Our study involving patients with chronic CVD reported worse HRQoL in several aspects of health during the COVID-19 outbreak, despite stability in their CVD. Specifically, there was increased anxiety and depression on serial EQ-5D-3L assessments. Results were more pronounced using EQ-5D-5L. The increase in anxiety and depression during the outbreak was clinically (small-to-moderate effect size) as well as statistically significant. To our knowledge, this is one of the first studies evaluating the impact of COVID-19 pandemic on the HRQoL of non-infected persons with CVDs.
Infectious diseases outbreaks are known to have health, social and economic implications, for infected and non-infected persons alike. Prior studies have shown the adverse psychological impact of COVID-19 and its containment measures in COVID-19 patients, frontline workers, patients with pre-existing psychiatric diseases and the general population [8, 9]. Our findings are consistent with prior literature, and further extended those reports by providing the perspectives of those with CVD.
The increase in anxiety and depression amongst our study participants, is unsurprising and may be explained by the following: 1) The swathe of information, from official organizations to social media platforms, re-iterating the increased risks of COVID-19 with CVDs, 2) Postponements of non-critical CVD follow-up appointments, and the emphasis on social and physical distancing may have altered their perception of healthcare accessibility, 3) Separation from family and friends during the Circuit Breaker, leading to social isolation, 4) Mask-wearing requirement in public areas, resulting in dyspnea for some people, and 5) Economic concerns, given the closures of businesses. Lingering memories of the devastating impact of the Severe Acute Respiratory Syndrome (SARS) outbreak in 2003, with 238 cases and 33 deaths in Singapore, may have also contributed to anxiety and depression [19]. An understanding of the relative contribution of these factors would have been helpful in shaping future policies and interventions; unfortunately, such data were not collected in this brief study.
The magnitude of change in HRQoL was small. In particular, there was little change in the physical dimensions of HRQoL, which partly reflected the stability of the participants’ underlying CVDs between the surveys done at baseline and during the COVID-19 outbreak. The subgroups bearing the brunt of the pandemic and its containment measures are usually the elderly [20], females [21–23], less educated [23, 24], and those from the low socioeconomic status [25, 26]. Our study participants of mostly older, middle-class males may not have been the vulnerable group. Furthermore, support from the government in response to the pandemic – rapid ramping up of resources and capabilities in terms of COVID-19 testing and provision of care, assurance that non-COVID care would not be compromised, shift towards telemedicine, and massive stimulus packages to cushion the economic impact, might have somewhat mitigated the impact of the pandemic.
There are several strengths of our study. First, all the HRQoL assessments were completed by participants themselves rather than proxies. Second, all participants had baseline assessments prior to the outbreak, thus acting as their own controls. Third, the impact of the pandemic on HRQoL was evaluated by two validated HRQoL measures (EQ-5D-3L and EQ-5D-5L) and both gave consistent results, leaving less room for random noise in the results. Fourth, the follow-up HRQoL assessment was carried out during the partial national lockdown which enabled us to adequately capture the impact of outbreak and containment measures on HRQoL.
Our study has a few limitations. First, the administration of HRQoL assessments was different pre-pandemic and during pandemic for some participants. All pre-pandemic HRQoL assessments were self-administered; majority of the follow-up assessments were administered by the interviewer over the phone. The follow-up assessments were conducted when physical outpatient visits were restricted. Although our preference was for self-administered assessments via email or post, some participants preferred interviewer-administered assessments over the phone. Therefore, we would not rule out some impact of this administration on their responses. Nevertheless, previous research has shown that interviewer-administration is likely to overestimate HRQoL, rather than underestimate [27]. That is, some participants could have under-reported their health problems. Therefore, our estimates of the impact of the pandemic on HRQoL should be considered as conservative estimates. Second, our study performed several hypotheses, including evaluating the pandemic impact on each dimension of EQ-5D separately, without multiplicity correction. There could be chances of inflated type-I error (false positive), and results should be considered as exploratory. Finally, our study was conducted in Asian patients with CVD. The findings may not be generalizable to other ethnicities or patient populations. We encourage further research in other countries and other disease groups to understand the impact of the pandemic.
The findings of adverse psychological impact on patients with CVD have important implications. It is plausible that the impact would be greater if our findings are extrapolated to more vulnerable populations – elderly, females, less educated, lower socioeconomic classes and poorly controlled CVD. Psychological ramifications can be long-lasting even after the pandemic has ended, and should not be ignored. At time of writing, there is no authoritative organizations that plans and coordinates psychological interventions in Singapore during the COVID-19 outbreak. In the meantime, cardiologists can do their part by proactively screening for psychological issues in patients who come for consultations, be it in-person or via telemedicine. Where necessary, psychosocial interventions can be implemented in collaboration with psychiatrists and psychologists.