The demographics of the three clinics is presented in Table 2. Data was extracted from 22,685 active patients on a weekly basis across 29 providers. On November 29, 2020 6,754 were eligible for cervical cancer screening and 492 were excluded since they met high risk or exclusion criteria according to the CTFPHC’s guidelines as presented in Table 1. A total of 7,168 were eligible for colorectal cancer screening and 200 were excluded. Lastly, 10,933 met eligibility criteria for type 2 diabetes screening and 1,469 met the exclusion criteria. The numbers from March 15, 2020 were also reported for reference.
Impact Of Covid-19 On Mean Preventive Care Screening Rates
The period of data collection covered 38 weeks from March 15, 2020 until November 29, 2020. Two weeks of data were excluded due to errors in the scheduled data export causing incomplete data to be exported.
During the 38 weeks since March 15, 2020, the mean preventive care screening rates decreased for cervical cancer screening (Fig. 1), colorectal cancer screening (Fig. 2), and type 2 diabetes screening (Fig. 3). Cervical cancer screening rates decreased by 7.5% (-0.3% to -14.7%; 95% CI). The mean colorectal cancer screening rates decreased by 8.1% (-0.3% to -15.8%; 95% CI). The mean type 2 diabetes screening rates decreased by 4.5% (-0.2% to -8.7%; 95% CI).
A line of best fit was generated for each screening test and the slope indicated the weekly rate of change during this period. Cervical cancer screening rates decreased by 0.23% per week (Fig. 1). Colorectal cancer screening rates decreased by 0.25% per week (Fig. 2). Type 2 diabetes screening rates decreased by 0.13% per week (Fig. 3).
The Government of Ontario’s stages of gradual reopening are indicated for reference to demonstrate the impact of re-opening efforts on screening rates (Fig. 1, 2, and 3). For colorectal cancer screening, the date that FIT testing could be ordered was also shown (Fig. 2). None of the re-opening measures reversed the decreased screening trends across the three observed screening tests.
Quantifying the Preventive Care Testing Needed to Return to Baseline Screening
The number of patients among the 22,685 active patients at the three clinics requiring screening to return to baseline, low-risk screening rates were determined. A total of 505 (20 to 993; 95% CI) patients would need to have Papanicolaou smear testing (Table 3), 577 (22 to 1,133; 95% CI) would need colorectal cancer screening (Table 4), and 489 (21 to 951; 95% CI) would need type 2 diabetes screening (Table 5).
Extrapolating these numbers to Ontario’s population provided an estimated number of Ontarians requiring screening to return to pre-COVID-19, low-risk screening rates. Potentially 288,000 Ontarians (11,000 to 565,000; 95% CI) would need Papanicolaou smear testing (Table 3), 326,000 Ontarians (13,000 to 638,000; 95% CI) would need CRC screening (Table 4), and 274,000 Ontarians (13,000 to 535,000; 95% CI) would need T2DM screening (Table 5).
Similarly, extrapolation to the Canadian population provided an estimate of the number of Canadians needing screening to return to pre-COVID-19, low-risk screening rates. Potentially 745,000 Canadians (28,000 to 1,467,000; 95% CI) would need Papanicolaou smear testing (Table 3), 860,000 Canadians (35,000 to 1,685,000; 95% CI) would need CRC screening (Table 4), and 715,000 Canadians (34,000 to 1,396,000; 95% CI) would need T2DM screening (Table 5).
This observational cohort study estimated that hundreds of thousands of Ontarians may have delayed or been unable to access preventive care services since March 15, 2020. This trend has not reversed with re-opening measures implemented by the Government of Ontario. These observations align with unofficial reports from Ontario Health, which indicate that preventive care screening has decreased since March 2020(2). Extrapolation to the Canadian population estimates many thousands more have delayed preventive care since March 2020.
According to a review of preventive care services, only cervical cancer screening requires in-person assessments(5). Therefore, the finding that cervical cancer screening decreased since March 2020 is as expected, because Ministry of Health directives recommended avoiding in-person assessments(19). However, CRC screening may be offered through virtual care(5). The observed decrease in CRC screening is not explained by fewer in-person appointments. Instead, both laboratories pausing FIT kit distribution to reserve capacity for COVID-19 testing(10) and the Ministry of Health recommendation to defer non-essential services(19) have likely contributed to decreased CRC screening. This recommendation to defer healthcare services has likely reduced T2DM screening, as screening could be offered through virtual care(5) without restrictions on hemoglobin A1c or fasting blood sugar testing. Similar findings of reduced utilization of healthcare services have been observed through fewer emergency department visits for heart failure(20), stroke(21), and pediatric assessments(22). Patient and provider clinical priorities may also shift from prevention and screening to management of active problems, like increased demand for mental healthcare services(23). Therefore, the findings of this study indicate that the reductions in preventive care service delivery are likely multifactorial.
Sustained reductions in preventive care are concerning since screening can detect early disease like cervical cancer, CRC, or T2DM. Accordingly, many cases of early disease are likely going undetected. Delayed diagnoses may have significant consequences as each four week delay in CRC treatment could increase mortality rates by 6 to 8%(3). This is supported by a recent model that predicted prolonged preventive care delays will cause higher cancer mortality and advanced disease at diagnosis(24). From a health system perspective, delayed cancer diagnoses may significantly increase cancer treatment costs(25). Prolonged undiagnosed and untreated T2DM is also expected to present problems since untreated T2DM increases the risk of cardiovascular disease mortality(26). Therefore, strategies to restore preventive care service delivery to pre-COVID-19 levels are essential. As COVID-19 restrictions persist and recur, the multifactorial patient, provider and health system factors impacting preventive care delivery need to be better understood and addressed.
This study has demonstrated that EMR data can be used to determine patients’ preventive care screening statuses. This automated function could be developed for other EMRs to generate monthly preventive care reports for providers(28)These reports could then be used for targeted preventive care delivery, prioritising in-person visits for those most overdue or needing tests that require in-person assessments. Additionally, point-of-care tools could support opportunistic preventive care delivery during visits for other reasons. The literature supports that digital solutions like EMR reminders(27) combined with active panel management(27, 28) can improve screening rates. However, for these data to raise preventive care rates, system capacity must be improved as laboratories have only recently restored some capacity for screening test(29).
Another potential strategy has already been implemented by the Government of Ontario to address the surgical backlog, including cancer surgeries(30). This strategy involves investments in system capacity and providing financial incentives for health service delivery(31). Directing additional resources upstream to support additional time and planning to restore preventive care services could effectively boost screening rates(32) and maintain early disease detection. This could help mitigate the anticipated increase in cancer mortality, later stage diagnoses,(24) and increased health care costs(25). These resources may also maintain the focus on early detection as large numbers of patients begin seeking care for neglected physical and mental conditions(33).
This study extrapolated data based on three clinics in Ottawa, a single urban centre in Ontario, Canada. Differences may exist between urban and rural preventive care service delivery and across Ontario. Additionally, the generalizability to the Canadian population could be impaired due to differences in local restrictions since Canada’s healthcare systems are provincially run. This study also relies on high quality EMR data which may suffer from accuracy, completeness, and consistency issues(34). These challenges arose when developing the data export. Screening data was not consistently encoded following the same method, therefore multiple exported data points had to be amalgamated to improve data quality. Lastly, the impact of COVID-19 on T2DM screening may be underestimated since a 3 year interval was used despite guidelines recommended 1 to 3 years based on calculated risk scores.