The impact of the COVID pandemic on primary care diabetes services in the UK: A cross-sectional national survey of views of health professionals delivering diabetes care

Adapting to compromised routines: Parental perspectives on physical activity and health for children and adolescents with type 1 diabetes in the UK during COVID-19 lockdown

PURPOSE

To determine how COVID-19 lockdown impacted physical activity (PA) levels, wellbeing, and diabetes management in children (aged 0-17 years) with type 1 diabetes (T1D), from the perspectives of their parent/guardian.

DESIGN AND METHODS

This qualitative descriptive study is part of a larger, parallel mixed-methods design study, which incorporated a cross-sectional survey and semi-structured one-to-one interviews. Interviewees were recruited from the survey, which was distributed to parents of children/adolescents with T1D in the UK. Interviews explored diabetes management, mental and physical wellbeing, changes in PA levels, sleep quality before/during lockdown, and the effects of lockdown on the individual and their family. The interviews were transcribed and the data were analysed thematically.

RESULTS

14 interviews were conducted with parents. Thematic analysis generated a central theme of routine disruption, with four further themes on diabetes management routines, harnessing the opportunities of lockdown, weighing up risk, and variable impact on wellbeing.

CONCLUSIONS

Maintaining or increasing PA during COVID-19 lockdown was associated with better diabetes management, sleep, and wellbeing for children/adolescents with T1D, despite significant disruption to established routines. Use of technology during the pandemic contributed positively to wellbeing.

PRACTICE IMPLICATIONS

It is crucial to emphasize the significance of maintaining a well-structured routine when treating patients with type 1 diabetes. A consistent routine, incorporating regular physical exercise and good sleep hygiene, will help with managing overall diabetes control.

Indirect effects of the COVID-19 pandemic on diagnosing, monitoring, and prescribing in people with diabetes and strategies for diabetes service recovery internationally

The COVID-19 pandemic has caused major disruptions in clinical services for people with chronic long-term conditions. In this narrative review, we assess the indirect impacts of the COVID-19 pandemic on diabetes services globally and the resulting adverse effects on rates of diagnosing, monitoring, and prescribing in people with type 2 diabetes. We summarise potential practical approaches that could address these issues and improve clinical services and outcomes for people living with diabetes during the recovery phase of the pandemic.

Characteristics and outcomes of people living with HIV hospitalised at tertiary healthcare institutions during the COVID-19 pandemic in Mexico City

BACKGROUND

While existing research on people living with HIV (PWH) during the COVID-19 pandemic primarily focused on their clinical outcomes, a critical gap remains in understanding the implications of COVID-19 delivery of in-hospital care services to PWH. Our study aimed to describe the characteristics and outcomes of PWH hospitalised during 2020 in Mexico City, comparing patients admitted due to COVID-19 vs. patients admitted due to other causes.

METHODS

All PWH hospitalised for ≥ 24 h at four institutions in Mexico City from January 1st to December 31st, 2020 were included. Patients were classified into two groups according to the leading cause of their first hospitalisation: COVID-19 or non-COVID-19. Characteristics among groups were compared using chi-square and Kruskal tests. A Cox model was used to describe the risk of death after hospitalisation and the characteristics associated with this outcome. Mortality and hospitalisation events were compared to data from 2019.

RESULTS

Overall, we included 238 PWH hospitalised in 2020. Among them, 42 (18%) were hospitalised due to COVID-19 and 196 (82%) due to non-COVID-19 causes, mainly AIDS-defining events (ADE). PWH hospitalised due to COVID-19 had higher CD4 + cell counts (380 cells/mm3 [IQR: 184-580] vs. 97 cells/mm3 [IQR: 34-272], p < 0.01) and a higher proportion of virologic suppression (VS) compared to those hospitalised due to non-COVID-19 causes (92% vs. 55%, p < 0.01). The adjusted hazard ratio (aHR) for AIDS was 3.1 (95%CI: 1.3-7.2). COVID-19 was not associated with death (aHR 0.9 [95%CI: 0.3-2.9]). Compared to 2019, mortality was significantly higher in 2020 (19% vs. 9%, p < 0.01), while hospitalisations decreased by 57%.

CONCLUSIONS

PWH with COVID-19 had higher VS and CD4 + cell counts and lower mortality compared to those hospitalised due to non-COVID-19-related causes, who more often were recently diagnosed with HIV and had ADEs. Most hospitalisations and deaths in 2020 in PWH were related to advanced HIV disease. The increased mortality and decreased hospitalisations of PWH during 2020 evidence the impact of the interruption of health services delivery for PWH with advanced disease due to the pandemic. Our findings highlight the challenges faced by PWH during 2020 in a country where advanced HIV remains a concern.

Interprofessional collaboration to improve care for patients with diabetes

BACKGROUND

The COVID-19 pandemic resulted in decreased access to routine diabetes care in rural areas and adversely affected self-management of diabetes.

METHODS

This article describes a descriptive pretest-posttest study conducted to assess efficacy in managing hemoglobin A1C (A1C) among patients with type 2 diabetes mellitus (T2DM) using a continuous glucose monitoring (CGM) system for 1 year.

RESULTS

A total of 14 participants completed the Diabetes Mellitus Self-Efficacy Scale survey. Of those 14, 11 used CGM for 1 year; of the 11 who maintained CGM use, A1C levels improved in 9.

CONCLUSIONS

Results indicate that CGM combined with medication management positively impacts self-efficacy in managing A1C levels among patients with T2DM. Interdisciplinary collaboration optimizes patient outcomes.

Impact of COVID-19 on essential healthcare services at the primary healthcare level in Armenia: a qualitative study

BACKGROUND

The COVID-19 pandemic has presented significant global healthcare challenges, particularly impacting the continuity of essential health services in low- and middle-income countries. This study investigates the impact of the COVID-19 pandemic on the utilization and provision of essential health services in Armenia.

METHODS

We employed a conventional qualitative study design, conducting semi-structured in-depth interviews (n = 17) within public and private primary healthcare (PHC) facilities in Armenia in 2021. Our study participants encompassed physicians providing specialty services in PHC facilities (e.g. endocrinologists, gynecologists/obstetricians, and pediatricians), regular visitors to PHC facilities (e.g. adults with chronic diseases, parents of children), and policymakers. Thematic analysis was conducted, yielding five emergent categories: mobilization and organization of PHC services during COVID-19; PHC visits during COVID-19; worsening of chronic conditions due to the decline in PHC visits; problems with routine childhood vaccinations; and patient-provider communication challenges.

RESULTS

The number of in-person visits to PHC facilities declined due to adaptations in service delivery, imposed lockdown measures, and the public's fear of visiting healthcare facilities. Maternal and child health services continued with no major disruptions. PHC providers deliberately limited the number of maternal and child visits to essential antenatal care, newborn screenings, and routine childhood immunizations. Still, children experienced some delays in vaccination administration. The pandemic resulted in a notable reduction in follow-up visits and monitoring of patients with chronic conditions, thereby exacerbating their chronic conditions. Phone calls were the primary method of patient-provider communication during the pandemic.

CONCLUSIONS

The COVID-19 pandemic has had a profound impact on the delivery and utilization of essential healthcare services at PHC facilities, especially for those with chronic conditions who needed continuous care. Unified national-level guidance and technical capacity are needed to direct the provision of essential services at the PHC level, promote effective health communication, and implement digital platforms for the uninterrupted provision of essential care during public health emergencies.

Urine ACR uptake in patients with a diagnosis of type 1 and 2 diabetes mellitus in a primary care setting: A cross sectional study

BACKGROUND AND OBJECTIVES

A recent change in the diabetes Quality and Outcomes Framework (QOF) retired the mandatory testing of urinary ACR. We designed a study demonstrates the impact of this change in a primary healthcare setting. This is relevant as a significant proportion of the NHS budget is spent on managing microvascular and macrovascular complications that result from type 1 and 2 Diabetes mellitus.

METHODS

Our cross-sectional study collected testing data for 482 patients in a primary care setting. Based on the results seen from the first set of data collection, an intervention was offered to the clinicians by way of clinical presentation that emphasised and refreshed the knowledge of the latest NICE guidelines on urine ACR collection. Subsequently, a second set of data collection was conducted to assess the success, if any, of changes implemented based on the intervention made RESULTS: Our study demonstrates the drastic decrease in uptake of ACR testing in the primary care setting that took place following the change in the diabetes QOF.

CONCLUSION

The study highlights the need for the reintroduction of such a QOF measure to enable regular monitoring of early signs of nephropathy, thereby allow the timely commencement treatment as deemed appropriate. Furthermore, detecting the development of such complications in diabetic patients, in a timely manner, has the potential to reduce the financial footprint associated with treating the complications resulting from this condition.

Delivering Primary Health Care (PHC) Services for Controlling NCDs During the COVID-19 Pandemic: A Scoping Review

Non-communicable diseases (NCDs) are the leading cause of death worldwide. NCDs also increase mortality from COVID-19 and primary health care (PHC) services are an important component in the prevention and control of long-term NCDs. The main goal of the present study was to review primary healthcare services for the NCDs patients via primary healthcare network during COVID-19 pandemic. In this scoping review, Search engines including PubMed, Scopus, and Science-direct up to 1st February 2022 were searched to identify studies regarding primary care services for NCDs patients via primary health care during COVID-19 pandemic. A total of 42 studies met the inclusion criteria and were included in our analysis. 24 studies were about the status and changes of primary health services for NCDs patients in PHC settings, while 18 studies focused on adaptive strategies used during COVID-19 in different countries including United States, Canada, United Kingdom, Portugal, Georgia, South Africa, Thailand, Mexico, India, Kenya, Guatemala and Saudi Arabia. These strategies included remote monitoring, follow up, consultation, empowerment and educational services as well as home visiting Disruption of NCDs services in PHC during the COVID-19 pandemic was observed in different countries, which highlights the urgency of attention of researchers and policy-makers to development of appropriate and adaptive policies to improve PHC service coverage and its quality during the pandemics.

Blood glucose, blood pressure, and cholesterol testing among adults with diabetes before and during the COVID-19 pandemic, USA, 2019 vs 2021

INTRODUCTION

Regular blood glucose/A1c, blood pressure (BP), and cholesterol (ABC) testing is important for diabetes management. It is unknown whether pandemic-related disruptions in medical care were negatively associated with ABC testing among US adults with diagnosed diabetes.

RESEARCH DESIGN AND METHODS

A cross-sectional analysis was conducted among adults ≥18 years with diagnosed diabetes who participated in the 2019 or 2021 National Health Interview Survey (n=3355 and n=3127, respectively). Adults with diabetes self-reported sociodemographic and diabetes-related characteristics, ABC testing in the past year, and delays or not getting medical care due to the pandemic (2021 only). Descriptive statistics were used to determine differences in ABC testing in 2019 vs 2021. Logistic regression models were used to assess the association between delays or not getting medical care due to the pandemic and ABC testing, adjusting for sociodemographic characteristics, diabetes duration, and diabetes medication use.

RESULTS

Overall, the prevalence of having a blood glucose/A1c or a BP test in the past year was high (>90%) but it was significantly lower in 2021 compared with 2019 (A1c: 94.2% vs 96.8%, p<0.001; BP: 96.8% vs 98.4%, p=0.002, respectively). Cholesterol testing remained stable (93.0% in 2021 vs 94.5% in 2019, p=0.053). In logistic regression analysis, after full adjustment, adults who reported delaying or not getting medical care when needed due to the pandemic were 50% less likely to get an ABC test in the past year compared with those who promptly received medical care (A1c: adjusted OR (aOR)=0.44, 95% CI 0.29-0.68; BP: aOR=0.48, 95% CI 0.27-0.85; cholesterol: aOR=0.48, 95% CI 0.31-0.75).

CONCLUSIONS

Disruptions in medical care during the pandemic were associated with a decrease in ABC testing. Future research is needed to assess whether blood glucose/A1c and BP testing returns to prepandemic levels and if reductions in these tests result in excess diabetes-related complications.

The Hypothetical Psychological Impact of the COVID-19 Pandemic on Pediatrics and Pediatric Emergency Admissions: Evidence from Autoregressive Distributed Lag Model Method

OBJECTIVE

The COVID-19 pandemic and related deaths affected the number of admissions of patients to hospitals. However, no study has been found that examines the short and long-term psychological effects of children or their possible psychiatric admissions to hospitals during the pandemic period. In this context, the study aims to analyze the behaviors of individuals under the age of 18 in their health service utilization during the COVID-19 pandemic period.

MATERIALS AND METHOD

For the study, whether the pandemic and psychiatry department (PSY) admissions affect the pediatrics department (PD) and pediatric emergency department (PED) admissions of children was investigated. The sample was taken from hospitals in Sivas between 2019 and 2021. Autoregressive dis- tributed lag (ARDL) model is applied. The ARDL is an econometric method that can estimate the existence of the long-term correlations (cointegration) of variables and the short and long-term effects of explanatory variables on the dependent variable.

RESULTS

In the PED application model, the number of deaths, representing the impact of the pandemic, decreased the number of PED applications, while the number of vaccinations increased. On the other hand, applications to the PSY decreased in the short term, but increased in the long term. In the model of pediatric department admissions, in the long term, the number of new COVID-19 cases has decreased the number of PD admissions, while the number of vaccines has increased. While applications made to PSY in the short term have decreased the applications of PD, they have increased in the long term. As a result, the pandemic decreased both children's department admissions. In addition, admissions to PSY, which had greatly decreased in the short term, increased rapidly in the long term.

CONCLUSION

Providing psychological support to both children and adolescents and their guardians during and after the pandemic should be included in planning.

Availability and access to pediatric diabetes care: a global descriptive study

A decade since the discovery of insulin, the increasing prevalence of type 1 diabetes mellitus (T1DM) has underscored the prevailing inequalities in the provision of essential care for T1DM worldwide. However, the details on the availability of insulin types and associated medical devices remain unclear. A cross-sectional electronic survey was distributed across a global network of pediatric societies under the umbrella of the International Pediatric Association (IPA). Access to and availability of pediatric diabetes care were investigated using standardized questions. Responses from 25 of 132 pediatric societies across six regions were included. Pediatric endocrinologists typically manage T1DM together with pediatricians or adult endocrinologists. Nonetheless, 24% of the respondents reported pediatricians to be the sole healthcare professionals. According to the respondents, the patients were either partially or completely responsible for payments of insulin (40%), A1C (24%), C-peptide (28%), and antibody testing for diagnosis (28%). Government support is generally available for insulin, but this was merely 20% for insulin pumps and 12% for continuous glucose monitors. There are considerable disparities in the access, availability, and affordability of diabetes testing, medications, and support between countries with significant out-of-pocket payments for care. Country- and region-specific improvements to national programs are necessary to achieve optimal pediatric diabetes care globally.

The Effect of the COVID-19 Pandemic on HbA1c Testing: Prioritization of High-Risk Cases and Impact of Social Deprivation

INTRODUCTION

Studies show that the COVID-19 pandemic disproportionately affected people with diabetes and those from disadvantaged backgrounds. During the first 6 months of the UK lockdown, > 6.6 M glycated haemoglobin (HbA1c) tests were missed. We now report variability in the recovery of HbA1c testing, and its association with diabetes control and demographic characteristics.

METHODS

In a service evaluation, we examined HbA1c testing across ten UK sites (representing 9.9% of England's population) from January 2019 to December 2021. We compared monthly requests from April 2020 to those in the equivalent 2019 months. We examined effects of (i) HbA1c level, (ii) between-practice variability, and (iii) practice demographics.

RESULTS

In April 2020, monthly requests dropped to 7.9-18.1% of 2019 volumes. By July 2020, testing had recovered to 61.7-86.9% of 2019 levels. During April-June 2020, we observed a 5.1-fold variation in the reduction of HbA1c testing between general practices (12.4-63.8% of 2019 levels). There was evidence of limited prioritization of testing for patients with HbA1c > 86 mmol/mol during April-June 2020 (4.6% of total tests vs. 2.6% during 2019). Testing in areas with the highest social disadvantage was lower during the first lockdown (April-June 2020; trend test p < 0.001) and two subsequent periods (July-September and October-December 2020; both p < 0.001). By February 2021, testing in the highest deprivation group had a cumulative fall in testing of 34.9% of 2019 levels versus 24.6% in those in the lowest group.

CONCLUSION

Our findings highlight that the pandemic response had a major impact on diabetes monitoring and screening. Despite limited test prioritization in the > 86 mmol/mol group, this failed to acknowledge that those in the 59-86 mmol/mol group require consistent monitoring to achieve the best outcomes. Our findings provide additional evidence that those from poorer backgrounds were disproportionately disadvantaged. Healthcare services should redress this health inequality.

Impact of COVID-19 Pandemic on Healthcare Utilization among Patients with Type 2 Diabetes Mellitus: A Systematic Review

As the COVID-19 pandemic continues, healthcare services have been grossly overwhelmed by the pandemic. Due to this circumstance, routine care for individuals with type 2 diabetes mellitus (T2DM) has been temporarily disrupted. The purpose of this systematic review was to summarize the evidence regarding the impact of the COVID-19 pandemic on healthcare utilization among patients with T2DM. A systematic search was conducted in the Web of Science, Scopus, and PubMed databases. The process of identifying the final articles followed the PRISMA guidelines. The inclusion criteria were articles published between 2020 and 2022, written in English, and studies focusing on the research question. Any proceedings and books were excluded. A total of fourteen articles relevant to the research question were extracted. Following that, the included articles were critically appraised using the Mixed Method Appraisal Tool (MMAT) and the Joanna Briggs Institute Critical Appraisal Tool to assess the quality of the studies. The findings were further classified into three themes: reduced healthcare utilization among T2DM patients in routine healthcare services, a surge of telemedicine usage, and delay in the delivery of healthcare services. The key messages include demands for monitoring the long-term effects of the missed care and that better preparedness is crucial for any pandemic in the future. A tight diagnostic workup at the community level and regular follow-ups are crucial in managing the impact of the pandemic among T2DM patients. Telemedicine should be on the agenda of the health system to maintain and complement healthcare services. Future research is warranted to determine effective strategies to deal with the impact of the pandemic on healthcare utilization and delivery among T2DM patients. A clear policy is essential and should be established.

Self-rated knowledge and competence regarding the management of chronic kidney disease in primary care: A cross-sectional European survey of primary care professionals

BACKGROUND

Diabetes is a major risk factor for chronic kidney disease (CKD), which is a leading cause of global morbidity and mortality and also associated with substantial costs to healthcare systems. Despite the current best practice standards of care, management of CKD in diabetes in the primary care setting remains an ongoing challenge. Using an online survey, we aimed to assess the self-rated knowledge and competence of primary care professionals involved in the management of CKD in diabetes in the European region.

METHODS

An online anonymous survey was developed by the Primary Care Diabetes Europe research group and administered to primary care professionals involved in managing CKD in diabetes from 23rd March 2022-9 th October 2022. Descriptive statistics were used to summarise questionnaire responses. Factors influencing ability to initiate treatment strategies were evaluated using logistic regression.

RESULTS

A total of 266 respondents (51.9% males) completed the questionnaire. Most respondents were GPs (82.7%) followed by nurses (9.4%). The age of respondents ranged from 25 to 72 years with a median of 51 years. About a third of respondents indicated that they were fully confident in the screening and diagnosis of CKD in diabetes. With regards to CKD presentation, staging and prognosis, 16.5-21.8% of respondents stated they were fully confident in this area; however, about 11% of respondents were not confident on how to predict CKD prognosis using established clinical guidelines. About a third of respondents stated they were confident without support regarding the complications of kidney disease in diabetes and it being a risk multiplier; just a quarter of respondents were fully confident. A third of respondents stated they were fully confident regarding appropriate management strategies for preventing or slowing down the progression of CKD and the initiation of newer agents. In multivariable analyses, confidence in the knowledge of the stages of kidney disease and criteria for the diagnosis of kidney disease were each associated with an increased odds in the confidence to select and initiate appropriate management strategies.

CONCLUSIONS

With regards to almost all aspects of management of CKD in diabetes, only up to a third of primary care professionals stated they are fully confident and are able to teach others; the majority are confident but would like to know more or require extra support. This may be a contributor to the challenges faced in providing optimal CKD care in people with diabetes in the primary care setting. Effective interventions that can promote the uptake of best practice clinical guidelines in primary care are urgently needed.

4. Comprehensive Medical Evaluation and Assessment of Comorbidities: Standards of Care in Diabetes-2023

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

The impact of the COVID-19 pandemic on diabetes services: planning for a global recovery

The COVID-19 pandemic has disproportionately affected certain groups, such as older people (ie, >65 years), minority ethnic populations, and people with specific chronic conditions including diabetes, cardiovascular disease, kidney disease, and some respiratory diseases. There is now evidence of not only direct but also indirect adverse effects of COVID-19 in people with diabetes. Recurrent lockdowns and public health measures throughout the pandemic have restricted access to routine diabetes care, limiting new diagnoses, and affecting self-management, routine follow-ups, and access to medications, as well as affecting lifestyle behaviours and emotional wellbeing globally. Pre-pandemic studies have shown that short-term delays in delivery of routine care, even by 12 months, are associated with adverse effects on risk factor control and worse microvascular, macrovascular, and mortality outcomes in people with diabetes. Disruptions within the short-to-medium term due to natural disasters also result in worse diabetes outcomes. However, the true magnitude of the indirect effects of the COVID-19 pandemic on long-term outcomes and mortality in people with diabetes is still unclear. Disasters tend to exacerbate existing health disparities; as we recover ambulatory diabetes services in the aftermath of the pandemic, there is an opportunity to prioritise those with the greatest need, and to target resources and interventions aimed at improving outcomes and reducing inequality.

COVID-19 pandemic impact on people with diabetes: results from a large representative sample of Italian older adults

AIMS

Restrictions imposed to prevent SARS-CoV-2 transmission should be weighed against consequences on vulnerable groups' health. Lifestyles and disease management of older people with diabetes might have been differentially impacted compared to non-chronic individuals.

METHODS

A cross-sectional study (LOST in Lombardia) was conducted on a representative full sample of 4 400 older adults (17^th-30^th November 2020), collecting data on lifestyles, mental health and access to care before and during the pandemic.

RESULTS

We compared 947 (51.9%) people with diabetes and 879 (48.1%) healthy subjects reporting no chronic conditions. People with diabetes reported more frequently increased physical activity (odds ratio, OR 2.65, 95% confidence internals, CI 1.69-4.13), drinks/week reduction (OR 6.27, 95%CI 3.59-10.95), increased consumption of fruit (OR 2.06, 95%CI 1.62-2.63), vegetables (OR 1.41, 95%CI 1.10-1.82), fish (OR 2.51, 95%CI 1.74-3.64) and olive oil (OR 3.54, 95%CI 2.30-5.46). People with diabetes increased telephone contacts with general practitioners (OR 3.70, 95%CI 2.83-4.83), hospitalisations (OR 9.01, 95%CI 3.96-20.51), visits and surgeries cancellations (OR 3.37, 95%CI 2.58-4.42) and treatment interruptions (OR 1.95, 95%CI 1.33-2.86).

CONCLUSIONS

Pandemic adverse effects occurred but are heterogenous in a population with chronic diseases, who seized the opportunity to improve health behaviours, despite health system difficulties guaranteeing routine care, within and beyond COVID-19.

Association of COVID-19 With Major Arterial and Venous Thrombotic Diseases: A Population-Wide Cohort Study of 48 Million Adults in England and Wales

BACKGROUND

Infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) induces a prothrombotic state, but long-term effects of COVID-19 on incidence of vascular diseases are unclear.

METHODS

We studied vascular diseases after COVID-19 diagnosis in population-wide anonymized linked English and Welsh electronic health records from January 1 to December 7, 2020. We estimated adjusted hazard ratios comparing the incidence of arterial thromboses and venous thromboembolic events (VTEs) after diagnosis of COVID-19 with the incidence in people without a COVID-19 diagnosis. We conducted subgroup analyses by COVID-19 severity, demographic characteristics, and previous history.

RESULTS

Among 48 million adults, 125 985 were hospitalized and 1 319 789 were not hospitalized within 28 days of COVID-19 diagnosis. In England, there were 260 279 first arterial thromboses and 59 421 first VTEs during 41.6 million person-years of follow-up. Adjusted hazard ratios for first arterial thrombosis after COVID-19 diagnosis compared with no COVID-19 diagnosis declined from 21.7 (95% CI, 21.0-22.4) in week 1 after COVID-19 diagnosis to 1.34 (95% CI, 1.21-1.48) during weeks 27 to 49. Adjusted hazard ratios for first VTE after COVID-19 diagnosis declined from 33.2 (95% CI, 31.3-35.2) in week 1 to 1.80 (95% CI, 1.50-2.17) during weeks 27 to 49. Adjusted hazard ratios were higher, for longer after diagnosis, after hospitalized versus nonhospitalized COVID-19, among Black or Asian versus White people, and among people without versus with a previous event. The estimated whole-population increases in risk of arterial thromboses and VTEs 49 weeks after COVID-19 diagnosis were 0.5% and 0.25%, respectively, corresponding to 7200 and 3500 additional events, respectively, after 1.4 million COVID-19 diagnoses.

CONCLUSIONS

High relative incidence of vascular events soon after COVID-19 diagnosis declines more rapidly for arterial thromboses than VTEs. However, incidence remains elevated up to 49 weeks after COVID-19 diagnosis. These results support policies to prevent severe COVID-19 by means of COVID-19 vaccines, early review after discharge, risk factor control, and use of secondary preventive agents in high-risk patients.

Less Timely Initiation of Glucose-Lowering Medication Among Younger and Male Patients With Diabetes and Similar Initiation of Blood Pressure-Lowering Medication Across Age and Sex: Trends Between 2015 and 2020

Aims: We aimed to assess trends in glycosylated hemoglobin A1c (HbA1c) and systolic blood pressure (SBP) thresholds at initiation of glucose- and blood pressure-lowering medication among patients with type 2 diabetes and assess the influence of age and sex on these trends.

Materials and Methods: We used the Groningen Initiative to ANalyze Type 2 diabetes Treatment (GIANTT) primary care database. Patients initiating a first non-insulin glucose-lowering or any blood pressure-lowering medication between 2015 and 2020 with an HbA1c or SBP measurement in the 120 days before initiation were included. We used multilevel regression analyses adjusted for potential confounders to assess the influence of calendar year, age or sex, and the interaction between calendar year and age or sex on trends in HbA1c and SBP thresholds at initiation of medication.

Results: We included 2,671 and 2,128 patients in the analyses of HbA1c and SBP thresholds, respectively. The overall mean HbA1c threshold at initiation of glucose-lowering medication significantly increased from 7.4% in 2015 to 8.0% in 2020 (p < 0.001), and particularly in the younger age groups. Compared to patients ≥80 years, patients aged 60–69 years initiated medication at lower levels mainly in the early years. Patients <60 years and between 70–79 years initiated medication at similar levels as patients ≥80 years. Females initiated medication at lower levels than males throughout the study period (p < 0.001). The mean SBP threshold at initiation of blood pressure-lowering medication varied from 145 to 149 mmHg without a clear trend (p = 0.676). There were no differences in SBP thresholds between patients of different ages or sex.

Conclusion: The rising trend in the HbA1c threshold for initiating glucose-lowering medication in the lower age groups was unexpected and requires further investigation. Males appear to receive less timely initiation of glucose-lowering medication than females. The lack of higher thresholds for the oldest age group or lower thresholds for the youngest age group in recent years is not in line with the age-related recommendations for personalized diabetes care and calls for health systems interventions.