Temporal trends in hospital-recorded pulmonary embolism in England before, during and after the COVID-19 pandemic (2008-2024): a population-based observational study

Abstract

Background: COVID-19 infection increases the risk of pulmonary embolism (PE). Up-to-date reporting of hospitalisation rates for PE is needed to inform service planning and for benchmarking in light of the pandemic. Our primary aim was to quantify monthly trends in first-time, hospital-recorded PE across England from 2008 to 2024, with particular focus on the pandemic period. A secondary aim was to examine how these trends varied by age, sex, socioeconomic deprivation, and region, providing ongoing public access through an interactive online dashboard.

Methods: We conducted an epidemiological population-based study of all first-time PE diagnoses using English national secondary care data from April 2008 to December 2024. Trends before and after the onset of the COVID-19 pandemic (March 2020) were compared, with analyses by age, sex, region, and deprivation.

Findings: A total of 750,109 first-time PE admissions were identified. Age-standardised first-time hospital-recorded PE rates rose from 5.4 per 100,000 population in April 2008 to 8.5 in January 2020, spiked to 16.8 in January 2021 during the pandemic. The spike was largely accounted for by PEs where COVID-19 was a co-existing diagnosis. Rates have since declined, returning to pre-pandemic levels by early 2023 (e.g. March 2023, 8.6 per 100,000), and may be continuing to decline, subject to further updates. Regional and deprivation gradients persisted throughout but were more pronounced during the pandemic.

Interpretation: Whilst incidence of hospital-recorded PE spiked during the COVID-19 pandemic, rates have since returned to levels observed immediately prior to the pre-pandemic. Whilst it is too early to determine whether the recent downward trend may begin to reverse some of the upward trend observed over the decade before the pandemic, continued surveillance of hospital-recorded PE reported via our online tool will keep these findings up to date. Ongoing monitoring of PE incidence by healthcare setting is important to undertake while clinical practice and policy on PE management pathways evolve, since it helps to support care planning; it also informs data-enabled clinical trials where PE is an outcome as well as the design of observational studies.

Funding: This work was supported by the NIHR Biomedical Research Centre, Oxford and by Health Data Research UK.

Keywords: COVID-19 pandemic; Hospital admissions; Pulmonary embolism; Temporal trend.

Fig. 1

Age-standardised first-time PE incidence rates with and without co-existing COVID-19 in England, 2008–2024. Numerators represent the number of first-time hospital admissions with pulmonary embolism (PE) per patient, recorded in any diagnostic position. Denominators are the mid-year population estimates from the Office for National Statistics. Rates are age-standardised to the 2013 European Standard Population. Box plots show the historical average age-standardised PE rate from April 2008 to December 2024 (median and interquartile range). The shaded area marks the first and second waves of the COVID-19 pandemic in England. Red line – adjusted counterfactual (expected trend based on the pre-pandemic period). Blue line – observed age-standardised rate. Blue dots – observed age-standardised rate without co-existing COVID-19.

Fig. 2

Effect of the COVID-19 pandemic on first-time PE incidence rates, with and without co-existing COVID-19, comparing post-pandemic months (March 2020 to December 2024) with pre-pandemic trend (April 2008 to February 2020). The model is adjusted for age (5-year age groups) and sex, with month treated as a continuous variable and each month from March 2020 onwards treated as a categorical variable. The IRR for the pre-pandemic trend represents the modelled increase per month observed during the pre-pandemic period. It is against this baseline trend, and its hypothetical continuation, that the months from March 2020 onwards are compared. For example, the IRR of 1.81 in January 2021 means the observed rate that month was 81% higher than would have been expected had the pre-pandemic trend continued. The orange shaded area indicates the first and second waves of the coronavirus pandemic in England.