The baseline characteristics of our population are presented in Table 1. The overall number of population over 14 years of age slightly increased since 2018 while other characteristics remained stable during the study period in terms of age, sex and socioeconomic status distibution.
Table 1
Baseline characteristics of the study population by year (2018–2022)
| 2018 | 2019 | 2020 | 2021 | 2022 |
Total | 4,852,961 (100%) | 4,957,155 (100%) | 4,991,716 (100%) | 5,053,670 (100%) | 5,108,878 (100%) |
Age |
15–44 | 2,183,988 (45%) | 2,209,398 (44.57%) | 2,216,414 (44.4%) | 2,204,497 (43.62%) | 2,218,929 (43.43%) |
45–59 | 1,267,021 (26.11%) | 1,306,846 (26.36%) | 1,334,878 (26.74%) | 1,370,374 (27.12%) | 1,392,801 (27.26%) |
60–69 | 607,066 (12.51%) | 622,656 (12.56%) | 635,927 (12.74%) | 651,006 (12.88%) | 660,190 (12.92%) |
70–79 | 450,636 (9.29%) | 479,562 (9.67%) | 480,311 (9.62%) | 489,048 (9.68%) | 499,086 (9.77%) |
> 79 years | 346,465 (7.14%) | 346,589 (6.99%) | 346,467 (6.94%) | 346,519 (6.86%) | 346,001 (6.77%) |
Sex |
Men | 2,370,318 (48.84%) | 2,421,966 (48.86%) | 2,440,227 (48.89%) | 2,475,074 (48.98%) | 2,499,848 (48.93%) |
Women | 2,482,643 (51.16%) | 2,535,189 (51.14%) | 2,551,489 (51.11%) | 2,578,991 (51.03%) | 2,609,701 (51.08%) |
Socioeconomic status |
Rural | 1,159,868 (23.9%) | 1,173,457 (23.67%) | 1,187,011 (23.78%) | 1,207,685 (23.9%) | 1,222,434 (23.93%) |
1st Q (least deprived) | 1,080,159 (22.26%) | 1,093,771 (22.06%) | 1,100,788 (22.05%) | 1,115,034 (22.06%) | 1,128,103 (22.08%) |
2nd Q | 753,137 (15.52%) | 763,990 (15.41%) | 769,916 (15.42%) | 778,361 (15.4%) | 788,254 (15.43%) |
3rd Q | 991,232 (20.43%) | 1,018,627 (20.55%) | 1,024,027 (20.51%) | 1,034,914 (20.48%) | 1,045,552 (20.47%) |
4th Q (most deprived) | 868,565 (17.9%) | 907,368 (18.3%) | 913,508 (18.3%) | 918,455 (18.17%) | 927,458 (18.15%) |
Overall, 740,820 new chronic diseases’ diagnoses were registered in the Catalan primary care EHR: 224,937 hypertension diagnosis, 150,214 hypercholesterolemia, 133,540 T2DM, 65,842 asthma, 62,313 HF, 55,762 COPD and 48,212 IHD. The annual number of chronic diseases were similar in 2018 and 2019 (with the exception of hypercholesterolemia, which slightly increased in 2019). However, in 2020 all diagnoses abruptly dropped. Mean age and percentage of women were similar across all years within each chronic condition but the percentage of rural areas decreased in 2020, 2021 and 2022 in some diagnoses (Supplementary Table S2 and Supplementary Figure S1).
Figure 1 shows the results of the segmented regression analysis. The trends of daily rates for all diseases were drastically interrupted on 14 March 2020 (the first day of the lockdown in Spain). During the subsequent months, we observed a general upward trend, although in some conditions the incidence at the end of the study period was still below the pre-pandemic level. Supplementary Table S3 shows the coefficients of the models for each disease.
Figure 2 shows the monthly-accumulated rates by year of each chronic disease. We observed that the incidence in 2020 decreased for all diseases around March - April 2020. Nevertheless, monthly rates in 2021 and 2022 were hovering at diagnosis level of 2019 or were higher for T2DM, hypertension, HF and hypercholesterolemia. On the other hand, rates of asthma, COPD and IHD remained below 2019 values.
Compared to 2019, the IRR associated with the reductions in 2020 are presented in Table 2 and Figure Supplementary S2. We observed reductions around 30% in asthma, IHD, T2DM, hypertension and hypercholesterolemia; a greater reduction of 42% (IRR: 0.58 [95% CI: 0.57 to 0.6]) in COPD rates and lesser drops in HF (IRR: 0.86 [95% CI: 0.84 to 0.88]). In contrast, in 2021 and 2022, T2DM, hypercholesterolemia, hypertension and HF showed increases in the recorded incidence, with IRR significantly > 1 (Table 2). For instance, in 2021 and 2022, the registered incidence of T2DM increased by 16% and 24%, respectively; and by 34% and 49% in the case of hypercholesterolemia. Conversely, in asthma, COPD and IHD we still observed reductions during 2021 and 2022 although smaller than those from 2020. In particular, COPD presented reductions of 42%, 31% and 15% in 2020, 2021 and 2022, respectively, while asthma diagnoses decreased by 31%, 16% and 7% in the same years.
Table 2
Annual rates per 100,000 inhabitants of chronic diseases and incidence rate ratios (IRR) compared to 2019.
Chronic disease | Year | Rate x 100,000 2019 | Rate x 100,000 | IRR | 95% CI |
Asthma | 2020 | 313.3 | 216.92 | 0.69 | [0.68–0.71] |
2021 | 313.3 | 262.01 | 0.84 | [0.82–0.86] |
2022$ | 211.55 | 197.34 | 0.93 | [0.91–0.96] |
Chronic obstructive pulmonary disease (COPD) | 2020 | 290.05 | 169.06 | 0.58 | [0.57–0.6] |
2021 | 290.05 | 199.4 | 0.69 | [0.67–0.71] |
2022$ | 195.15 | 166.51 | 0.85 | [0.83–0.88] |
Heart failure (HF) | 2020 | 259.6 | 223.63 | 0.86 | [0.84–0.88] |
2021 | 259.6 | 290.9 | 1.12 | [1.09–1.15] |
2022$ | 180.35 | 223.85 | 1.24 | [1.21–1.28] |
Hypercholesterolemia | 2020 | 600.61 | 432.72 | 0.72 | [0.71–0.73] |
2021 | 600.61 | 807.45 | 1.34 | [1.32–1.36] |
2022$ | 397.37 | 591.75 | 1.49 | [1.46–1.52] |
Hypertension | 2020 | 977.29 | 690.78 | 0.71 | [0.7–0.72] |
2021 | 977.29 | 1074.13 | 1.1 | [1.09–1.11] |
2022$ | 653.84 | 784.58 | 1.2 | [1.18–1.22] |
Ischemic heart disease (IHD) | 2020 | 231.99 | 160.97 | 0.69 | [0.67–0.71] |
2021 | 231.99 | 203.46 | 0.88 | [0.85–0.9] |
2022$ | 154.3 | 141.26 | 0.92 | [0.89–0.95] |
Type 2 diabetes mellitus (T2DM) | 2020 | 579.06 | 396.86 | 0.69 | [0.67–0.7] |
2021 | 579.06 | 669.04 | 1.16 | [1.14–1.17] |
2022$ | 386.23 | 470.85 | 1.22 | [1.2–1.24] |
$ Data until August
When we compared the observed diagnoses registered during the pandemic period (from 14 March 2020 until 30 August 2022) with the expected ones in order to determine if the increase in some diagnoses in 2021 and 2022 compensated for the drops, we observed, that after more than two years since the beginning of the pandemic, there was still a reduction of -24% (IC95%: -27.94% to -19.68%) in asthma diagnoses, a reduction of -38.39% (IC95%: -41.94% to -34.37%) in COPD diagnoses, a reduction of -21.25% (95%CI: -25.6% to -16.37%) in IHD and a reduction of -8.53% (IC95%: -13.5% to -2.95%) in hypertension. We estimated that the overall reduction during the whole pandemic period accounted for 14,644, 9,719, 6,264 and 10,926 fewer COPD, asthma, IHD and hypertension diagnoses, respectively. Conversely, a 8.51% (95% CI: 1.81 to 16.15%) excess of registered diagnoses was observed in hypercholesterolemia when compared to the expected. Finally, for T2DM and HF we observed a statistically non-significant difference of -3.81% (95%CI: -9.36–2.46%) and 2.88% (95% CI: -2.39–8.76%) respectively (Fig. 3 and Supplementary Table S4).
In general, similar findings were observed when we stratified data by age groups, sex and socioeconomic status (Fig. 3 and Supplementary Table S4 ). However, some differences were observed in more advanced age groups with an excess of T2DM and hypercholesterolemia diagnoses; and also with an increase of registered diagnoses of HF in more deprived areas and younger people. No difference were observed regarding sex.
Finally, we estimated the time frame when the compensation for T2DM, HF and hypercholesterolemia occurred by comparing the daily cumulative observed diagnoses during the pandemic period to the daily cumulative expected diagnoses. Compensation for hypercholesterolemia took place at the beginning of November 2021, for HF in mid-December 2021 and for T2DM at the end of April 2022. Excess of hypercholesterolemia diagnoses was observed at the end of May 2022 (Fig. 4 and Supplementary Table S5).