According to the EASD, more than 6.6 million diabetes tests were missed nationally over a 6-month period in 2020

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Over a 6-month period in 2020, more than 6.6 million diabetes tests were missed nationally, including 5.2 million diagnostic and 1.4 million monitoring HbA1c tests, according to a retrospective study presented at this year’s virtual meeting of the European Association for the Study of Diabetes (EASD). 

The analysis estimates that these data represent approximately 690,000 missed prediabetes and 68,500 missed diabetes diagnoses (mostly type 2 diabetes), with a resulting delay in lifestyle advice and treatment. Of those who missed HbA1c monitoring, the study estimated that more than 500,000 people would have had high HbA1c levels. 

The results were presented by Dave Holland, Lead Author from The Benchmarking Partnership, who worked in close collaboration with Tony Fryer, Professor of Clinical Biochemistry at Keele University. 

‘As many as a third of COVID-19 deaths in the UK have been in people with diabetes, and more may be at risk of the worst of the virus’ effects because so many have been unable to manage their diabetes effectively or have gone undiagnosed’, said Mr Holland.  

Professor Fryer explained that patients with suboptimal blood glucose levels that are poorly controlled experience worse outcomes with COVID-19. ‘These patients are also more likely to have complications, due to missed diagnoses or uncontrolled diabetes, that might not have occurred otherwise. Often, new diagnoses already have very high HbA1c levels, so they are at risk of complications if their diagnosis is delayed.’

Backlog 

Nikki Joule, Policy Manager at Diabetes UK, expressed her concern at the findings: ‘As we emerge from the pandemic, we know that many people are still waiting for a diabetes blood test or to see their diabetes team … if [the Government] is serious about preventing more costly complications from diabetes, it must urgently address the backlog in routine care. Further investment is vital to restore diabetes services and improve access to routine healthcare, to ensure people with diabetes have the care and support they need to live well with the condition.’ 

The number of missed HbA1c tests, both for diagnostic and monitoring purposes, were estimated during what the researchers termed the ‘COVID Impact Period’ between 23 March and 30 September 2020.

Also commenting, Professor Rousseau Gama, Consultant Chemical Pathologist at Black Country Pathology Services, The Royal Wolverhampton NHS Trust, said: ‘The COVID-19 pandemic led to reduced non-COVID healthcare delivery. This large study demonstrates the importance of regular blood tests to avoid missed or delayed diagnosis of diabetes, and in the management of patients with diabetes.  Although the consequences of these are unknown, it is clear that the pandemic has had a major impact on healthcare care delivery in diabetes. It is now important that people with diabetes are not left behind in the effort to address the backlog caused by the focus on COVID.’

Study details 

Data on HbA1c, used as a surrogate for disease control, were drawn from six UK testing laboratories representing 6% of the total UK population (3.7 million people). A combination of rural and urban populations, and various levels of deprivation, were included. In total, data on 3.6 million HbA1c tests in 1.7 million people were analysed. 

Mr Holland and Professor Fryer examined the potential impact of tests missed because of the COVID-19 pandemic on three subcategories of people: ‘monitoring’, including those already diagnosed with diabetes; ‘screening’, as part of general health screening schemes such as the Health Check programme in England; and ‘diagnostic’, for new cases of type 1 and 2 diabetes (mostly type 2) in those people presenting with symptoms of diabetes considered at risk.  

Findings of HbA1c testing across the six centres over the 6-month period, compared with the 12 months before lockdown, showed that: the number of monitoring tests dropped from 32,000 to 19,000 per month; screening tests fell from 46,000 to 32,000 per month; and diagnostic tests more than halved, from 31,000 to 12,000 per month. In April 2020, overall HbA1c testing levels fell by 80%.

Across the 6 months, 79,000 monitoring tests were missed, 28,500 of these among people with suboptimal control. Professor Fryer said that missed tests in this population were particularly concerning: ‘These patients have most to lose with COVID, considering that diabetes and COVID makes for a bad combination. 

‘In these [patients], we see an average increase in HbA1c of 2–3 mmol/l over 6 months’, he added. ‘In contrast, in those who are well controlled, the missed tests didn’t make much difference. 

‘We believe that those patients who miss monitoring tests come off the worst of all, because their disease is usually more advanced’, Professor Fryer explained. ‘The question is, will we be able to catch up and help these patients regain the 6 months lost? This is still unknown, and I would be surprised if this happens.’

More than 149,000 screening tests in high-risk groups—people with comorbidities, such as diabetes in pregnancy, polycystic ovary syndrome, cardiovascular disease, or sleep apnoea, as well as those screened as part of Health Check programmes—were also missed. This included nearly 27,000 people with HbA1c values within the pre-diabetes range, in whom lifestyle advice would have been delayed.

In addition, 142,000 diagnostic tests were missed in those who sought a test as a result of concerning symptoms. Of these, around 12,000 would be expected to be in the prediabetes range for HbA1c, and 3800 in the diabetes range. 

‘It is estimated that 5–10% of patients with prediabetes convert to diabetes each year’, Professor Fryer said. ‘This suggests that tens of thousands of these patients are likely to become patients with full-blown diabetes across the UK because of the missed tests.’

When results were extrapolated across the UK, missed or delayed diagnostic or screening tests amounted to 5.19 million (on average, 0.82 million per month) over the 6-month period. This would have included approximately 690,000 people in the prediabetes range and 68,500 delayed new diagnoses of diabetes (approximately 110,000 and 11,000 per month, respectively).  

Routine tests cancelled through fear of infection  

‘COVID-19 caused more damage than we realised’, explained Mr Holland. ‘Access to GP services became particularly difficult during the pandemic, with GP practices cancelling or postponing appointments for routine testing and review as the country went into “lockdown”.  Furthermore, many “high-risk” patients—including people with diabetes—were reluctant to visit their GP, fearful that they might catch COVID-19.’

On reflection, Professor Fryer pointed out: ‘COVID has pushed us in the direction of finding different solutions—so, for example, finger-prick tests [rather than standard blood tests] might have meant patients could have continued to monitor at home rather than miss a surgery appointment.’

He also highlighted that the findings showed that better ways of identifying at-risk groups were needed. ‘Our data show that, in people whose diabetes is well controlled, we don’t need to monitor so frequently because it doesn’t make a huge amount of difference—but those whose diabetes is less well controlled need to be supported more effectively, especially in the context of challenging situations as seen with COVID.’ 

Mr Holland said: ‘With limited resources available, we should use these on those patients most at risk of complications.’

Presented at the online meeting of the Annual Meeting of the EASD, Abstract 30. Tuesday 27 September 2021.

This article originally appeared on Medscape, part of the Medscape Professional Network.

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