Diabetes, the Covid Cinderella

You take a call tomorrow from Mr Ali. He is 68 and has type 2 diabetes. He is calling about recent onset heel pain and has what sounds like plantar fasciitis. You give appropriate advice, signpost self-help and resources, and offer to follow up if things do not improve. You have a long list of other calls to make and you are eager to move on. So, do you take the time to opportunistically check when he last had his diabetes reviewed?

In 2020 the impact of the pandemic on healthcare provision was of course profound in many areas, and in particular, the impact on mental health and cancer diagnosis has received a lot of publicity. But evidence is only now starting to emerge on the impact on diabetes care, begging the question is diabetes a forgotten casualty of the pandemic, a new ‘Covid Cinderella’?

Recent data Lancet, Diabetes & Endocrinology May 2021 suggests that it is. This is the first UK wide study reporting the indirect effects of the pandemic on type 2 diabetes and shows that the impact of the pandemic on diabetes services has been ‘enormous’. Based on data from 25M patients from 1831 UK general practices the authors found:

• Significant reductions in new diagnoses of type 2 diabetes in UK primary care last year when compared with a 10 year historical trend, with a rate reduction of new diagnoses of 0.70
• They estimate that between March and December there were 60,000 missed or delayed diagnoses of diabetes across the UK
• People aged over 65, men and those from deprived areas had the greatest reductions in diagnosis rates
• There was evidence of significantly reduce monitoring, with rates of HBA1c testing greatly reduced in 2020 across the UK especially in older people e.g. a rate reduction of 0.3 in England between March and December
• There were significant reductions in new prescriptions, including metformin reflecting the reduced rate of diagnoses and insulin reflecting a failure to intensify care

The authors conclude that this evidence of reductions in diagnosis, monitoring and treatment of type 2 diabetes during the pandemic has important clinical and public health implications and we need to prioritise diabetes care now especially in men, those aged over 65 and those living in deprived communities. Pre-pandemic there were already concerns of ‘clinical inertia’, with failure to appropriately escalate treatment when needed, and the authors express concern that this will now be much worse.  

It is hard to argue with these conclusions and I suspect that most practices are now working very hard trying to catch up with their diabetes checks.  But, in the face of the current huge workload and pent-up demand across the system there are clearly risks of further diagnostic delays and missed treatment opportunities. When reviews are done and diabetes control is found to be sub-optimal, heavy workload and the associated ‘hassle bias’ is likely to add significantly to ‘clinical inertia’. All of this has serious potential implications for our patients’ long-term health.

So how will this data affect how I handle my call with Mr Ali tomorrow? His plantar fasciitis is painful and needs help, but it is not going to cause serious vascular, renal or metabolic consequences or shorten his life. In the face of covid we need to prioritise, and this new data confirm that diabetes absolutely needs to be a priority to prevent it becoming a new ‘Covid Cinderella’. So, ‘note to self’, I will take the few extra minutes I need with Mr Ali to check and make sure his diabetes is not forgotten collateral damage from the pandemic, and I’ll take those minutes back from lower priority cases later in the day.  

To help you get to grips again with diabetes care, do join us for our live and fully interactive diabetes course on June 12th. The course will also be available on demand and is of course included in your NB Plus subscription.