Impact of COVID-19 on diagnoses, monitoring and mortality in people with type 2 diabetes: a UK-wide cohort study involving 14 million people in primary care

  1. Matthew J. Carr
  2. Alison K. Wright
  3. Lalantha Leelarathna
  4. Hood Thabit
  5. Nicola Milne
  6. Naresh Kanumilli
  7. Darren M. Ashcroft
  8. Martin K. Rutter

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Abstract

AIMS

To compare trends in diagnoses, monitoring and mortality in patients with type 2 diabetes, before and after the first COVID-19 peak.

METHODS

We constructed a cohort of 25 million patients using electronic health records from 1831 UK general practices registered with the Clinical Practice Research Datalink (CPRD), including 14 million patients followed between March and December 2020. We compared trends using regression models and 10-year historical data. We extrapolated the number of missed/delayed diagnoses using UK Office for National Statistics data.

RESULTS

In England, rates of new type 2 diabetes diagnoses were reduced by 70% (95% CI 68%-71%) in April 2020, with similar reductions in Northern Ireland, Scotland and Wales. Between March and December, we estimate that there were approximately 60,000 missed/delayed diagnoses across the UK. In April, rates of HbA 1c testing were greatly reduced in England (reduction: 77% (95% CI 76%-78%)) with more marked reductions in the other UK nations (83% (83-84%)). Reduced rates of diagnosing and monitoring were particularly evident in older people, in males, and in those from deprived areas. In April, the mortality rate in England was more than 2-fold higher (112%) compared to prior trends, but was only 65% higher in Northern Ireland, Scotland and Wales.

CONCLUSIONS

As engagement increases, healthcare services will need to manage the backlog and anticipate greater deterioration of glucose control due to delayed diagnoses and reduced monitoring in those with pre-existing diabetes. Older people, men, and those from deprived backgrounds will be groups to target for early intervention.

RESEARCH IN CONTEXT

What is already known about this subject?

  • The higher COVID-related death rate in people with diabetes has been well-documented

  • A study involving the residents of Salford, UK showed 135 fewer diagnoses of type 2 diabetes than expected between March and May 2020, which amounted to a 49% reduction in activity

  • There is limited data on the impact of the COVID-19 pandemic on the diagnosis and monitoring of type 2 diabetes

What is the key question?

  • What has been the impact of the COVID-19 pandemic on the diagnosis and monitoring of type 2 diabetes across the UK?

What are the new findings?

  • Across the UK, the rate of new type 2 diabetes diagnoses was reduced by up to 70% in April 2020 compared to 10-year historical trends

  • Between March and December 2020, it is estimated that 60,000 people have had a missed or delayed diagnosis

  • The frequency of HbA 1c monitoring in type 2 diabetes was reduced by 77-83% in April 2020 and by 31-37% overall between March and December 2020

How might this impact on clinical practice in the foreseeable future?

  • During this pandemic and associated lockdowns, effective public communications should ensure that patients remain engaged with diabetes services including HbA 1c screening and monitoring

Article activity feed

  1. ScreenIT

    SciScore for 10.1101/2020.10.25.20200675: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    Institutional Review Board Statementnot detected.
    Randomizationnot detected.
    Blindingnot detected.
    Power Analysisnot detected.
    Sex as a biological variablenot detected.

    Table 2: Resources

    Software and Algorithms
    SentencesResources
    Data sources: We conducted a retrospective cohort study using primary care electronic health records obtained from the Clinical Practice Research Datalink (CPRD) Aurum and GOLD databases 6,7.
    GOLD
    suggested: (GOLD, RRID:SCR_000188)
    All data processing and statistical analyses were conducted using Stata version 16 (StataCorp LP, College Station, TX).
    StataCorp
    suggested: (Stata, RRID:SCR_012763)
    We followed RECORD (REporting of studies Conducted using Observational Routinely-collected health Data) guidance 10.
    RECORD
    suggested: (RECORD, RRID:SCR_009097)

    Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).

    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
    Our study has some limitations: First, ethnicity coding is not adequately captured in primary care and therefore we had limited ability to explore ethnicity-related variation in care and outcomes. Future studies will incorporate linked secondary care data that has more complete capture of ethnicity data. Second, it is possible that some diabetes diagnoses may have been made in a hospital setting following an acute presentation and that the related primary care coding had not been updated at the time of our data extraction. While hospital presentation of incident diabetes may have occurred in some instances, it would not explain the reductions in new prescribing for metformin and this potential explanation does not fit with our local experience. In general, people have avoided hospital attendance during the pandemic. For example, one study documented a 23% reduction in emergency admissions in the UK 24. Finally, although our results and conclusions are relevant to the UK population, generalisability to other healthcare systems may be limited. However, a pan-European study of diabetes specialist nurses reported that diabetes services and the level of care provided to people with diabetes had been significantly disrupted during the pandemic with perceived reductions in new diabetes diagnoses, routine care provision, diabetes education and psychological support 25. In conclusion, we highlight marked reductions in the diagnosis and monitoring of type 2 diabetes as indirect consequ...

    Results from TrialIdentifier: No clinical trial numbers were referenced.

    Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

    Results from JetFighter: We did not find any issues relating to colormaps.

    Results from rtransparent:
    • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
    • No funding statement was detected.
    • No protocol registration statement was detected.

    About SciScore

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  2. Version published to 10.1101/2020.10.25.20200675v2 on medRxiv
  3. Version published to 10.1101/2020.10.25.20200675v1 on medRxiv