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Assessment of the effect of the COVID-19 pandemic on UK HbA1c testing: implications for diabetes management and diagnosis
  1. David Holland1,
  2. Adrian H Heald2,3,
  3. Mike Stedman4,
  4. Fahmy Hanna5,6,
  5. Pensee Wu7,8,
  6. Christopher Duff8,9,
  7. Lewis Green10,
  8. Sarah Robinson9,
  9. Ian Halsall11,
  10. Neil Gaskell12,
  11. John Pemberton13,
  12. Christine Bloor13,
  13. Anthony A Fryer8,9
  1. 1 The Benchmarking Partnership, Alsager, UK
  2. 2 Department of Diabetes and Endocrinology, Salford Royal NHS Foundation Trust, Salford, UK
  3. 3 The School of Medicine and Manchester Academic Health Sciences Centre, The University of Manchester, Manchester, UK
  4. 4 Res Consortium, Andover, UK
  5. 5 Department of Diabetes and Endocrinology, Univerisity Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
  6. 6 Centre for Health and Development, Staffordshire University Faculty of Health Sciences, Stoke-on-Trent, UK
  7. 7 Academic Department of Obstetrics and Gynaecology, Univerisity Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
  8. 8 School of Medicine, Keele University, Keele, UK
  9. 9 Department of Clinical Biochemistry, Univerisity Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
  10. 10 Department of Clinical Biochemistry, St Helens and Knowsley Teaching Hospitals NHS Trust, Prescot, UK
  11. 11 Department of Clinical Biochemistry, Addenbrooke's Hospital, Cambridge, UK
  12. 12 Department of Pathology, Warrington & Halton Teaching Hospitals NHS Foundation Trust, Warrington, UK
  13. 13 Diabetes UK (North Staffordshire Branch), Stoke, UK
  1. Correspondence to Professor Anthony A Fryer, School of Medicine, Keele University, Keele, Staffordshire, UK; a.a.fryer{at}


Aims The COVID-19 pandemic, and the focus on mitigating its effects, has disrupted diabetes healthcare services worldwide. We aimed to quantify the effect of the pandemic on diabetes diagnosis/management, using glycated haemoglobin (HbA1c) as surrogate, across six UK centres.

Methods Using routinely collected laboratory data, we estimated the number of missed HbA1c tests for ‘diagnostic’/‘screening’/‘management’ purposes during the COVID-19 impact period (CIP; 23 March 2020 to 30 September 2020). We examined potential impact in terms of: (1) diabetes control in people with diabetes and (2) detection of new diabetes and prediabetes cases.

Results In April 2020, HbA1c test numbers fell by ~80%. Overall, across six centres, 369 871 tests were missed during the 6.28 months of the CIP, equivalent to >6.6 million tests nationwide. We identified 79 131 missed ‘monitoring’ tests in people with diabetes. In those 28 564 people with suboptimal control, this delayed monitoring was associated with a 2–3 mmol/mol HbA1c increase. Overall, 149 455 ‘screening’ and 141 285 ‘diagnostic’ tests were also missed. Across the UK, our findings equate to 1.41 million missed/delayed diabetes monitoring tests (including 0.51 million in people with suboptimal control), 2.67 million screening tests in high-risk groups (0.48 million within the prediabetes range) and 2.52 million tests for diagnosis (0.21 million in the pre-diabetes range; ~70 000 in the diabetes range).

Conclusions Our findings illustrate the widespread collateral impact of implementing measures to mitigate the impact of COVID-19 in people with, or being investigated for, diabetes. For people with diabetes, missed tests will result in further deterioration in diabetes control, especially in those whose HbA1c levels are already high.

  • diabetes mellitus
  • diagnosis
  • COVID-19

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Data availability statement

Data are available upon reasonable request. Data are available on reasonable request from the authors.

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  • Handling editor Tahir S Pillay.

  • Contributors AAF, DH, AHH and MS devised the original concept. CD, LG, SR, IH and NG were responsible for extraction and initial cleaning of the data from laboratory records at each of the six centres. DH and AAF performed the data manipulation and analysis. AHH, FH, PW and AAF provided the clinical interpretation. CD, LG, SR, IH and NG provided data quality checking and interpretation of results from each of their respective centres. CB and JP provided a patient perspective and interpretation of the study findings as part of their long-standing relationship with AAF, FH and CD. AAF, AHH, MS, DH, PW and FH wrote the initial draft of the paper, which was then critiqued by all other authors as part of regular team meetings and manuscript revision process. All authors approved the final version of the manuscript.

  • Funding This study as supported by a National Institute for Health Research Healthcare Scientist Fellowship award (HCS/08/011), supervised by AAF.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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