TY - JOUR
T1 - Ethnic differences in the indirect effects of the COVID-19 pandemic on clinical monitoring and hospitalisations for non-COVID conditions in England: a population-based, observational cohort study using the OpenSAFELY platform
AU - Costello, Ruth E.
AU - Tazare, John
AU - Piehlmaier, D
AU - Herrett, Emily
AU - Parker, Edward P.K.
AU - Zheng, Bang
AU - Mansfield, Kathryn E.
AU - Henderson, Alasdair D.
AU - Carreira, Helena
AU - Bidulka, Patrick
AU - Wong, Angel Y.S.
AU - Warren-Gash, Charlotte
AU - Hayes, Joseph F.
AU - Quint, Jennifer K.
AU - MacKenna, Brian
AU - Mehrkar, Amir
AU - Eggo, Rosalind M.
AU - Katikireddi, Srinivasa Vittal
AU - Tomlinson, Laurie
AU - Langan, Sinéad M.
AU - Mathur, R
AU - Chaturvedi, Nishi
AU - Park, Chloe
AU - Carnemolla, Alisia
AU - Williams, Dylan
AU - Knueppel, Anika
AU - Boyd, Andy
AU - Turner, Emma L.
AU - Evans, Katharine M.
AU - Thomas, Richard
AU - Berman, Samantha
AU - McLachlan, Stela
AU - Crane, Matthew
AU - Whitehorn, Rebecca
AU - Oakley, Jacqui
AU - Foster, Diane
AU - Woodward, Hannah
AU - Campbell, Kirsteen C.
AU - Timpson, Nicholas
AU - Kwong, Alex
AU - Soares, Ana Goncalves
AU - Griffith, Gareth
AU - Toms, Renin
AU - Jones, Louise
AU - Annie, Herbert
AU - Mitchell, Ruth
AU - Palmer, Tom
AU - Sterne, J
AU - Walker, V
AU - Huntley, L
AU - Fox, L
AU - Denholm, R
AU - Knight, R
AU - Northstone, K
AU - Kanagaratnam, A
AU - Horne, E
AU - Forbes, H
AU - North, T
AU - Taylor, K
AU - Arab, MAL
AU - Walker, Scott
AU - Coronado, JIC
AU - Karthikeyan, AS
AU - Ploubidis, G
AU - Moltrecht, B
AU - Booth, C
AU - Parsons, S
AU - Wielgoszewska, B
AU - Bridger-Staatz, C
AU - Steves, C
AU - Thompson, E
AU - Garcia, P
AU - Cheetham, N
AU - Bowyer, R
AU - Freydin, M
AU - Roberts, A
AU - Goldacre, B
AU - Walker, A
AU - Morley, J
AU - Hulme, W
AU - Nab, L
AU - Fisher, L
AU - MacKenna, Brian
AU - Andrews, C
AU - Curtis, H
AU - Hopcroft, L
AU - Green, A
AU - Patalay, P
AU - Maddock, J
AU - Wei, Yinghui
PY - 2023/7
Y1 - 2023/7
N2 - Background
The COVID-19 pandemic disrupted healthcare and may have impacted ethnic inequalities in healthcare. We aimed to describe the impact of pandemic-related disruption on ethnic differences in clinical monitoring and hospital admissions for non-COVID conditions in England.
Methods
In this population-based, observational cohort study we used primary care electronic health record data with linkage to hospital episode statistics data and mortality data within OpenSAFELY, a data analytics platform created, with approval of NHS England, to address urgent COVID-19 research questions. We included adults aged 18 years and over registered with a TPP practice between March 1, 2018, and April 30, 2022. We excluded those with missing age, sex, geographic region, or Index of Multiple Deprivation. We grouped ethnicity (exposure), into five categories: White, Asian, Black, Other, and Mixed. We used interrupted time-series regression to estimate ethnic differences in clinical monitoring frequency (blood pressure and Hba1c measurements, chronic obstructive pulmonary disease and asthma annual reviews) before and after March 23, 2020. We used multivariable Cox regression to quantify ethnic differences in hospitalisations related to diabetes, cardiovascular disease, respiratory disease, and mental health before and after March 23, 2020.
Findings
Of 33,510,937 registered with a GP as of 1st January 2020, 19,064,019 were adults, alive and registered for at least 3 months, 3,010,751 met the exclusion criteria and 1,122,912 were missing ethnicity. This resulted in 14,930,356 adults with known ethnicity (92% of sample): 86.6% were White, 7.3% Asian, 2.6% Black, 1.4% Mixed ethnicity, and 2.2% Other ethnicities. Clinical monitoring did not return to pre-pandemic levels for any ethnic group. Ethnic differences were apparent pre-pandemic, except for diabetes monitoring, and remained unchanged, except for blood pressure monitoring in those with mental health conditions where differences narrowed during the pandemic. For those of Black ethnicity, there were seven additional admissions for diabetic ketoacidosis per month during the pandemic, and relative ethnic differences narrowed during the pandemic compared to the White ethnic group (Pre-pandemic hazard ratio (HR): 0.50, 95% confidence interval (CI) 0.41, 0.60, Pandemic HR: 0.75, 95% CI: 0.65, 0.87). There was increased admissions for heart failure during the pandemic for all ethnic groups, though highest in those of White ethnicity (heart failure risk difference: 5.4). Relatively, ethnic differences narrowed for heart failure admission in those of Asian (Pre-pandemic HR 1.56, 95% CI 1.49, 1.64, Pandemic HR 1.24, 95% CI 1.19, 1.29) and Black ethnicity (Pre-pandemic HR 1.41, 95% CI: 1.30, 1.53, Pandemic HR: 1.16, 95% CI 1.09, 1.25) compared with White ethnicity. For other outcomes the pandemic had minimal impact on ethnic differences.
Interpretation
Our study suggests that ethnic differences in clinical monitoring and hospitalisations remained largely unchanged during the pandemic for most conditions. Key exceptions were hospitalisations for diabetic ketoacidosis and heart failure, which warrant further investigation to understand the causes.
AB - Background
The COVID-19 pandemic disrupted healthcare and may have impacted ethnic inequalities in healthcare. We aimed to describe the impact of pandemic-related disruption on ethnic differences in clinical monitoring and hospital admissions for non-COVID conditions in England.
Methods
In this population-based, observational cohort study we used primary care electronic health record data with linkage to hospital episode statistics data and mortality data within OpenSAFELY, a data analytics platform created, with approval of NHS England, to address urgent COVID-19 research questions. We included adults aged 18 years and over registered with a TPP practice between March 1, 2018, and April 30, 2022. We excluded those with missing age, sex, geographic region, or Index of Multiple Deprivation. We grouped ethnicity (exposure), into five categories: White, Asian, Black, Other, and Mixed. We used interrupted time-series regression to estimate ethnic differences in clinical monitoring frequency (blood pressure and Hba1c measurements, chronic obstructive pulmonary disease and asthma annual reviews) before and after March 23, 2020. We used multivariable Cox regression to quantify ethnic differences in hospitalisations related to diabetes, cardiovascular disease, respiratory disease, and mental health before and after March 23, 2020.
Findings
Of 33,510,937 registered with a GP as of 1st January 2020, 19,064,019 were adults, alive and registered for at least 3 months, 3,010,751 met the exclusion criteria and 1,122,912 were missing ethnicity. This resulted in 14,930,356 adults with known ethnicity (92% of sample): 86.6% were White, 7.3% Asian, 2.6% Black, 1.4% Mixed ethnicity, and 2.2% Other ethnicities. Clinical monitoring did not return to pre-pandemic levels for any ethnic group. Ethnic differences were apparent pre-pandemic, except for diabetes monitoring, and remained unchanged, except for blood pressure monitoring in those with mental health conditions where differences narrowed during the pandemic. For those of Black ethnicity, there were seven additional admissions for diabetic ketoacidosis per month during the pandemic, and relative ethnic differences narrowed during the pandemic compared to the White ethnic group (Pre-pandemic hazard ratio (HR): 0.50, 95% confidence interval (CI) 0.41, 0.60, Pandemic HR: 0.75, 95% CI: 0.65, 0.87). There was increased admissions for heart failure during the pandemic for all ethnic groups, though highest in those of White ethnicity (heart failure risk difference: 5.4). Relatively, ethnic differences narrowed for heart failure admission in those of Asian (Pre-pandemic HR 1.56, 95% CI 1.49, 1.64, Pandemic HR 1.24, 95% CI 1.19, 1.29) and Black ethnicity (Pre-pandemic HR 1.41, 95% CI: 1.30, 1.53, Pandemic HR: 1.16, 95% CI 1.09, 1.25) compared with White ethnicity. For other outcomes the pandemic had minimal impact on ethnic differences.
Interpretation
Our study suggests that ethnic differences in clinical monitoring and hospitalisations remained largely unchanged during the pandemic for most conditions. Key exceptions were hospitalisations for diabetic ketoacidosis and heart failure, which warrant further investigation to understand the causes.
U2 - 10.1016/j.eclinm.2023.102077
DO - 10.1016/j.eclinm.2023.102077
M3 - Article
SN - 2589-5370
VL - 61
JO - eClinicalMedicine
JF - eClinicalMedicine
IS - 0
ER -