24 August 2022
The Covid-19 pandemic impacted health care services around the world, with many patients having delays in treatment or diagnosis for other conditions. In the National Health Service (NHS) in England, we are seeing some of the consequences of this now, with 6.5 million people waiting for treatment, an almost doubling of the waiting list since 2020.
To get a better understanding of which patients have been affected by this backlog, we used data about prescription medicines dispensed from pharmacies in England to track the trends in medicine usage before, during and after the pandemic. This way of looking at the impact of the pandemic is helpful because it provides a view into how many patients are being treated or starting treatment over time.
Danielle Robinson will present these findings in more detail at the ISPE conference in August 2022.
Identifying changes due to the pandemic
We looked at all categories of medicines to compare how prescribing trends before the Covid-19 pandemic differed to prescribing trends after the onset of the pandemic. By projecting forward the trends and patterns that existed before March 2020, we can compare the actual prescriptions with what would have happened if the Covid-19 pandemic had not occurred. We classified a substantial change as a >3% increase or decrease when the expected number of prescriptions was compared to the observed number of prescriptions.
We found that, out of 90 categories of medicines, the trend for 50 had substantially changed around the time of the pandemic (Figure 1), prescriptions for 26 of these had increased, and 24 had decreased.
In general, the categories of medicine for which prescribing had increased can be classified into two groups of potential causes:
- potential treatments for Covid & long Covid, such as cough preparations; and
- changes in how health care services were provided during the pandemic, such as switching patients from injectable vitamins to tablets.
There were also two main drivers of decreases in medicine use:
- delayed or missed diagnoses for chronic diseases, such as drugs for dementia; and
- fewer treatments for minor infections, such as use of antibiotics.
These findings about medicine use provide a window into the ongoing impact of the pandemic on patients and the treatments they receive. Probably the most notable finding is the substantial number of medicines used to treat serious and long-term conditions, where usage has not been as high as would have been expected in the absence of the pandemic. Although other explanations cannot be ruled out, it seems likely that at least part of this is the result of delayed or missed diagnoses for chronic (long-term) diseases.
Example 1: Anticoagulant medicines
Anticoagulants ('blood thinners') are commonly prescribed medicines that reduce the risk of blood clots. They are used for two main reasons: first, to reduce the risk of a blood clot in someone who is at higher risk of one. A common example of this is the heart rhythm disorder atrial fibrillation, which can cause stroke unless patients take an anticoagulant. The second main reason is to treat patients who have had a major blood clot, such as a deep vein thrombosis or pulmonary embolus. Our analysis shows that prescriptions for anticoagulants were 5% lower than expected (see Figure 2). This may be the result of fewer people being diagnosed or treated for atrial fibrillation or fewer people having a major clot and requiring treatment. If people are missing out on being diagnosed or treated for atrial fibrillation, then this could result in more people having an avoidable stroke.
Example 2: Hormone treatments for cancer
Another example are hormone treatments used to treat people with cancer. Certain types of breast and prostate cancers are treated with these medicines, and we found that prescriptions for them were 4.4% lower than expected (Figure 3). This could be the result of delays in diagnosing people with cancer and starting them on treatment.
What could this reduction in prescribing for chronic conditions mean?
Jonathan Pearson-Stuttard and Melissa Shaw described the impact of the Covid-19 pandemic on excess deaths and found that deaths due to dementia and Alzheimer’s increased by 22%, and that heart disease and stroke deaths were the largest contributors of excess death in the community for men in 2020. The changes in prescribing we have observed help to explain why we may be seeing more people dying from these types of diseases, and are a warning sign that the backlog in healthcare from the pandemic is likely to have an impact for many years to come.