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

Abstract

Objective: 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.

Keywords: COVID-19; diabetes mellitus; health services research; primary care.

Figure 1

Observed and expected care process rates in people with type 2 diabetes during 2019 and 2020, in England. (A–F) Blue lines indicate observed monthly rates (years 2019 and 2020), and green-shaded regions indicate expected rates with 95% CIs based on 10-year historical trends from January 2010; the vertical line at 1 March 2020 separates the rates in primary care before and after the start of the COVID-19 pandemic, and x-axis markers indicate mid-months. Created by the authors.

Figure 2

Stratified care process rates in people with type 2 diabetes during 2019 and 2020, in England. (A–F) Lines indicate observed monthly rates (years 2019 and 2020); the vertical line at 1 March 2020 separates the rates in primary care before and after the start of the COVID-19 pandemic, and x-axis markers indicate mid-months. Created by the authors.

Figure 3

Observed and expected rates of new medication initiation in people with type 2 diabetes during 2019 and 2020, in England. (A–D) Blue lines indicate observed monthly rates (years 2019 and 2020), and green-shaded regions indicate expected rates with 95% CIs based on 10-year historical trends from January 2010; the vertical line at 1 March 2020 separates the rates in primary care before and after the start of the COVID-19 pandemic, and x-axis markers indicate mid-months. Created by the authors.

Figure 4

Observed and expected new and repeat medication prescribing rates in people with type 2 diabetes during 2019 and 2020, in England. (A–D) Blue lines indicate observed monthly rates (years 2019 and 2020), and green-shaded regions indicate expected rates with 95% CIs based on 10-year historical trends from January 2010; the vertical line at 1 March 2020 separates the rates in primary care before and after the start of the COVID-19 pandemic, and x-axis markers indicate mid-months. Created by the authors.