Changes in cardiovascular disease monitoring in English primary care during the COVID-19 pandemic: an observational cohort study

  1. Clare R Bankhead
  2. Sarah Lay-Flurrie
  3. Brian D Nicholson
  4. James P Sheppard
  5. Chris P Gale
  6. Harshana Liyanage
  7. Dylan McGagh
  8. Mark Minchin
  9. Rafael Perera
  10. Julian Sherlock
  11. Margaret Smith
  12. Nicholas PB Thomas
  13. Cynthia Wright Drakesmith
  14. Simon de Lusignan
  15. FD Richard Hobbs

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Abstract

Objective

To quantify the impact and recovery in cardiovascular disease monitoring in primary care associated with the first COVID-19 lockdown.

Design

Retrospective nationwide primary care cohort study, utilising data from 1st January 2018 to 27 th September 2020.

Setting

We extracted primary care electronic health records data from 514 primary care practices in England contributing to the Oxford Royal College of General Practitioners Clinical Informatics Digital Hub (ORCHID). These practices were representative of English primary care across urban and non-urban practices.

Participants

The ORCHID database included 6,157,327 active patients during the study period, and 13,938,390 patient years of observation (final date of follow-up 27 th September 2020). The mean (SD) age was 38±24 years, 49.4% were male and the majority were of white ethnicity (65% [21.9% had unknown ethnicity])

Exposure

The primary exposure was the first national lockdown in the UK, starting on 23 rd March 2020.

Main outcome measures

Records of cholesterol, blood pressure, HbA1c and International Normalised Ratio (INR) measurement derived from coded entries in the primary care electronic health record.

Results

Rates of cholesterol, blood pressure, HbA1c and INR recording dropped by 23-87% in the week following the first UK national lockdown, compared with the previous week. The largest decline was seen in cholesterol (IRR 0.13, 95% CI 0.11 to 0.15) and smallest for INR (IRR 0.77, 95% CI 0.72 to 0.81).

Following the immediate drop, rates of recorded tests increased on average by 5-9% per week until 27 th September 2020. However, the number of recorded measures remained below that expected for the time of year, reaching 51.8% (95% CI 51.8 to 51.9%) for blood pressure, 63.7%, (95% CI 63.7% to 63.8%) for cholesterol measurement and 70.3% (95% CI 70.2% to 70.4%) for HbA1c. Rates of INR recording declined throughout the previous two years, a trend that continued after lockdown. There were no differences in the times series trends based on sex, age, ethnicity or deprivation.

Conclusions

Cardiovascular disease monitoring in English primary care declined substantially from the time of the first UK lockdown. Despite a consistent recovery in activity, there is still a substantial shortfall in the numbers of recorded measurements to those expected. Strategies are required to ensure cardiovascular disease monitoring is maintained during the COVID-19 pandemic.

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  1. ScreenIT

    SciScore for 10.1101/2020.12.11.20247742: (What is this?)

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

    Table 1: Rigor

    Institutional Review Board StatementIRB: The protocol for this study was accepted by an independent approval committee and received ethical approval from the University of Oxford, Medical Sciences Interdivisional Research Ethics Committee (ref: R69874/RE001).
    Randomizationnot detected.
    Blindingnot detected.
    Power Analysisnot detected.
    Sex as a biological variablenot detected.

    Table 2: Resources

    No key resources detected.

    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:
    Strengths and limitations: This is the first analysis of nationally representative data from primary care in England showing both the immediate drop in cardiovascular disease monitoring and subsequent recovery during the COVID-19 pandemic. Data were derived from the ORCHID database which is capable of weekly data downloads, permitting some of the most timely and up-to-date analyses of primary care data in the world. Analyses are limited to those coded in patients’ electronic health records. It is possible that changes in clinical practice, such as the switch to remote consultations 1,3,4 or reduced administrative support for general practitioners may have affected coding of risk factor measurement. In addition, some patients may have continued to monitor their cardiovascular risk factors remotely through self-monitoring, 23-25 but this may not have been captured in the electronic health record. We focussed on cardiovascular disease since this is responsible for most premature deaths and major morbidity In the UK, but there are major disease prevention strategies possible with the focus on the early detection of risk factors and the close management of these risk factors monitored by follow up testing. General practice is largely responsible for this major public health delivery. This was an observational study and analyses were not designed to infer causality between the initiation of a national lockdown and subsequent cardiovascular disease monitoring. In addition, due to th...

    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.
    • Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
    • No protocol registration statement was detected.

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  2. Version published to 10.1101/2020.12.11.20247742v1 on medRxiv