COMMENTARY

How 2020 Changed Diabetes and Primary Care

Prof Kamlesh Khunti 

Disclosures

December 24, 2020

This transcript has been edited for clarity.

Hello, my name is Kamlesh Khunti, I’m professor of primary care diabetes and vascular medicine at the University of Leicester.

We are nearly at the end of the year and what a year it's been. The COVID-19 pandemic has had a major impact globally, with 71 million people being infected worldwide, and 1.6 million deaths due to COVID as of mid-December 2020. Little did we know in March that we would expand our vocabulary, with new words and phrases that would be used in daily conversations. These include social distancing, furlough scheme, R reproduction number, social isolation, quarantine, lockdown, and long COVID, are some of them.

Little did we envisage that wearing masks would become mandatory, or that working from home would become the norm for many who would become experts at MS Teams and Zoom virtual meetings, and learn even to change our virtual backgrounds.

Practice Changes

During the COVID-19 pandemic attention has been diverted away from primary care’s key roles in early detection of disease and management of long-term conditions. Clinical practice has changed beyond recognition, with the majority of consultations being by telephone or virtually.

Our patients have been very understanding and have embraced the new ways of working.

Some primary care practices have been innovative and seen patients in the carpark to reduce exposure by having the consultations outside.

Unfortunately, this is not ideal for people with chronic long-term conditions, particularly cardiometabolic conditions. Although telehealth reduces patients’ direct exposures to infection, it cannot entirely replace face-to-face contacts. Physical examinations are still needed to make certain diagnoses and to enhance the human connections between patients and clinicians.

Certain conditions, such as diabetes, cardiovascular disease, hypertension, chronic kidney disease, and chronic obstructive pulmonary disease have been shown to be associated with the increased risk of infection, hospitalisation, and mortality.

However, there have been excess deaths due to also the disruption of services because of the pandemic. Unfortunately, delays in diagnosis and suboptimal management of people with long-term conditions will cause rises in non-COVID mortality going forward as well.

Global surveys have shown that diabetes was the condition most reported impacted by the reduction in healthcare resources due to COVID-19, followed by chronic obstructive pulmonary disease, hypertension, heart disease, asthma, cancer, and depression.

Additionally, the two most common co-occuring chronic conditions for which care was impacted by COVID-19 were diabetes and hypertension.

A lack of access to routine health care is a leading cause of morbidity and mortality after disasters, and we've seen this in other disasters. So things such as stroke, acute myocardial infarctions, and diabetes complications are all shown to increase after the immediate threat has been dissipated.

However, there is now some good news on the horizon, with the prospect of a COVID vaccine being our main hope of coming out of this dreaded pandemic.

2021

So what should we be planning for the new year?

Well, the priority will be to vaccinate the most vulnerable, including the elderly and those with chronic conditions. Psychological stress has also increased during the pandemic and many people with chronic long-term conditions such as diabetes, and cardiovascular disease have been shielding, and have been unable to continue with routine lifestyle interventions such as exercise.

All these factors and the added burden of mental health will lead to worse risk factor control.

We therefore need to resume normal services and start arranging routine bloods and review clinics for our patients with chronic conditions.

We need to ensure we improve risk factor control for our patients with chronic cardiometabolic conditions, including blood pressure, HbA1c, and lipid control.

We will also have a number of patients who have been affected with COVID, and we will need to monitor these people very closely for consequences of long COVID.

It is too early to predict what the 'new normal' will look like. We must learn the important lessons from COVID-19 and previous pandemics to avoid the suboptimal management of long-term conditions contributing to the avoidable excess mortality in the medium-term.

Practitioners will need to consider ways of proactively identifying these patients with long-term conditions, who are most at risk of suboptimal management, to ensure that the necessary care is maintained urgently after we come out of COVID.

In summary, people with cardiometabolic conditions have been impacted significantly during the pandemic, and now we need to plan to get back to normal services and ensure we reduce the risk of major indirect consequences of COVID in our patients with long-term conditions.

On that note, I wish you a happy, safe, and peaceful festive break. Thank you.

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