type of procedure postponed. The SARS-CoV-2 pandemic has hit large cities and minorities hardest, where social determinants of health often shape outcomes, interactions between clinicians and minority patients have been reported to be of lower quality, and interruptions in health care have been perceived to be related to racial bias, resulting in lack of trust in the health care system.13,14 While no association was found with measured patient characteristics and skepticism regarding rescheduling of their elective procedures, possible unmeasured health literacy factors or patient characteristics may play an important role.
Finally, few of our patients were tested for SARS-CoV-2 and only 2 patients tested positive, but testing overall was associated with disagreement with postponement. As a majority of patients tested negative in our study population, they may have felt more at ease going through with their procedures having had the reassurance of a negative test for SARS-CoV-2, and thus may have felt impatient with postponement.
Limitations
The study’s cross-sectional design allowed for only measures of prevalence and association, and not causation. The socio-demographic diversity of the study population may limit generalizability to more homogenous communities. Income level of each patient was based on publicly reported medians by zip code, and was not self-reported. Anxiety was self-reported and there was no validated instrument used to measure anxiety. Therefore, our findings cannot be interpreted as a diagnostic assessment of anxiety. Finally, any potential detriment to patient's health related to procedural postponement was beyond the scope of the study.
Supplemental Material
sj-docx-1-jpx-10.1177_23743735211048054 - Supplemental material for Patient Perceptions of Cardiac Electrophysiology Procedural Postponement at an Urban Center During the SARS-CoV-2 Pandemic
Supplemental material, sj-docx-1-jpx-10.1177_23743735211048054 for Patient Perceptions of Cardiac Electrophysiology Procedural Postponement at an Urban Center During the SARS-CoV-2 Pandemic by Anne-Sophie Lacharite-Roberge, Abdullah Haddad, Benjamin Khazan, Joseph Noto, Lauren E. Tragesser, Rebecca Garber, Chethan Gangireddy, Edmond M. Cronin, Anuj K. Basil, George A. Yesenosky, Richard M. Greenberg, Anjali Vaidya, Meredith A. Brisco-Bacik, Joshua M. Cooper and Isaac R. Whitman in Journal of Patient Experience
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship and/or publication of this article.
Supplemental Material
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References
Supplementary Material
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