Impact of COVID-19 restrictions on diabetes health checks and prescribing for people with type 2 diabetes: a UK-wide cohort study involving 618 161 people in primary care
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Abstract
To compare rates of performing National Institute for Health and Care Excellence-recommended health checks and prescribing in people with type 2 diabetes (T2D), before and after the first COVID-19 peak in March 2020, and to assess whether trends varied by age, sex, ethnicity and deprivation.
Methods
We studied 618 161 people with T2D followed between March and December 2020 from 1744 UK general practices registered with the Clinical Practice Research Datalink. We focused on six health checks: haemoglobin A1c, serum creatinine, cholesterol, urinary albumin excretion, blood pressure and body mass index assessment. Regression models compared observed rates in April 2020 and between March and December 2020 with trend-adjusted expected rates derived from 10-year historical data.
Results
In April 2020, in English practices, rates of performing health checks were reduced by 76%–88% when compared with 10-year historical trends, with older people from deprived areas experiencing the greatest reductions. Between May and December 2020, the reduced rates recovered gradually but overall remained 28%–47% lower, with similar findings in other UK nations. Extrapolated to the UK population, there were ~7.4 million fewer care processes undertaken March–December 2020. In England, rates for new medication fell during April with reductions varying from 10% (95% CI: 4% to 16%) for antiplatelet agents to 60% (95% CI: 58% to 62%) for antidiabetic medications. Overall, between March and December 2020, the rate of prescribing new diabetes medications fell by 19% (95% CI: 15% to 22%) and new antihypertensive medication prescribing fell by 22% (95% CI: 18% to 26%), but prescribing of new lipid-lowering or antiplatelet therapy was unchanged. Similar trends were observed across the UK, except for a reduction in new lipid-lowering therapy prescribing in the other UK nations (reduction: 16% (95% CI: 10% to 21%)). Extrapolated to the UK population, between March and December 2020, there were ~31 800 fewer people with T2D prescribed a new type of diabetes medication and ~14 600 fewer prescribed a new type of antihypertensive medication.
Conclusions
Over the coming months, healthcare services will need to manage this backlog of testing and prescribing. We recommend effective communications to ensure patient engagement with diabetes services, monitoring and opportunities for prescribing, and when appropriate use of home monitoring, remote consultations and other innovations in care.
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SciScore for 10.1101/2021.04.21.21255869: (What is this?)
Please note, not all rigor criteria are appropriate for all manuscripts.
Table 1: Rigor
Ethics not detected. Sex as a biological variable not detected. Randomization not detected. Blinding not detected. Power Analysis not detected. Table 2: Resources
Software and Algorithms Sentences Resources Statistical Analysis: The data were structured in a time-series format with event counts and ‘person-months at risk’ aggregated (by year and month) with stratification by gender, age group, deprivation quintile and region (or nation in GOLD). GOLDsuggested: (GOLD, RRID:SCR_000188)All data processing and statistical analyses were conducted using Stata version 16 (StataCorp LP, College Station, TX). StataCorpsuggested: (Stata, RRID:SCR_012763)We followed RECORD (REporting of studies Conducted using … SciScore for 10.1101/2021.04.21.21255869: (What is this?)
Please note, not all rigor criteria are appropriate for all manuscripts.
Table 1: Rigor
Ethics not detected. Sex as a biological variable not detected. Randomization not detected. Blinding not detected. Power Analysis not detected. Table 2: Resources
Software and Algorithms Sentences Resources Statistical Analysis: The data were structured in a time-series format with event counts and ‘person-months at risk’ aggregated (by year and month) with stratification by gender, age group, deprivation quintile and region (or nation in GOLD). GOLDsuggested: (GOLD, RRID:SCR_000188)All data processing and statistical analyses were conducted using Stata version 16 (StataCorp LP, College Station, TX). StataCorpsuggested: (Stata, RRID:SCR_012763)We followed RECORD (REporting of studies Conducted using Observational Routinely-collected health Data) guidance 10. RECORDsuggested: (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, we did not report data on retinopathy, smoking and foot checks (the remaining 3 of the 9 health checks recommended by NICE. Retinopathy screening is performed in the community and therefore these data are not available in primary care records. Whist assessments of smoking status and foot checks are performed in primary care, we were less confident in defining whether or not these checks had been performed based on the available data. Second, we do not present data on type 1 diabetes as the majority of care for these individuals is delivered in secondary care centres. Third, ethnicity coding is not adequately captured in primary care and therefore we had limited ability to explore ethnicity-related variation in outcomes. Fourth, we did not assess risk factor levels because our focus was on processes of care and prescribing. Fifth, our data would not capture assessments of weight and blood pressure assessed by patients in their homes. Results of home blood pressure recordings may have had an influence on prescribing between March and December 2020 because the reduction in prescribing of new antihypertensive agents (∼13%) was less than the reduction in BP monitoring performed in primary care (∼51%). Finally, although our results and conclusions are relevant to the UK population, generalisability to other healthcare systems may be limited. However, a pan-European survey of diabetes specialist nurses reported that the level of care provided f...
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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