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JJ竞技 2022 ; 378 doi: (Published 17 August 2022) Cite this as: JJ竞技 2022;378:o2045
  1. Jacqui Wise
  1. Kent

In addition to the health harms that arose as a direct consequence of the pandemic, significant indirect impacts include reduced diagnosis of some long term conditions. Jacqui Wise reports

A recent detailed briefing from the Department of Health and Social Care, in collaboration with the Office for National Statistics, summarises what is known about the short and long term health harms that have arisen as a consequence of covid-19 infections and mitigating behaviours. 1

How has the diagnosis of long term conditions been affected?

The report summarises an analysis by the Health Foundation’s REAL Centre showing persistent monthly reductions in recorded incidence of some conditions during the pandemic, particularly coronary heart disease (CHD), asthma, and atrial fibrillation (Afib).

The analysis uses the Clinical Practice Research Datalink, containing data from 19 million patients from 738 primary care practices in England. However, the analysis covers January 2016 to December 2021 and so precedes the period in which omicron was the dominant variant.

When compared with the 2019 average, from March 2020 to December 2021 an estimated 59 000 fewer new cases of Afib were recorded, 65 000 fewer new cases of CHD, and 17 000 fewer new cases of heart failure. This corresponds to a “missing” incidence (as a percentage of estimated prevalence in December 2021) of 4.7% of Afib, 3.3% of CHD, and 2.5% of heart failure.

The same period saw an estimated 107 000 fewer new cases of asthma and 87 000 fewer cases of chronic obstructive pulmonary disease (COPD). This corresponds to a missing prevalence of 1.5% of asthma and 8% of COPD.

Although the incidence of these conditions recovered somewhat in the latter part of 2020, it remains mostly below pre-pandemic levels. And, when compared with the 2019 average, March 2020 to December 2021 saw an estimated 26 000 fewer new cases of stroke and transient ischaemic attacks (TIAs), corresponding to a “missing” prevalence of 2.5%.

The report notes a sharp drop in the incidence of diabetes in March 2020 at the beginning of the pandemic, but by spring 2021 it had returned to the pre-pandemic trend.

Why were diagnoses of some conditions affected?

“During the pandemic, reduced use of primary care and infection control measures, which impacted some diagnostic testing, are likely to have led to reductions in the diagnoses of some conditions,” the report says.

While the incidence of heart failure has mostly returned to pre-covid levels, the rates of Afib and CHD have been largely below pre-pandemic trends, suggesting that new diagnoses were not formally made. This may be because testing for Afib is usually conducted in person as part of routine checks for elderly patients. Therefore, a potential contributory factor could be the shift to remote GP consultations, particularly at the beginning of the pandemic.

The lower rates of stroke and TIA were probably due to patients avoiding seeking care, especially early in the pandemic, rather than fewer strokes or TIAs occurring, the briefing paper says. 2 While the incidence per patient returned closer to the pre-pandemic trend in autumn 2020, the rate fell notably in July 2021 and has since been below the pre-covid trend.

On asthma and COPD, the report says that part of the rate reduction can be explained by the restrictions in spirometry testing that were implemented for infection control purposes during the pandemic. In addition, behavioural changes due to the pandemic have led to reductions in air pollution and lower circulation of respiratory viruses, which are triggers for asthma exacerbations.

Are cases truly being missed?

The report says that this is hard to know for certain, as it is not known how prevalence has changed during the pandemic. This can be influenced by a number of factors including changes in mortality, migration, and lifestyles. Patients can live with some conditions undiagnosed for long periods, such as COPD and Afib, while other people have a much shorter life expectancy with the same condition.

Are remote GP appointments to blame?

Although GP consultation rates fell sharply at the start of the pandemic, they mostly returned to pre-pandemic levels by autumn 2020, and primary care appointments and referrals were resilient during the omicron wave of infection.

However, lower overall activity throughout the pandemic has led to “missing” appointments and referrals. The report highlights that a proportion of these may return in the future with patients in a worse state of health, while others will not return for a variety of reasons.

Before the pandemic only around 20% of appointments were delivered remotely, but by April 2020 this reached an estimated peak of 70% of consultations. The proportion of consultations delivered remotely has been decreasing since then, and recent figures from NHS Digital show that the proportion of face-to-face appointments was 63% as of April 2022. 3

The number of total referrals through the NHS e-Referral Service (e-RS) dropped sharply at the beginning of the pandemic and returned to pre-pandemic levels by summer 2021. However, some missing referrals will probably not return because of self-limiting conditions, patients using private or secondary care, changes in how GPs refer, and deaths from covid-19.

Were all effects on population health negative?

No. For example, reporting of norovirus during the pandemic has generally been much lower than the pre-pandemic average. Since covid restrictions were eased some resurgence has occurred, with higher levels of norovirus reported in 2021-22 than in 2020-21, although this is still below the five season average.

Flu-like illness rates have been very low throughout the pandemic, including in winter 2021-22. Since April 2020, hospital admission rates for flu have also been very low, particularly when compared with pre-pandemic years. This is probably due to behavioural changes in response to covid-19, driven partly by lockdowns and guidance, as well as the successful flu vaccination campaign.

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