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Introduction The COVID‐19 pandemic has transformed lives across the world. In the UK, a public health driven policy of population “lockdown” has had enormous personal and economic impact. Methods We compare UK response and outcomes with European countries of similar income and healthcare resources. We calibrate estimates of the economic costs as different % loss in Gross Domestic Product (GDP) against possible benefits of avoiding life years lost, for different scenarios where current COVID‐19 mortality and comorbidity rates were used to calculate the loss in life expectancy and adjusted for their levels of poor health and quality of life. We then apply a quality‐adjusted life years (QALY) value of £30,000 (maximum under national guidelines). Results There was a rapid spread of cases and significant variation both in severity and timing of both implementation and subsequent reductions in social restrictions. There was less variation in the trajectory of mortality rates and excess deaths, which have fallen across all countries during May/June 2020. The average age at death and life expectancy loss for non‐COVID‐19 was 79.1 and 11.4 years, respectively, while COVID‐19 were 80.4 and 10.1 years; including adjustments for life‐shortening comorbidities and quality of life plausibly reduces this to around 5 QALY lost for each COVID‐19 death. The lowest estimate for lockdown costs incurred was 40% higher than highest benefits from avoiding the worst mortality case scenario at full life expectancy tariff and in more realistic estimations they were over 5 times higher. Future scenarios showed in the best case a QALY value of £220k (7xNICE guideline) and in the worst‐case £3.7m (125xNICE guideline) was needed to justify the continuation of lockdown. Conclusion This suggests that the costs of continuing severe restrictions are so great relative to likely benefits in lives saved that a rapid easing in restrictions is now warranted.

Objectives One important group of people at higher risk from the SARS‐CoV‐2(COVID‐19) pandemic are those with autoimmune conditions including rheumatoid arthritis/inflammatory bowel disease. To minimise infection risk, many people have been switched from intravenous to subcutaneous biologics including biosimilars. Design The survey was designed to understand comparative economic issues related to the intravenous infusion vs subcutaneous biologic administration routes for infliximab. The survey focused on direct cost drivers/indirect cost drivers. Acquisition costs of medicines were not included due to data not being available publicly. Wider policy implications linked to the pandemic were also explored. Setting/participants Semistructured single telephone interviews were carried out with twenty key stakeholders across the National Health Service(NHS) from 35 clinical/42 pharmacy/28 commissioning roles. The interviews were undertaken virtually during April 2020. From interview (n = 20) results, a simple cost analysis was developed plus a qualitative analysis of reports on wider policy/patient impacts. Results Key findings included evidence of significant variation in local infusion tariffs UK wide, with interviewees reporting that not all actual costs incurred are captured in published tariff costs. A cost analysis showed administration costs 50% lower in the subcutaneous compared to infusion routes, with most patients administering subcutaneous medicines themselves. Other indirect benefits to this route included less pressure on infusion unit waiting times/reduced risk of COVID‐19 infection plus reduced patient ‘out of pocket’ costs. However, this was to some extent offset by increased pressure on home‐care and community/primary care services. Conclusions Switching from infusion to subcutaneous routes is currently driven by the COVID‐19 pandemic in many services. A case for biologics (infusion vs subcutaneous) must be made on accurate real‐world economic analysis. In an analysis of direct/indirect costs, excluding medicine acquisition costs, subcutaneous administration appears to be the more cost saving option for many patients even without the benefit of industry funded home‐care. What's known One important group of people at high risk in COVID‐19 pandemic are those with autoimmune conditions, including those with rheumatoid arthritis and inflammatory bowel disease. Depending on the complexity of their condition, some of the patients in this group may be receiving intravenous biologic infusion therapy which under normal circumstances is administered within a hospital or day hospital setting. The National Institute for Health and Care Excellence has published new guidance to ensure that patients having intravenous treatment are assessed for possible switching to the same treatment in subcutaneous form. What’s new A cost analysis showed that administration costs for subcutananous routes are 50% lower than for infusion routes, with most patients administering subcutaneous medicines themselves. Other indirect benefits to this route included less pressure on infusion unit waiting times and reduced risk of COVID‐19 infection, along with reduced patient costs. Cost savings were partly offset by increased pressure on home‐care and community/primary care services.

Better patient outcomes require robust data collection and greater clinician awareness

Introduction Vaccination against the COVID‐19 virus began in December 2020 in the UK and into Spring 2021 has been running at 5% population/week. High levels of social restrictions were implemented for the third time in January 2021 to control the second wave and resulting increases in hospitalisations and deaths. Easing those restrictions must balance multiple challenging priorities, weighing the risk of more deaths and hospitalisations against damage done to mental health, incomes and standards of living, education and provision of non‐Covid‐19 healthcare. Methods Weekly and monthly officially published data for 2020/21 were used to estimate the influence of seasonality and social restrictions on the spread of COVID‐19 by age group, on the economy and on healthcare services. These factors were combined with the estimated impact of vaccinations and immunity from past infections into a model that retrospectively reflected the actual numbers of reported deaths closely both in 2020 and early 2021. The model was applied prospectively to the next 6 months to evaluate the impact of different speeds of easing social restrictions. Results The results show vaccinations as significantly reducing the number of hospitalisations and deaths. The central estimate is that relative to rapid easing, the avoided loss of 57 000 life‐years from a strategy of relatively slow easing over the next several  months comes at a cost in terms of GDP reduction of around £0.4 million/life‐year loss avoided. This is over 10 times higher than the usual limit the NHS uses for spending against Quality Adjusted Life Years (QALYs) saved. Alternative assumptions for key factors affecting the spread of the virus give significantly different trade‐offs between costs and benefits of different speeds of easing. Disruption of non‐Covid‐19 Healthcare provision also increases in times of higher levels of social restrictions. Conclusion In most cases, the results favour a somewhat faster easing of restrictions in England than current policy implies.

AimsThe 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.MethodsUsing 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.ResultsIn 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).ConclusionsOur 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.

ObjectivesWe conducted a Pakistan-wide community-based survey on the prevalence of type 2 diabetes using glycated haemoglobin (HbA1c) as the screening test. The aim was to estimate diabetes prevalence across different demographic groups as well as all regions of Pakistan.Design, settings and participantsMultistaged stratified cluster sampling was used for the representative selection of people aged ≥20 years, residing in 378 sampled clusters of 16 randomly selected districts, in this cross-sectional study. Eligible participants had blood drawn for HbA1c analyses at field clinics near to their homes. The oral glucose tolerance test (OGTT) was conducted on a subsample of the participants. Overall and stratified prevalence of type 2 diabetes and its association with risk factors were estimated using logistic regression models.Main outcome measuresPrevalence of prediabetes and type 2 diabetes.ResultsOf 18 856 eligible participants the prevalence of prediabetes was 10.91% (95% CI 10.46 to 11.36, n=2057) and type 2 diabetes was 16.98% (95% CI 16.44 to 17.51, n=3201). Overall, the mean HbA1c level was 5.62% (SD 1.96), and among newly diagnosed was 8.56% (SD 2.08). The prevalence was highest in age 51–60 years (26.03%, p<0.001), no formal education (17.66%, p<0.001), class III obese (35.09%, p<0.001), family history (31.29%, p<0.001) and female (17.80%, p=0.009). On multivariate analysis, there was a significant association between type 2 diabetes and older age, increase in body mass index and central obesity, positive family history, and having hypertension and an inverse relation with education as a categorical variable. On a subsample (n=1027), summary statistics for diagnosis of diabetes on HbA1c showed a sensitivity of 84.7%, specificity of 87.2% and area under the receiver operating characteristic curve 0.86, compared with OGTT.ConclusionsThe prevalence of type 2 diabetes and prediabetes is much higher than previously thought in Pakistan. Comprehensive strategies need to be developed to incorporate screening, prevention and treatment of type 2 diabetes at a community level.

Background The COVID‐19 pandemic has led to radical political control of social behaviour. The purpose of this paper is to explore data trends from the pandemic regarding infection rates/policy impact, and draw learning points for informing the unlocking process. Methods The daily published cases in England in each of 149 Upper Tier Local Authority (UTLA) areas were converted to Average Daily Infection Rate (ADIR), an R‐value ‐ the number of further people infected by one infected person during their infectious phase with Rate of Change of Infection Rate (RCIR) also calculated. Stepwise regression was carried out to see what local factors could be linked to differences in local infection rates Findings By the 19th April 2020 the infection R has fallen from 2.8 on 23rd March before the lockdown and has stabilised at about 0.8, sufficient for suppression. However there remain significant variations between England regions. Regression analysis across UTLAs found that the only factor relating to reduction in ADIR was the historic number of confirmed number infection/000 population, There is however wide variation between Upper Tier Local Authorities (UTLA) areas. Extrapolation of these results showed that unreported community infection may be 150 times higher than reported cases, providing evidence that by the end of the second week in April, 26.8% of the population may already have had the disease and so have increased immunityExtrapolation of these results showed that unreported community infection may be 150 times higher than reported cases, providing evidence that by the end of the second week in April, 26.8% of the population may already have had the disease and so have increased immunity. Interpretation Analysis of current case data using infectious ratio has provided novel insight into the current national state and can be used to make better‐informed decisions about future management of restricted social behaviour and movement.

Introduction The approach to thyroid hormone replacement varies across centres, but the extent and determinants of variation is unclear. We evaluated geographical variation in levothyroxine (LT4) and liothyronine (LT3) prescribing across General Practices in England and analysed the relationship of prescribing patterns to clinical and socioeconomic factors. Methods Data was downloaded from the NHS monthly General Practice Prescribing Data in England for the period 2011‐2020. Results The study covered a population of 19.4 million women over 30 years of age, attending 6,660 GP practices and being provided with 33.7 million prescriptions of LT4 and LT3 at a total cost of £90million/year. Overall, 0.5% of levothyroxine treated patients continue to receive liothyronine. All Clinical Commission Groups (CCGs) in England continue to have at least one liothyronine prescribing practice and 48.5% of English general practices prescribed liothyronine in 2019‐2020. Factors strongly influencing more levothyroxine prescribing (model accounted for 62% of variance) were the CCG to which the practice belonged and the proportion of people with diabetes registered on the practice list plus antidepressant prescribing, with socioeconomic disadvantage associated with less levothyroxine prescribing. Whereas factors that were associated with increased levels of liothyronine prescribing (model accounted for 17% of variance), were antidepressant prescribing and % of type 2 diabetes mellitus individuals achieving HbA1c control of 58 mmol/mol or less. Factors that were associated with reduced levels of liothyronine prescribing included smoking and higher obesity rates. Conclusion In spite of strenuous attempts to limit prescribing of liothyronine in general practice a significant number of patients continue to receive this therapy, although there is significant geographical variation in the prescribing of this as for levothyroxine, with specific general practice and CCG‐related factors influencing prescribing of both levothyroxine and liothyronine across England.

ObjectiveExperimental evidence has shown potential cardioprotective actions of phosphodiesterase type-5 inhibitors (PDE5is). We investigated whether PDE5i use in patients with type 2 diabetes, with high-attendant cardiovascular risk, was associated with altered mortality in a retrospective cohort study.Research design and methodsBetween January 2007 and May 2015, 5956 men aged 40–89 years diagnosed with type 2 diabetes before 2007 were identified from anonymised electronic health records of 42 general practices in Cheshire, UK, and were followed for 7.5 years. HRs from multivariable survival (accelerated failure time, Weibull) models were used to describe the association between on-demand PDE5i use and all-cause mortality.SM110.1136/heartjnl-2015-309223.supp1Supplementary appendixResultsCompared with non-users, men who are prescribed PDE5is (n=1359) experienced lower percentage of deaths during follow-up (19.1% vs 23.8%) and lower risk of all-cause mortality (unadjusted HR=0.69 (95% CI: 0.64 to 0.79); p<0.001)). The reduction in risk of mortality (HR=0.54 (0.36 to 0.80); p=0.002) remained after adjusting for age, estimated glomerular filtration rate, smoking status, prior cerebrovascular accident (CVA) hypertension, prior myocardial infarction (MI), systolic blood pressure, use of statin, metformin, aspirin and β-blocker medication. PDE5i users had lower rates of incident MI (incidence rate ratio (0.62 (0.49 to 0.80), p<0.0001) with lower mortality (25.7% vs 40.1% deaths; age-adjusted HR=0.60 (0.54 to 0.69); p=0.001) compared with non-users within this subgroup.ConclusionIn a population of men with type 2 diabetes, use of PDE5is was associated with lower risk of overall mortality and mortality in those with a history of acute MI.