Excess years of life lost to COVID-19 and other causes of death by sex, neighbourhood deprivation and region in England & Wales during 2020

BackgroundDeaths in the first year of the COVID-19 pandemic in England & Wales have been shown to be unevenly distributed socioeconomically and geographically. However, the full scale of inequalities may have been underestimated as most measures of excess mortality do not adequately account for varying age profiles of deaths between social groups. We measured years of life lost (YLL) attributable to the pandemic, directly or indirectly, comparing mortality across geographic and socioeconomic groups. MethodsYLL for registered deaths in England & Wales, from 27th December 2014 until 25th December 2020, were calculated using 2019 single year sex-specific life tables for England & Wales. Panel time-series models were used to estimate expected YLL by sex, geographical region, and deprivation quintile between 7th March 2020 and 25th December 2020 by cause: direct deaths (COVID-19 and other respiratory diseases), cardiovascular disease & diabetes, cancer, and other indirect deaths - all other causes). Excess YLL during the pandemic period were calculated by subtracting observed from expected values. Additional analyses focused on excess deaths for region and deprivation strata, by age-group. FindingsBetween 7th March 2020 and 25th December 2020 there were an estimated 763,550 (95% CI: 696,826 to 830,273) excess YLL in England & Wales, equivalent to a 15% (95% CI: 14 to 16) increase in YLL compared to the equivalent time period in 2019. There was a strong deprivation gradient in all-cause excess YLL, with rates per 100,000 population ranging from (916; 95% CI: 820 to 1,012) for the least deprived quintile to (1,645; 95% CI: 1,472 to 1,819) for the most deprived. The differences in excess YLL between deprivation quintiles were greatest in younger age groups; for all-cause deaths, an average of 9.1 years per death (95% CI: 8.2 to 10.0) were lost in the least deprived quintile, compared to 10.8 (95% CI: 10.0 to 11.6) in the most deprived; for COVID-19 and other respiratory deaths, an average of 8.9 years per death (95% CI: 8.7 to 9.1) were lost in the least deprived quintile, compared to 11.2 (95% CI: 11.0 to 11.5) in the most deprived. There was marked variability in both all-cause and direct excess YLL by region, with the highest rates in both in the North West. InterpretationDuring 2020, the first calendar year of the COVID-19 pandemic, longstanding socioeconomic and geographical health inequalities in England & Wales were exacerbated, with the most deprived areas suffering the greatest losses in potential years of life lost. FundingNone

Temporal trends in primary care-recorded self-harm during and beyond the first year of the COVID-19 pandemic: time series analysis of electronic healthcare records for 2.8 million patients in the Greater Manchester Care Record

BackgroundSurveillance of clinically treated self-harm episode frequency is an important component of suicide prevention in the dynamic context of COVID-19. Studies published to date have investigated the initial months following the onset of the pandemic, despite national and regional restrictions persisting to Summer 2021. MethodsWe conducted a descriptive time series analysis utilising data from the Greater Manchester Care Record, which contains de-identified, primary care health records of 2.8 million patients. Counts of incident and all episodes of self-harm recorded between 1st January 2019 and 31st May 2021 were made for all patients, with stratification by sex, age group, ethnicity, and index of multiple deprivation (IMD) quintile and examination of overall differences by national and regional restriction phases. FindingsBetween 1st January 2019 and 31st May 2021, 33,444 episodes of self-harm by 13,148 individuals were recorded. Frequency ratios of incident and all episodes of self-harm were 0.59 (95% CI 0.51 to 0.69) and 0.69 (CI 0.63 to 0.75) respectively in April 2020 compared to February 2020. Between August 2020 and May 2021 frequency ratios were 0.92 (CI 0.88 to 0.96) for incident episodes and 0.86 (CI 0.84 to 0.88) for all episodes compared to the same months in 2019. Reductions were largest among men and people living in the most deprived neighbourhoods. An increase in all-episode self-harm (frequency ratio 1.09, CI 1.03 to 1.16) was observed for adolescents aged 10-17 between August 2020 and May 2021. InterpretationThe COVID-19 pandemic has had a sustained impact on help seeking for self-harm. Reductions in primary care recorded self-harm have implications for clinicians ability to assess the needs and risks of individuals. Some patients may be experiencing prolonged untreated deterioration in their mental health while other groups are presenting in higher numbers. Our findings have important implications for primary care and mental health services in manging ongoing demand. FundingUKRI COVID-19 Rapid Response Initiative (grant reference COV0499), University of Manchester Presidential Fellowship (SS), and NIHR Greater Manchester Patient Safety Translational Research Centre.

COVID-19 infection and subsequent psychiatric morbidity, sleep problems and fatigue: analysis of an English primary care cohort of 226,521 positive patients

ObjectivesThe primary hypothesis was that the risk of incident or repeat psychiatric illness, fatigue and sleep problems increased following COVID-19 infection. The analysis plan was pre-registered (https://osf.io/n2k34/). DesignMatched cohorts were assembled using a UK primary care registry (the CPRD-Aurum database). Patients were followed-up for up to 10 months, from 1st February 2020 to 9th December 2020. SettingPrimary care database of 11,923,499 adults ([≥]16 years). ParticipantsFrom 232,780 adults with a positive COVID-19 test (after excluding those with <2 years historical data or <1 week follow-up), 86,922 without prior mental illness, 19,020 with anxiety or depression, 1,036 with psychosis, 4,152 with fatigue and 4,539 with sleep problems were matched to up to four controls based on gender, general practice and year of birth. A negative control used patients who tested negative for COVID-19 and patients negative for COVID with an influenza diagnosis. Main Outcomes and MeasuresCox proportional hazard models estimated the association between a COVID-19 positive test and subsequent psychiatric morbidity (depression, anxiety, psychosis, or self-harm), sleep problems, fatigue or psychotropic prescribing. Models adjusted for comorbidities, ethnicity, smoking and BMI. ResultsAfter adjusting for observed confounders, there was an association between testing positive for COVID-19 and almost all markers of psychiatric morbidity, fatigue and sleep problems. The adjusted hazard ratio (aHR) for incident psychiatric morbidity was 1.75 (95% CI 1.56-1.96). However, there was a similar risk of incident psychiatric morbidity for those with a negative COVID-19 test (aHR 1.57, 95% CI 1.51-1.63) and a larger increase associated with influenza (aHR 2.97, 95% CI 1.36-6.48). ConclusionsThere is consistent evidence that COVID-19 infection elevates risk of fatigue and sleep problems, however the results from the negative control analysis suggests that residual confounding may be responsible for at least some of the association between COVID-19 and psychiatric morbidity.

Impact of COVID-19 restrictions on diabetes health checks and prescribing for people with type 2 diabetes: a UK-wide cohort study involving 618,161 people in primary care

OBJECTIVETo compare rates of performing NICE-recommended health checks and prescribing in people with type 2 diabetes (T2D), before and after the first COVID-19 peak in March 2020, and to assess whether trends varied by age, sex and deprivation. METHODSWe constructed a cohort of 618,161 people with T2D followed between March and December 2020 from 1744 UK general practices registered with the Clinical Practice Research Datalink (CPRD; Aurum and GOLD databases). We focused on the following six health checks and prescribing: HbA1c, serum creatinine, cholesterol, urinary albumin excretion, blood pressure and BMI assessment, comparing trends using regression models and 10-year historical data. RESULTSIn April 2020, in English practices, rates of performing health checks were reduced by 76-88% when compared to 10-year historical trends, with older people from deprived areas experiencing the greatest reductions. Between May and December 2020, the reduced rates recovered gradually but overall remained 28% and 47% lower compared to historical trends, with similar findings in other UK nations. In England, rates of prescribing of new medication fell during April with reductions varying from 10% (4-16%) for antiplatelet agents to 60% (58-62%) for antidiabetic medications. Overall, between March and December 2020, the overall rate of prescribing new diabetes medications was reduced by 19% (15-22%) and new antihypertensive medication by 22% (18-26%). Similar trends were observed in other UK nations, except for a reduction in new lipid-lowering therapy prescribing March to December 2020 (reduction: 16% (10-21%)). CONCLUSIONSOver the coming months, healthcare services will need to manage this backlog of testing and prescribing. Effective communications should ensure that patients remain engaged with diabetes services, monitoring and opportunities for prescribing, and make use of home monitoring and remote consultations.

Primary care clinical management following self-harm during the first wave of COVID-19 in the UK

BackgroundA substantial reduction in GP-recorded self-harm occurred during the first wave of COVID-19 but effects on primary care management of self-harm are unknown. AimTo examine the impact of COVID-19 on clinical management within three months of an episode of self-harm. Design and settingProspective cohort study using data from the UK Clinical Practice Research Datalink. MethodWe compared cohorts of patients with an index self-harm episode recorded during a pre-pandemic period (10th March-10th June, 2010-2019) versus the COVID-19 first-wave period (10th March-10th June 2020). Patients were followed up for three months to capture psychotropic medication prescribing, GP/practice nurse consultation and referral to mental health services. Results48,739 episodes of self-harm were recorded during the pre-pandemic period and 4,238 during the first-wave COVID-19 period. Similar proportions were prescribed psychotropic medication within 3 months in the pre-pandemic (54.0%) and COVID-19 first-wave (54.9%) cohorts. Likelihood of having at least one GP/practice nurse consultation was broadly similar (83.2% vs. 80.3% in the COVID-19 cohort). The proportion of patients referred to mental health services in the COVID-19 cohort (3.4%) was around half of that in the pre-pandemic cohort (6.5%). ConclusionDespite the challenges experienced by primary healthcare teams during the initial COVID-19 wave, prescribing and consultation patterns following self-harm were broadly similar to pre-pandemic levels. However, the reduced likelihood of referral to mental health services warrants attention. Accessible outpatient and community services for people who have self-harmed are required as the COVID-19 crisis recedes and the population faces new challenges to mental health.

Impact of COVID-19 on the diagnoses, HbA1c monitoring and mortality in people with type 2 diabetes: a UK-wide cohort study involving 13 million people in primary care

AIMSTo compare trends in diagnoses, monitoring and mortality in patients with type 2 diabetes, before and after the first COVID-19 peak. METHODSWe constructed a cohort of 25 million patients using electronic health records from 1831 UK general practices registered with the Clinical Practice Research Datalink (CPRD), including 14 million patients followed between March and December 2020. We compared trends using regression models and 10-year historical data. We extrapolated the number of missed/delayed diagnoses using UK Office for National Statistics data. RESULTSIn England, rates of new type 2 diabetes diagnoses were reduced by 70% (95% CI 68%-71%) in April 2020, with similar reductions in Northern Ireland, Scotland and Wales. Between March and December, we estimate that there were approximately 60,000 missed/delayed diagnoses across the UK. In April, rates of HbA1c testing were greatly reduced in England (reduction: 77% (95% CI 76%-78%)) with more marked reductions in the other UK nations (83% (83-84%)). Reduced rates of diagnosing and monitoring were particularly evident in older people, in males, and in those from deprived areas. In April, the mortality rate in England was more than 2-fold higher (112%) compared to prior trends, but was only 65% higher in Northern Ireland, Scotland and Wales. CONCLUSIONSAs engagement increases, healthcare services will need to manage the backlog and anticipate greater deterioration of glucose control due to delayed diagnoses and reduced monitoring in those with pre-existing diabetes. Older people, men, and those from deprived backgrounds will be groups to target for early intervention. RESEARCH IN CONTEXTO_ST_ABSWhat is already known about this subject?C_ST_ABSO_LIThe higher COVID-related death rate in people with diabetes has been well-documented C_LIO_LIA study involving the residents of Salford, UK showed 135 fewer diagnoses of type 2 diabetes than expected between March and May 2020, which amounted to a 49% reduction in activity C_LIO_LIThere is limited data on the impact of the COVID-19 pandemic on the diagnosis and monitoring of type 2 diabetes C_LI What is the key question?O_LIWhat has been the impact of the COVID-19 pandemic on the diagnosis and monitoring of type 2 diabetes across the UK? C_LI What are the new findings?O_LIAcross the UK, the rate of new type 2 diabetes diagnoses was reduced by up to 70% in April 2020 compared to 10-year historical trends C_LIO_LIBetween March and December 2020, it is estimated that 60,000 people have had a missed or delayed diagnosis C_LIO_LIThe frequency of HbA1c monitoring in type 2 diabetes was reduced by 77-83% in April 2020 and by 31-37% overall between March and December 2020 C_LI How might this impact on clinical practice in the foreseeable future?O_LIDuring this pandemic and associated lockdowns, effective public communications should ensure that patients remain engaged with diabetes services including HbA1c screening and monitoring C_LI