This article highlights practice issues regarding health disparities and the need for outreach in effective prescribing and treatment opportunities for all people with diabetes in the UK. The National Institute for Health and Care Excellence (NICE, 2020) guideline regarding management of type 2 diabetes in adults (NG28) was updated in 2020 and includes evidence in informing first choice intensification medications, including the introduction and earlier use of glucagon-like peptide-1 (GLP-1) receptor agonists and sodium-glucose co-transporter-2 (SGLT2) inhibitors in treatment opportunities. The inclusion of a new drug pathway in the NICE NG28 (2020) that focuses on cardiovascular disease (CVD) prevention, chronic renal failure, age and frailty are also welcomed. However, 2020/2021 also brought many challenges for individuals with diabetes and also healthcare professionals, with the pandemic appearing in the arena in March 2020. This has caused disparities in access to diabetes care and health beliefs, as highlighted by Holman et al (2020).
COVID-19 and diabetes
There has been a bidirectional relationship between COVID-19 and diabetes, with increased rates of new diagnosis and an increased risk of severe COVID-19 for those already diagnosed (Rubino et al, 2020). Feldman et al (2020) described COVID-19 and diabetes as a ‘collision and collusion: the perfect storm’; each making the other worse in terms of severe metabolic complications in those already diagnosed (Li et al, 2020; Ren et al, 2020). Greater incidences of fasting hyperglycaemia and acute-onset diabetes have been repeatedly reported amongst those with COVID-19. This aggregates the hypothesis of the potential diabetogenic effect of COVID-19, which is currently being investigated by the COVIDIAB Registry (2020). In the UK alone, around 14 000 people with known diabetes died in the first 4 months of the COVID-19 pandemic (one third of all deaths) (Petrie et al, 2020). This highlights the need for development and enablement of diabetes healthcare services and accessibility for all communities.
Diabetes UK (Rayman et al, 2020) published guidelines for the management of diabetes services and patients during the COVID-19 pandemic. This was an attempt both to avoid unnecessary admissions but also to guide clinicians who are not diabetes specialists, ensuring they deliver expert inpatient care for people admitted with diabetes with or without COVID-19. People with diabetes admitted to hospital are much more acutely unwell with suspected or confirmed COVID-19 and experience less favourable outcomes than those without diabetes (Zhang et al, 2020). Disproportionally higher numbers of people from black or South Asian populations have been found to be at increased risk of diabetes and COVID-19 (Williamson et al, 2020; Singh et al, 2021). However, Santorelli et al (2021) reported through Wellcome-funded research as part of the Born in Bradford study, that there is little to no evidence of people of South Asian ethnicity hospitalised with COVID-19 having worse outcomes than their white counterparts; this is contrary to the findings of Singh et al's (2021) observational study in Wolverhampton.
New diagnosis
Since March 2020, new diagnoses of type 1 diabetes presenting in diabetic ketoacidosis in children and young people (CYP) under 19 years old has been increasingly reported across Europe (Rabbone et al, 2020). This is certainly being experienced in all CYP diabetes centres across the UK (Ng et al, 2020); delayed presentation of type 1 diabetes have been attributed to fear about contracting COVID-19 and/or an inability to contact or access a medical provider for timely assessment. This is an example of what Rayman et al (2020) were trying to avoid, in terms of diabetes services still being accessible despite having to dramatically change in delivery since March 2020.
Suwanwongse and Shabareck (2021) described new presentations of diabetes in acutely unwell adults with COVID-19, in particular with an increase in patients being admitted in ketoacidosis with type 2 diabetes, which is a more uncommon presentation. Diabetes negatively impacts COVID-19 and can worsen mortality (Zhou et al, 2020); however, newly diagnosed cases of diabetes with COVID-19 could easily have revealed existing and undiagnosed type 2 diabetes rather than actually causing type 2 diabetes (Zhou et al, 2020) This indicates that earlier screening for type 2 diabetes within general practices and proactive prescribing following evidence-based guidelines once diagnosed is of vital importance (Guidelines, 2020).
Barron et al (2020) reported COVID-19 related mortality with type 1 and type 2 diabetes across England in a whole-population study, which was evidence of diabetes being independently associated with significant increased odds of an in-hospital death with COVID-19. This is contrary to Santorelli et al's (2021) findings from the Born in Bradford subset.
Practitioners need awareness of the psychological fear and response to a new diagnosis of type 1 or type 2 associated with extreme illness. Adaptation and developing coping abilities will take adjustment and time to physiologically recover from such an acute diagnosis (Petrie et al, 2021; Pouwer et al, 2020). This can cause individuals affected to find long-term self-management more troubling, compared to a less dramatic diagnosis when an individual is less acutely unwell (Stewart, 2020). Adjustment does take time post diagnosis, so framing consultations in knowing the individual and their story is always profoundly helpful in making their consultation conversations and prescribing meaningful (Shersher et al, 2021).
Health inequalities
Health inequalities are defined as the ‘preventable, unfair and unjust differences between populations or individuals that arise from the unequal distribution of social, environmental and economic conditions within societies, which determine the risk of people getting ill, their ability to prevent sickness or opportunities to take action and access treatment when ill health occurs’ (NHS England, 2019a). Landmark work by Wilkinson and Pickett (2013) challenged prejudice and judgement, which unfortunately many vulnerable communities within our localities still experience in access to healthcare and diabetes care escalation. This includes access to newer medications for people with type 2 diabetes and diabetes technologies for people with type 1 diabetes.
Linder et al (2018) reported lower socioeconomic status and higher area deprivation are associated with a higher risk of experiencing diabetic ketoacidosis in individuals of all ages with type 1 diabetes, highlighting access to care in socially deprived or rural communities needs to be enhanced and funded. This was further apparent during lockdown and home schooling, where rural communities found access to Wi-Fi and online learning more challenging (gov.uk, 2021).
Parsons et al (2021) undertook a review of pre-lockdown missed appointments in general practice and pinpointed this as multifactorial. However, missed appointments or ‘did not attend’ appointments do cost the NHS millions of pounds a year (NHS England, 2019b), and has been linked to populations living in high deprivation areas (Williamson et al, 2017). With general practices converting rapidly to remote and virtual appointments, which are often delayed in availability (British Medical Association, 2020), this further compounds the issue of vulnerable communities who experience health inequalities, delaying or being potentially unable to access effective treatments in a timely manner. Carr et al (2020) reported on the impact of COVID-19, delayed diagnosis and reduced HbA1c monitoring in a UK-wide cohort study. Their results involving 14 million participants from primary care are concerning and clearly demonstrate how healthcare services will need to manage the ‘backlog’ of delayed diagnoses and early treatment intensification through effective prescribing and patient facing education in type 2 diabetes. In particular, older people, men and those from deprived backgrounds with type 2 diabetes were identified as being most affected (Carr et al, 2020). These are perhaps the groups of practice populations to target for early intervention.
The World Health Organization (WHO, 2020) defined determinates of health as a multi-dimensional social construct that includes educational, economic and occupational status. This is a stronger predictor for disease diagnosis and progression including diabetes. Hill-Briggs et al (2020) determined that decades of research have demonstrated that diabetes affects racial and ethnic minorities and low-income adult communities disproportionately, with relatively intractable patterns seen in higher rates of both preventable complications and increased mortality (Golden et al, 2012).
Misunderstandings about medications and what individual prescriptions are for within communities facing health inequalities can inevitably cause difficulties (McQuaid and Landier, 2018). Delayed escalation of newer available prescribing agents in diabetes care, such as SGLT-2 inhibitors and GLP-1 agonists, and reduced access to glucose and insulin delivery technologies, such as insulin pumps and continuous glucose monitors, in type 1 diabetes (Barnard-Kelly and Cherñavvsky, 2020) have routinely been reported in these communities. Hill-Briggs et al (2020) suggest that health disparities cause divisions in communities and less favourable outcomes in diabetes care. For example, when in the UK, equal access and availability of medications and practitioner knowledge and skill should be available to every individual and community requiring the same the same level of knowledge and practitioner skill with medication awareness and prescribing.
Ethnic minority considerations
Lower levels of healthcare use by international migrants to the UK compared with the UK-born population is evident in all aspects of primary and secondary care delivery, apart from maternity care (Saunders et al, 2021). Migrants in vulnerable circumstances, often with under-diagnosed diabetes or untreated complications of diabetes, including being caused by a lack of access to medications and insulin, are particularly vulnerable and at risk (Montesi et al, 2016), especially in lockdown situations. This corresponds with the research from Carr et al (2020). Equally, populations and communities with limited fluency of English, lack of affordable and reliable transport, sub-standard housing or living in economically deprived areas are at particular risk. The recent pandemic has brought these issues into sharper focus and these communities have been disproportionately affected (Jayaweera, 2021).
The UK population is recognised for its growing diversity, as was evident in the last census of England and Wales (Office for National Statistics, 2011). Type 2 diabetes has a significant increased impact in populations of South Asian and Afro-Caribbean ancestry (Goff, 2019). Type 2 diabetes is estimated to be two to three times higher in incidence in minority ethnic communities in the UK, with its onset taking place 10–12 years earlier in these populations (Goff, 2019). Reaching out to local communities and taking public health measures to inform people of the benefits of early treatment of type 2 diabetes alongside effective public engagement and structured education programmes is essential. These need to be multi-lingual and available in different formats to reach individuals and take account of communities' health literacy needs (Goff, 2019), which is of vital importance. Additionally, working alongside members of local communities and faiths can help share diabetes awareness and prompt early treatment access to enable escalation of care as required (Admiraal et al, 2013).
Goff (2019) suggests that type 2 diabetes is a major public health concern and that current health disparities are underpinned by a complexity of social, biological, clinical and health system access and community population trust factors. Tackling health inequalities in prescribing and access to diabetes treatments to reduce variations amongst communities and localities requires clinical competency, negotiation and culturally sensitive interventions with explanations that are tailored and informed by health beliefs and practices of different cultural groups (Goff, 2019). Reaching into local communities is vitally important in effective diabetes care delivery to share education, discuss health beliefs and aim to dispel misunderstandings or mistrust, for example about insulin use and the need for repeated medication prescriptions (Rebolledo and Arellano, 2016).
Escalation of care
Communities of South Asian ancestry have further risks of earlier onset obesity, type 2 diabetes and CVD (Wolf et al, 2020). Individuals born outside the UK are often born with a lower birth weight but with greater adiposity than other ethnic groups, which contributes to their risk of developing insulin resistance, type 2 diabetes and CVD (Yajnik et al, 2003; Modi et al, 2009). Additionally, insulin resistance also perpetuates non-alcoholic fatty liver disease (NAFLD), which is commonly also associated with CVD (Singh et al, 2017). NAFLD has been reported to be a worsening condition in South Asian communities and is strongly associated with pre-diabetes, and worsens when individuals engage with the western diet in the UK (McCarthy and Rinella, 2012).
NAFLD can affect non-obese populations with a South Asian ancestry, known as the ‘Asian paradox’ or ‘lean NAFLD’. It is a trigger for atherosclerosis and CVD (Thakur et al, 2012). All of this indicates the need for extra care approaches and careful and timely escalation of treatments for CVD and type 2 diabetes in people with a South Asian ancestry in the UK and within practice populations. As Goff (2019) advised, because of genetics, people from a South Asian ancestry have increased and earlier onset type 2 and CVD risk, and these need regular screening for during health encounters.
In particular, men of South Asian ancestry in the UK can be much harder to engage with regarding their health (Public Health England, 2018). This is often as a result of them working very long hours in non-professional types of employments or being self-employed. This makes attending appointments for health reviews and diabetes care much more difficult (Emadian et al, 2017). Sharing health-related messages needs cultural sensitivity and for local community leaders to be involved, to encourage engagement. This was particularly illustrated recently, with the efforts nationally to encourage and support ethnic minority populations to engage with the COVID-19 vaccination programme within hesitant communities (Razai et al, 2021).
Equitable diabetes care?
There are disparities in glycaemic control, monitoring and prescribing of type 2 diabetes medications amongst patients across England. Whyte et al (2019) found that patients from socio-economically challenged areas and ethnic minorities were adversely affected by prescribing inequalities. The implication of this evidence is that higher risk populations are more at risk of earlier preventable complications and greater adverse outcomes (Goff, 2019); however, these communities can often experience clinical inertia on the part of the prescriber (Strain et al, 2014).
Additionally, Whyte et al (2019) reported that individuals from the most deprived quintile of socio-economically challenged and deprived areas and from ethnic minority groups experienced less monitoring of HbA1c, eGFR, retinopathy and neuropathy, although no disparity for monitoring of blood pressure was found. Additionally, there was relatively less prescribing of GLP-1 receptor agonists and SGLT2 inhibitors in black and Asian individuals than in white individuals. Similarly, McCoy et al (2019) further reported less retinopathy screening, and less prescribing of insulin, SGLT2 inhibitors and GLP-1 receptor agonists in the black and south Asian population compared with white individuals; but increased prescribing of long-standing medications such as metformin and sulfonylureas, with a limited evidence base to their continued use compared to newer alternative options and prescribing pathways (Guidelines, 2020).
This is further compounded by evidence from the US both about reduced rates of prescribing of SGLT2 inhibitors with non-white patients and the increased rates of readmission of non-white patients, all of which highlight worrying racial and ethnic barriers to effective diabetes care (Rodriguez-Gutierre et al, 2019).
Considering these vulnerable population groups have increased risks of earlier onset type 2 diabetes and CVD (Goff, 2019), racial and ethnic inequalities in access to effective evidence-based efficacious prescribing and equal access has to be a priority. As McCoy et al (2019) highlighted, it has been more than five decades since Martin Luther King Jr (1966) declared: ‘of all forms of inequality, injustice in health is still the most shocking and inhuman’. Challenging inequalities and recognising disparities in clinical decision making and prescribing effective anti-diabetes agents to all who need these must be a the priority.
Reaching out to local communities
With all this evidence facing healthcare practitioners and public health specialists, now is the time to face and embrace change to bring more unity and access to the most vulnerable communities and groups who have an increased risk of diabetes, as well as many with diagnosed diabetes and increased risk of avoidable complications (Goff, 2019). Design and outreach of multilingual educational resources written and designed with health literacy advisers and spiritual advisers from local communities needs consideration and potential charitable investment. Goff (2019) recommended healthcare practitioners also have access to education and training opportunities in cultural awareness and cultural competency. Relating these aspects to sharing information about prescribing and escalation of medications is especially important, so this is accepted and understood to avoid mistrust and non-engagement (Rebolledo and Arellano, 2016).
Escalating and descaling medications as individuals require needs clinical engagement and motivation to challenge clinical inertia (Strain et al, 2014). This inertia has no place in effective inclusive diabetes care provision through equal partnership working for every individual with diabetes (Phillips et al, 2020). However, this also takes education for both healthcare practitioners and people with diabetes; as Yeats (no date) suggested, ‘Education is not filling of a pail, but the lighting of a fire’.
Conclusion
Undoubtedly, the move to telemedicine and virtual consultations happened rapidly. However, perhaps now is the time to reflect on and rethink local practice populations, prescribing habits and embrace change. Through considering opportunities to share individualised and person-centred diabetes education and knowledge with adaptability of resources and keener prescribing, this is recommended to aim to meet and respond to each local populations needs.
Key Points
- There has been a bidirectional relationship between Covid-19 and diabetes with increased rates of new diagnosis and also for people already diagnosed an increased risk of severe Covid-19
- Practitioners need awareness of the psychological fear and response to a new diagnosis of type 1 or type 2 associated with extreme illness
- Misunderstandings about medications and what individual prescriptions are for within communities facing health inequalities inevitably can cause difficulties
- Equal access and availability of medications and practitioner knowledge and skill should be available to every individual and community requiring the same
- Tackling health inequalities in diabetes treatments and access requires clinical competency, negotiation and culturally sensitive interventions with explanations that are tailored and informed by health beliefs and practices of different cultural groups
- Vulnerable population groups have increased risks of earlier onset type 2 diabetes and CVD, racial and ethnic inequalities in access to effective evidence based efficacious prescribing and equal access has to be a priority.
CPD reflective questions
- Considering the local population your diabetes care services, can you reflect and undertake a health needs assessment with regards to their prescribing needs?
- Can you identify your usual patterns of prescribing and what evidence do you base your practice upon?
- How do you choose which agents to prescribe – is this undertaken in an informed manner with each individual and their needs?
- Can you identify areas when your prescribing practice could be improved potentially?