medwireNews: The disruption of routine diabetes care during the pandemic may have resulted in an increased risk for mortality from causes not linked to COVID-19, research suggests.
In a commentary linked to the publication in The Lancet Diabetes & Endocrinology, David Hopkins and Francesco Rubino, both from King’s College London in the UK, say the findings are “a stark reminder that diabetes remains a serious and potentially deadly disease.”
They note: “Even before the pandemic, there were difference[s] in mortality among people with diabetes according to completeness of the care processes; an effect that has been amplified by the disruption to routine care that has occurred since March, 2020.”
The study authors, led by Jonathan Valabhji (NHS England and Improvement, London, UK), found that even pre-pandemic (2019–2020), only 48.1% of people received all eight care processes under study, these being measurement of glycated hemoglobin, blood pressure, cholesterol, serum creatinine, urine albumin, and BMI, as well as receipt of foot surveillance and assessment of smoking status.
But in the pandemic period (2020–2021) this fell to just 26.5%, the team reports, with the largest decreases seen among the most deprived people and among those of White versus non-White ethnicity. Foot surveillance had the largest relative decrease between the pre-pandemic and pandemic periods, of 37.5%, and serum creatinine measurement the smallest, of 12.1%.
The study data came from the UK National Diabetes Audit and encompassed 3,218,570 people with complete data on care processes, of whom 7.6% had type 1 diabetes, 90.9% had type 2 diabetes, and 1.5% had other types.
Comparing two 15-week periods between July and October – one in 2019 and one in 2021 – the researchers found an 11% increase in the rate of mortality from causes other than COVID-19, with unadjusted rates per 100,000 people with diabetes of 912 and 936 in 2019 and 2021, respectively.
The incidence rate ratio for death was a significantly elevated 1.023 in 2021 compared with 2019 after accounting for age, sex, ethnicity, deprivation, and diabetes type.
Valabhji and team found “a clear dose-response relationship” between receipt of care processes mortality and risk, both pre-pandemic and during the pandemic. People who received all eight care processes in both of the preceding years had the lowest non–COVID-19 mortality rate and those who did not receive them in either had the highest rate, with intermediate rates seen in people who received them all in one year but not the other.
In 2021, people who had not received all eight care processes during either of the previous 2 years were a significant 2.67-fold more likely to die than those who received them in both years, after accounting for confounders.
The study authors say that, had there not been a pandemic-related reduction in receipt of diabetes care processes, there would have been 3075 fewer deaths among people with the condition. The expected mortality rate per 100,000 people with diabetes was 840, but the observed rate was 936.
In their commentary, Hopkins and Rubino observe that the researchers were unable to assess the impact of pandemic disruption on nonfatal outcomes “such as hospital admission or progression of diabetes complications,” and call for more studies to address this.
“Furthermore, given the time course for progression of diabetes complications, the effect of the disruption of care due to the pandemic on diabetes outcomes will probably persist for some years,” they say.
Finally, the commentators highlight the “risk that restoration of both routine (mostly provided in a primary care setting) and specialist diabetes care might receive less attention than present major areas of focus of recovery planning: restoring elective surgery and diagnostic procedures, particularly around cancer pathways.”
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Lancet Diabetes Endocrinol 2022; doi:10.1016/S2213-8587(22)00131-0
Lancet Diabetes Endocrinol 2022; doi:10.1016/S2213-8587(22)00162-0