In this study, we demonstrate that there is a significant trend in established datasets towards reduced proportion of people having tests consistent with diabetes in ED but not in GP. Indeed, in contrast to the effect seen in ED, there appear to be more people attending GP with diabetes in 2021 than the prior rate in adults during 2019/20. While this may be related to increased testing, it is also likely to be some evidence of replacement of services as people have avoided hospitals and instead attended GP clinics for their chronic disease during COVID-19.
Moreover, at the onset of the COVID-19 pandemic, there was a steep increase in use of VC services in two hospitals in western Sydney. From a very low baseline of less than 10% of services provided through VC, clinics pivoted to provide many or even most appointments through VC modalities. This has allowed these outpatient chronic care services to continue despite ongoing restrictions during the pandemic, and has no noticeable acutely negative impact on patient care.
This is similar to trends seen elsewhere during the pandemic. Numerous studies have demonstrated reduced use of hospital and GP services during lockdowns and other high-transmission periods internationally (13, 14). Moreover, there has been a hypothesized impact on diabetes-specific services during COVID-19 from patients wary of infection or unable to attend services due to lockdowns (15, 16). We have now proven that these worries may be well-founded, as people with diabetes have substantially reduced their interaction with hospital services during the pandemic, especially during high-transmission periods.
These findings have important implications to current and future practice. While it may be difficult to manage diabetes during a pandemic, the fact that people with diabetes began avoiding the hospital and community services well before cases peaked in various waves has some potential negative connotations. While NSW began locking down on the 16th of March, there were at this point few deaths in the state. However, there was a marked decline in both the number and proportion of people with HbA1c consistent with diabetes attending ED, and fewer people attending their GP, perhaps indicating an undercurrent of fear in the general population of being infected with the virus, in terms of accessing health services. The concern here is that individuals with diabetes may become unwell independent of factors directly related to the pandemic; any delay in them presenting to hospital may result in a more severe and complicated illness.
However, there is also a positive reading of these data. If this represents a replacement of services, it may actually be a good outcome, by reducing the usage of high-cost tertiary services and pushing people towards more care in the community. This is also noticeable in the massively increased use of VC in hospital clinics that has continued even after restrictions were lifted.
This may also be seen in a positive light. During this time of increased activity within the health facilities preparing to combat COVID-19, a reduction in presentations of individuals with chronic disease to higher risk facilities is possibly ideal to reduce the risk of viral infection. The fact that GP attendance for the management of diabetes has not dropped, and appear to have increased slightly, may represent a shift towards telemedicine during this time, although the data is not yet in to demonstrate this.
However, this reluctance to attend ED and GP has led to the rapid development and maturation of services to support community based management with the availability of new funding through the Medicare Benefits Scheme (MBS) facilitating the process. In Blacktown Hospital, the majority of ambulatory care services, including clinics for complex type 2 diabetes have been converted from face-to-face encounters to telephone and telehealth services, which persisted in some form throughout the pandemic period. This includes the provision of video consultations for joint GP-specialist case conferencing and diabetes education, the establishment of pathways for flash glucose monitoring utilizing local pharmacies and a package of app-based interventions, to ensure that people with diabetes are still able to access care during this period.
Indeed, the potential replacement of ED with other service echoes international evidence demonstrating that patients have often switched from existing services to virtual care modalities to avoid in-person consultations during the pandemic (17). This change in the use of healthcare services has the potential to improve diabetes care, insofar as it reduces reliance on high-cost emergency services and provides more sustainable chronic care for patients who have long-term chronic disease (18). However, this approach may also have drawbacks – these primary care services do not always have sufficient resources to treat severe or complex cases (19), and the reduction in presentations to ED does not perfectly mirror the increases seen in GP. It is likely that some individuals have missed out on needed care even if some replacement took place, which may represent a burden in terms of untreated chronic disease as time goes on (4).
Overall, we demonstrated that during a during the COVID-19 pandemic, the rate of presentations consistent with diabetes in a busy ED declined significantly from 17.4–13.1% per week. The rate of attendances to GP clinics for diabetes in the same area was not similarly impacted, with the proportion of patients diagnosed with diabetes actually increasing, however the total number of presentations was reduced. This was primarily driven by a smaller proportion of older patients presenting, with a younger median age in the group attending the ED than in previous periods and a significant age interaction with the trend, and may indicate a less acute patient population overall in the hospital outside of COVID-19 presentations. This complex interaction requires further exploration, and may have both costs and benefits for the healthcare system. A key future goal will be to identify whether people have replaced their missed ED care through GP services, or if this represents a worrying increase in diabetes service use in the healthcare system more broadly.