Recovery JSNA: Cardiovascular Disease and Respiratory Conditions
The COVID-19 pandemic has had a direct impact of on morbidity and mortality, the pandemic also has indirect consequences on healthcare for other diseases. Since the start of the pandemic, healthcare systems have adopted unprecedented measures to minimise disease transmission and prepare for COVID-19 patients. Consultations, routine diagnostic evaluations, and non-essential procedures were cancelled or deferred in order to prioritise the care of patients with COVID-19 and to limit the risk of contamination at the hospital. In addition, governments and health authorities worldwide recommended the deferral of elective procedures in order to preserve health staff and hospital resources, including cardiac services.
COVID-19 infection can have a significant impact on the patient during the period of infection but it also has longer term impacts on the heart and lungs. This is similar to infection with rheumatic fever which impacted infected peoples heart valves even if they were asymptomatic.
This report looks at the impact of the COVID-19 pandemic on Cardiovascular Disease and Respiratory Conditions both of which have short and longer term implications as a result of COVID-19 infection.
This chapter covers:
Cardiovascular disease background
Cardiovascular diagnosis and treatment gaps
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Cardiovascular disease background
The COVID-19 pandemic has had a direct impact of on morbidity and mortality, the pandemic also has indirect consequences on healthcare for other diseases. Since the start of the pandemic, healthcare systems have adopted unprecedented measures to minimise disease transmission and prepare for COVID-19 patients. Consultations, routine diagnostic evaluations, and non-essential procedures were cancelled or deferred in order to prioritise the care of patients with COVID-19 and to limit the risk of contamination at the hospital. In addition, governments and health authorities worldwide recommended the deferral of elective procedures in order to preserve health staff and hospital resources, including cardiac services.
COVID-19 infection can have a significant impact on the patient during the period of infection but it also has longer term impacts on the heart and lungs. This is similar to infection with rheumatic fever which impacted infected peoples heart valves even if they were asymptomatic.
This report looks at the impact of the COVID-19 pandemic on Cardiovascular Disease and Respiratory Conditions both of which have short and longer term implications as a result of COVID-19 infection. .
Cardiovascular trends
Trend in premature Coronary Heart Disease mortality (Age <75)

In the years 2017 - 2019, around 400 people (26.6 per 100,000 people) aged under 75 in Wiltshire died from a CHD related condition.
While the rate has decreased, the number of deaths has remained broadly similar for the period.
Trend in cardiology referrals

Within Bath and North East Somerset, Swindon and Wiltshire (BSW) CCG in the weeks prior to lockdown the average number of referrals per week to Cardiology was over 400.
During the first lockdown in April this dropped to less than 100 per week. Referrals have not recovered to the levels seen prior to the start of the pandemic suggesting patients may not be accessing primary care or presenting with symptoms.
There is a similar drop in referral in the first week of January at the start of the second lockdown.
Trend in Coronary Heart Disease admissions

Around 2,200 Wiltshire registered patients (408.2 per 100,000 people) were admitted to hospital for CHD related condition in 2019/20. This was a reduction of 200 on 2018/19.
The trend in the admission rate has been declining as the population has increased and the number of admissions has remained broadly similar.
Further work is needed to understand if the reduction in admissions is related to the pandemic response.
Cardiovascular diagnosis and treatment gaps
Atrial fibrillation diagnosis and treatment gaps

Within BSW CCG there were 26,670 patients registered with Atrial Fibrillation (AF). Modelling suggests there is a gap of around 3,500 people with undiagnosed AF. In percentage terms this is better than England but worse than the SW.
The gap in patients with high risk and not on a DOAC is broadly similar to the England and SW average at around 5%. For BSW this is around 2,200 patients.
Hypertension treatment gap

Within BSW CCG there are 140,000 patients registered with Hypertension. QOF guidelines are to control patients blood pressure to a level depending on the age of the patient.
Within BSW close to a third of patients are not controlled to the levels suggested in the contract. This means around 43,000 patients have a higher blood pressure than expected.
Respiratory conditions background
Respiratory conditions such as Asthma and Chronic Obstructive Pulmonary Disease (COPD) are a major challenge for health systems in the UK. Someone in the UK dies of lung disease every five minutes, and it is the poorest people in our society who are twice as likely to develop lung cancer or chronic obstructive pulmonary disease.
Before the pandemic, 1 in 3 people waited longer than six months for a diagnosis of lung disease. Some lung conditions, can have a substantial impact on life expectancy, so any delays to diagnosis could have a monumental impact on a person’s ability to access timely treatment and care. Analysis of referral data showed that during the first lockdown alone, around 500-600 people may have missed out on a referral for specialist care, treatment or diagnosis in BANES, Swindon and Wiltshire CCG.
The potential backlog is likely to have led to many people with lung disease needing to seek emergency care because they will not have had timely support to manage their condition. As data on respiratory care is patchy, it is difficult to tell the full impact on people living with lung conditions. But what we know so far, presents a deeply worrying picture of what the true cost of the pandemic, to patients living with lung disease, may look like.
In addition evidence is being published showing that like many respiratory infections COVID-19 can cause lasting lung damage for patients who become infected, leading to potentially new referrals to these already stretched services. .
Respiratory conditions trends
Trend in premature respiratory mortality (age <75)

In the 3 years 2016-2018, around 170 people (11.9 per 100,000 people) aged under 75 in Wiltshire died from a Respiratory related condition.
While the rate in Wiltshire has decreased in the last period, generally there has been a slight upward trend in the number of premature deaths related to respiratory conditions.
Trend in mortality from COPD (All ages)

In the 3 years 2016-2018 around 550 people in Wiltshire have died from COPD (34 per 100,000 people). This represents a reduction of over 50 on the 2015-17 total.
Prior to 2016-18 the number of deaths from COPD had been increasing slightly while the rate has remained fairly consistent reflecting the increasing population of Wiltshire.
Provisional data for 2018-20 shows 477 people died from COPD, giving a rate of 34 per 100,000 population, maintain the downward trend.
Source: INHALE - INteractive Health Atlas of Lung conditions in England, PHE, extracted March 2021 and provisional data extracted from Wiltshire Primary Care Mortality Database, April 2021
Trend in mortality from Asthma (All ages)

In the 3 years 2016-2018, around 25 people (1.5 per 100,000 people) in Wiltshire have died from Asthma. The number of deaths has been fairly consistent in the most recent periods.
Provisional data for 2018-20 shows 28 people died from Asthma, giving a rate of 1.9 per 100,000 population.
Source: INHALE - INteractive Health Atlas of Lung conditions in England, PHE, extracted March 2021 and provisional data extracted from Wiltshire Primary Care Mortality Database, April 2021
Trend in Respiratory referrals

In the first quarter of 2020 there were on average around 80 referrals per week to respiratory services. During April 2020 this dropped to less than 10 and has subsequently increased to around 40.
This drop in referrals may result in some patients remaining undiagnosed which may results in faster disease progression and poorer outcomes for the patient.
Trend in COPD admissions

Around 700 Wiltshire registered patients were admitted to hospital for COPD in 2018-19 (131.8 admissions per 100,000 people). This was a reduction of around 40 admissions on the 2017-18 admissions.
There was a step change increase in admissions to 2016-17 from just over 600 admissions to over 700 admissions. Since then admissions have fallen slightly.
Trend in Asthma admissions

Around 250 Wiltshire registered patients were admitted to hospital for asthma in 2018-19 (82.1 admissions per 100,000 people). This was an increase of around 30 admissions on the 2017-18 admissions.
Respiratory conditions diagnosis and treatment gaps
Asthma and COPD diagnosis gaps

There are around 67,000 patients with Asthma and 17,000 patients with COPD on the QOF registers of the GP practices within BSW CCG.
Modelling suggests within BSW CCG there maybe around 24,000 undiagnosed Asthma and 21,000 people with undiagnosed COPD.
Source: Qualities Outcomes Framework, NHS Digital, extracted March 2021 and Expected Prevalence extracted from Modelled Prevalence estimates, PHE, extracted 2021
Asthma and COPD treatment gaps

Every year Asthma patients are supposed to be reviewed in order to asses Asthma control. In 2019-20 just over 22,000 patients were not assessed.
COPD patients with a Medical Research Council (MRC) dyspnoea scale ≥3 in the previous year are supposed to be offered pulmonary rehabilitation. In 2019-20 around 4,500 patients were eligible and only around 1,650 patients were offered rehabilitation.
Closing the gaps will help ensure better outcomes for patients.
Source: Qualities Outcomes Framework, NHS Digital, extracted March 2021 and Expected Prevalence extracted from Modelled Prevalence estimates, PHE, extracted 2021