Editor's note, 28 September 2021: This article was updated with additional comment.
Over a 6 month period in 2020 there were more than 6.6 million missed diabetes tests, including 5.2 million diagnostic and 1.4 million monitoring HbA1c tests nationally, 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 pre-diabetes and 68,500 missed diabetes diagnoses (mostly type 2 diabetes), with the resulting delay in lifestyle advice and treatment. Of those that missed HbA1c monitoring, it estimated that more than 500,000 people would have had high HbA1c levels.
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.
Prof Fryer explained that patients with suboptimal blood glucose levels that are poorly controlled experience worse outcomes with COVID. "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."
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 it [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 Mar 2020 and 30 Sep 2020.
Also commenting, Professor Rousseau Gama, consultant chemical pathologist, Black Country Pathology Services, The Royal Wolverhampton NHS Trust, told Medscape News UK: "The COVID 19 pandemic led to reduced non-COVID health care 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."
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 Prof Fryer examined the potential impact of these missed tests due to the COVID-19 pandemic on three sub-categories 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 the lockdown, showed that the number of monitoring tests dropped from 32,000 to 19,000 per month, while 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, with 28,500 of these for people with suboptimal control. These are a particular concern, Prof Fryer told Medscape News UK. "These patients have most to lose with COVID, considering that diabetes and COVID makes for a bad combination.
"In these, 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," Prof 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 co-morbidities, for example, 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 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 due to symptoms. Of these, around 12,000 would be expected to be in the pre-diabetes range for HbA1c, and 3800 in the diabetes range.
"It is estimated that 5-10% of patients with pre-diabetes convert to diabetes each year," Prof Fryer added. "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 in the pre-diabetes range and 68,500 delayed new diagnoses of diabetes (approximately 110,000 and 11,000 per month, respectively).
Routine Tests Cancelled, Fear of Infection and Spread
"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, Prof 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 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."
COI: The authors declare no conflicts of interest.
Presented at the online meeting of the Annual Meeting of the European Association for the Study of Diabetes (EASD), Abstract 30. Tuesday 27 September, 2021.
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Cite this: Becky McCall. More Than Six Million Diabetes Tests Missed Over Pandemic - Medscape - Sep 27, 2021.