Ethnic Disparities in Quality of Care Among Type 2 Diabetic Patients Before and During the COVID-19 Pandemic: A Before and After Study Using UK Electronic Health Records

Date of Approval
Application Number
Lay Summary

The 2019 novel coronavirus has rapidly spread throughout the world, involving more than 100 million individuals and their related chronic conditions could have adverse implications due to the pandemic. Diabetes represents one of the most prevalent chronic diseases worldwide, it's estimated that about half a billion people have diabetes and this number is likely to increase by 25% in 2030. Specifically, the most common form of diabetes is type 2 diabetes, which is a leading cause of mortality. Research on these two diseases is of increasing relevance since they both are conditions that are widespread in the world today. However, previous research has mostly covered the direct risks of COVID-19 among type 2 diabetic patients but currently, there are limited comprehensive studies aiming to address the indirect effects of COVID-19, such as its impacts on the quality of care.

The overall aim of this study is to determine factors such as ethnicity, age, sex, and health status, that influences quality of care among type 2 diabetic patients in the context of COVID-19 in the United Kingdom. Data will be assessed using electronic health records from the Clinical Practice Research Datalink, where participants will be recruited based on their type 2 diabetes diagnosis. This study is a prospective cohort study to further explore the association between the quality of diabetic care during the pandemic and comparing this to pre-pandemic levels. Data analysis will be performed using survival analysis and recommendations will be made to reduce existing social inequalities in diabetic care.

Technical Summary

Ethnic disparities in T2DM diagnosis and care remain a pervasive health problem in the UK. Studies have reported higher prevalence of T2DM among ethnic minorities, with Asians and Blacks having 2-4 times the T2DM prevalence compared to Whites (Whicher et al, 2020). There are also recognized inequalities in healthcare services, which may have been exacerbated by COVID-19. Currently, there are no known UK studies that address ethnic disparities in T2DM health checks, comparing care indicators before and during the pandemic.

This study uses primary care data to compare ethnic differences in routine health checks for T2DM patients before and during COVID-19. Ethnic minorities are disproportionally affected by T2DM, and by changes in healthcare delivery imposed by COVID-19, this study aims to observe variation in diabetes care by ethnicity. Since deprivation and ethnicity may overlap, the Index of Multiple Deprivation is used to explore how deprivation modifies the relationship between ethnicity and quality of diabetes care provision.

There will be two cohorts (1) pre-pandemic cohort where individuals with T2DM actively registered in the database on March 11, 2019 and (2) pandemic time cohort consisting of T2DM patients actively registered on March 11, 2021. WHO declared COVID-19 a pandemic on March 11, 2020, March 11, 2021 is chosen as the start of the pandemic time-cohort. To allow for the same analysis time, March 11, 2019, is used as the start of the pre-pandemic cohort. The same analysis is performed in both time-periods and is compared.

Quality of diabetes care is defined using three outcomes of interest: BP measurement, blood sugar measurement, and foot examination. Cox proportional hazards regression will quantify ethnic differences in time to receipt the care metrics separately for the pre-pandemic and pandemic cohort. Differences in the ethnic patterning of diabetes care between the two time-periods will be described qualitatively.

Health Outcomes to be Measured

There are three main outcomes of interest: (1) blood pressure measurement, (2) blood sugar measurement (HbA1c), and (3) foot examination


Rohini Mathur - Chief Investigator - London School of Hygiene & Tropical Medicine ( LSHTM )
Yunqing Zhu - Corresponding Applicant - London School of Hygiene & Tropical Medicine ( LSHTM )


ONS Death Registration Data;Patient Level Index of Multiple Deprivation;Practice Level Index of Multiple Deprivation