Abstract
Pulmonary hypertension is frequently underdiagnosed, and referral is delayed with subsequent impact on outcomes. During the SARS-CoV-2 pandemic, restrictions on daily life and changes in hospitals' daily routine care were introduced in Germany. This multi-centre study provides evidence for a negative influence of these restrictions on patient care in pulmonary hypertension expert referral centres.
Keywords: pulmonary hypertension, SARS-CoV-2, Covid-19
To the Editor:
The first infection with SARS-CoV-2 in Germany was reported in January 2020.1 The incidence of SARS-CoV-2 cases dramatically increased from the end of February 2020 reaching over 178,000 cases including 8280 deaths, so far.2,3 According to the high contagiosity, strict rules were constantly discussed and finally launched by the German Government. In the beginning of March, a lockdown was proposed, restricting the daily life as well as the routine care in hospitals.4 In pulmonary hypertension (PH), an early diagnosis is a demanding but crucial target5–7 and the importance of regular visits to constantly monitor treatment in expert centres is highlighted in the current guidelines as well as the proceedings of the 6th World Symposium on PH.7,8 In general, patients are either scheduled for out-patient visits according to their urgency (next day, within one week, within one month) or for immediate hospital admission. Initiation and/or adjustments of PH-specific therapies and background medications, respectively, are usually made during the above-mentioned patient visits. Independent of SARS-CoV-2-associated restrictions, fast-track referrals were offered throughout for severe cases. The impact of SARS-CoV-2 associated restrictions on PH out-patient departments in Germany, however, has not been systematically evaluated. Thus, we aimed to evaluate whether and to which extent the current pandemic impacted new patient referrals to specialised PH services in Germany.
The number of referrals of new patients in seven large PH specialised centres in Germany was analysed retrospectively. In detail, the number of patients with suspected PH referred from non-expert centres or office-based physicians as well as the number of patients in whom PH-specific treatment was subsequently started were collected. The study period, covering the lockdown, lasted from 1 March 2020 to 30 April 2020. Three control periods were respectively defined as the corresponding time in 2018 (defined as control period 1) and 2019 (defined as control period 2) as well as 1 January 2020 to 29 February 2020 (defined as control period 3) (Table1). These numbers were compared with the Poisson regression using SPSS Statistics 26 (IBM, Armonk, USA). Moreover, p-values < 0.05 were considered statistically significant.
During the study period, 111 patients were recorded (Table 1). Noteworthy, the total number of admissions significantly decreased in the study period (incidence ratio 0.544 (0.432, 0.686), p < 0.001 compared to the first control period, 0.489 (0.390, 0.614), p < 0.001 compared to the second control period and 0.483 (0.385, 0.605), p < 0.001 compared to the third control period, Table 1). During the lockdown, 37 patients were initiated on a PH-targeted therapy (Table 1). Again, the total number decreased in the study period (incidence ratio 0.597 (0.397, 0.897), p = 0.013 compared to the first control period, 0.740 (0.484, 1.132), p = 0.165 compared to the second control period and 0.544 (0.365, 0.812), p = 0.003 compared to the third control period, Table 1) while the ratio of patients in whom PH-targeted therapy was initiated to the total number of new admissions did not differ significantly between the periods (study period: 33%, control period 1: 30%, control period 2: 22%, control period 3: 30%; Chi-square p = 0.325, p = 0,301, p = 0,364, respectively).
Table 1.
Number of admissions and therapy initiations during the study period and the control periods.
| Control periods |
||||
|---|---|---|---|---|
| Study period 1.3.20–30.4.20 | Control period 3 1.1.20–29.2.20 | Control period 2 1.3.20–30.4.19 | Control period 1 1.3.20–30.4.18 | |
| No. of admissions | 111 | 230 | 227 | 204 |
| Incidence rate ratio (95% CI) | 0.483 (0.385, 0.605) | 0.489 (0.390, 0.614) | 0.544 (0.432, 0.686) | |
| P value | <0.001 | <0.001 | <0.001 | |
| No. of therapy initiations | 37 | 68 | 50 | 62 |
| Incidence rate ratio (95% CI) | 0.544 (0.365, 0.812) | 0.740 (0.484, 1.132) | 0.597 (0.397, 0.897) | |
| P value | 0.003 | 0.165 | 0.013 | |
Incidence rate ratio calculated as incidence rate study period/incidence rate respective control period; p values result from Wald Chi-square statistics.
This study provides evidence for the significant impact of SARS-CoV-2 and the related restrictions on the medical care of patients with (suspected and subsequently confirmed) PH in Germany. The total number of new appointments and absolute numbers of subsequently initiated PH-specific therapy decreased by almost 50%, compared to corresponding time periods in previous years. Of note, the relative fraction of patients with subsequently initiated PH-specific therapy remained constant during the SARS-CoV-2 pandemic. PH patients are already facing a substantial delay from onset of symptom to definite diagnosis and treatment initiation in PH centres.5,6 As diagnostic delays might influence the overall outcome in PH,5 reducing this gap has been defined as a major goal during the last PH world symposium.8 Therefore, the SARS-CoV-2 pandemic and its related impact on social behaviour worsened the hitherto described diagnostic delay and increased the referral gap in PH. These results are in line with the impact of hospital admission of patients with acute coronary syndrome but contrary to the impact of SARS-CoV-2 on patients' adherence on continuous positive airway pressure (CPAP) therapy at home.9,10 In essence, while SARS-CoV-2-associated restrictions implemented in Germany might have prevented from an uncontrolled spread of the virus in the general population, and was well received by the majority of the society as well as by health care professionals, social distancing and potential other concerns which reduce the number of patient referrals to PH specialised centres might have a negative impact on the best care for the fragile PH patients.
Supplementary Material
Conflict of interest
The author(s) declare that there is no conflict of interest.
Funding
This study is funded by the Deutsche Forschungsgemeinschaft (DFG, German Research Foundation) – Projektnummer 268555672 – SFB 1213, Project B08.
ORCID iDs
Athiththan Yogeswaran https://orcid.org/0000-0001-9505-8608
Henning Gall https://orcid.org/0000-0001-7016-7373
Katrin Milger https://orcid.org/0000-0003-2914-8773
Supplemental material
Supplemental material for this article is available online.
References
- 1.Spiteri G, Fielding J, Diercke M, et al. First cases of coronavirus disease 2019 (COVID-19) in the WHO European Region, 24 January to 21 February 2020. Euro Surveill 2020, pp. 25 DOI: 10.2807/1560-7917.ES.2020.25.9.2000178. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Institut RK. Coronavirus disease 2019 (COVID-19) – daily situation report of the Robert Koch Institute. Institut RK, 2020.
- 3.Dong E, Du H, Gardner L. An interactive web-based dashboard to track COVID-19 in real time. Lancet Infect Dis 2020; 20: 533–534. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Sanche S, Lin YT, Xu C, et al. High contagiousness and rapid spread of severe acute respiratory syndrome coronavirus 2. Emerg Infect Dis 2020; 26: 1470–1477. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Khou V, Anderson JJ, Strange G, et al. Diagnostic delay in pulmonary arterial hypertension: insights from the Australian and New Zealand pulmonary hypertension registry. Respirology 2020. 2020/01/31. DOI: 10.1111/resp.13768. [DOI] [PubMed] [Google Scholar]
- 6.Strange G, Gabbay E, Kermeen F, et al. Time from symptoms to definitive diagnosis of idiopathic pulmonary arterial hypertension: the delay study. Pulm Circ 2013; 3: 89–94. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Galie N, Humbert M, Vachiery JL, et al. 2015 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension: The Joint Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS): Endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC), International Society for Heart and Lung Transplantation (ISHLT). Eur Respir J 2015; 46: 903–975. [DOI] [PubMed] [Google Scholar]
- 8.McGoon MD, Ferrari P, Armstrong I, et al. The importance of patient perspectives in pulmonary hypertension. Eur Respir J 2019, pp. 53 DOI: 10.1183/13993003.01919-2018. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.De Filippo O, D'Ascenzo F, Angelini F, et al. Reduced rate of hospital admissions for ACS during Covid-19 outbreak in Northern Italy. N Engl J Med 2020. 383: 88–89. 2020/04/29. DOI: 10.1056/NEJMc2009166. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Attias D, Pepin JL, Pathak A. Impact of COVID-19 lockdown on adherence to continuous positive airway pressure (CPAP) by obstructive sleep apnoea patients. Eur Respir J 2020. . DOI: 10.1183/13993003.01607-2020. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.