Exploring the impact of the COVID-19 pandemic on patients with type 2 diabetes and primary care utilisation: a scoping review

Exploring the impact of the COVID-19 pandemic on patients with type 2 diabetes and primary care utilisation: a scoping review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Exploring the impact of the COVID-19 pandemic on patients with type 2 diabetes and primary care utilisation: a scoping review Irantzu Bengoa-Urrengoechea, Sara Malo, Mª José Rabanaque, Mª Antonia Sánchez-Calavera, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6255075/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: During the coronavirus disease 2019 (COVID-19) pandemic, changes in healthcare organisation may have affected the management of chronic patients, such as those with type 2 diabetes (T2D), who require close monitoring. Although there are studies that analyse the access and management of patients with T2D in Primary Care (PC) during the pandemic, there is no synthesis of the results that inform us about the care provided. The aim of this study is to summarise the existing evidence on the care provided in PC settings to patients with T2D during the COVID-19 pandemic, as well as their follow-up care and outcomes, in order to understand the impact of the pandemic on their management. Methods: A scoping review was conducted according to the approach described by Arksey and O'Malley. Structured search strategies were developed for each of the selected databases (PubMed, EMBASE and Web of Science). We included articles published in English and Spanish up to 30 November 2024 on access to care for patients with T2D in PC during the pandemic. Two independent reviewers screened titles and abstracts to select studies related to the population, intervention, and outcomes of interest. In cases of disagreement, a third reviewer resolved the discrepancy. One of the reviewers extracted data and summarised them. Results: From a total of 441 articles, 19 full-text articles were finally selected for inclusion. Europe had the highest number of publications. The majority of the studies were retrospective cohort studies and the most commonly used source of data was electronic health records. The two topics of interest were identified: access to healthcare services and results regarding disease management. There was a general decrease in face-to-face visits made by patients with T2D, with reduced checks of laboratory parameters, blood pressure and weight. The results of monitoring during and after the pandemic were not always worse that the results previously obtained. Conclusions: During the COVID-19 pandemic, face-to-face care for patients with T2D in PC was reduced without a clear impact on control outcomes, highlighting the importance of virtual visits to ensure continuity of care. Protocol registration number INPLASY202360057. Diabetes mellitus Type 2 Primary health care COVID-19 pandemic Figures Figure 1 BACKGROUND Diabetes mellitus is a chronic condition characterised by elevated blood glucose levels. According to the International Diabetes Federation, diabetes is one of the fastest-growing global health emergencies of the 21st century. In 2021, it was estimated that 537 million people worldwide had diabetes. This number is projected to reach 643 million by 2030 and 783 million by 2045 ( 1 ). Type 2 diabetes (T2D) accounts for more than 90% of diabetes cases worldwide. It has significant individual and social consequences due to the increased risk of acute and chronic complications, particularly chronic macrovascular and microvascular complications, resulting from abnormal and sustained high blood glucose levels. To prevent the onset of T2D, controlling risk factors and maintaining a healthy lifestyle through diet, physical activity, and smoking cessation are crucial ( 2 ). These goals should be achieved mainly through primary care (PC) services. The COVID-19 pandemic has caused a substantial decrease in access to PC services in some areas, which has had a particularly negative impact on chronic patients who depend on regular healthcare for disease management( 3 ). This limited access led to deterioration in the control of chronic conditions and increased vulnerability among those affected ( 4 ). Some studies have shown that a reduction in follow-up care has resulted in poorer outcomes and fewer resources for patients with T2D, which has significantly worsened the results of the monitoring indicators, screening and vaccination of patients in PC ( 5 , 6 ) and potentially exacerbated their health issues and increased complications ( 7 ). Understanding the attention received by patients with T2D from PC during the COVID-19 pandemic is crucial for understanding the impact of the pandemic on these patients in terms of control and follow-up. Therefore, the objective of this scoping review is to summarise how people with T2D access and use PC during the COVID-19 pandemic and how their disease was monitored and controlled. Our findings will be valuable in suggesting measures to improve the care of these patients in any future comparable scenarios. METHODS Protocol design A scoping review was conducted according to the approach described by Arksey and O'Malley (2005)(8). The approach comprises five steps: (1) formulation of the research question, (2) identification of relevant studies, (3) selection of eligible studies, (4) collection of data and (5) data summary and synthesis of results. The review protocol has been included in the international platform for the registration of systematic reviews and meta-analysis protocols INPLASY® (INPLASY registration number: INPLASY202360057) (9), which provides an online database where protocols are maintained as permanent public records and whose website (www.inplasy.com) can be accessed. Formulation of the research question We used an iterative process, as recommended by Arksey and O’Malley(8), to develop the research question. The main research question aimed to understand how patients with T2D accessed PC services during the pandemic and how this affected their follow-up and disease management. The following questions guided the review: - Did patients with T2D continue to attend PC appointments during the COVID-19 pandemic? - During the COVID-19 pandemic, did general practitioners (GPs) continue monitoring and reviewing patients with T2D? - Have the results of follow-up care been maintained for patients who received it during the pandemic? - What are the limitations, gaps, and opportunities of these types of studies? Identification of relevant studies To identify relevant studies, structured search strategies were developed for each of the selected databases (PubMed, EMBASE and Web of Science). The strategy in PubMed included the MeSH terms “diabetes mellitus, type 2”, “hypoglycemic agents”, “primary health care”, “primary nursing”, “primary care nursing”, “physicians, primary care”, and “covid-19”. To increase the sensitivity of the search, additional general terms were added to title and abstract such as to make the search more sensitive, generic terms such as “non-insulin dependent diabetes mellitus” or "ambulatory care facilities" were added to the title and abstract. This search was adjusted for all other sources of information in accordance with their own specific search criteria. The search strategies for each of the databases used can be found in Additional file 1. Selection of eligible studies Inclusion criteria The inclusion criteria for this study were published manuscripts that evaluated healthcare for patients with T2D in PC during the pandemic. The review included observational studies published in English or Spanish between January 1, 2020, and November 30, 2024. Exclusion criteria Studies that did not collect data within the specified timeframe or reported the impact of the COVID-19 pandemic on healthcare were excluded. Additionally, studies that did not provide PC-specific data or included patients with T2D were excluded. Studies that focused on adults admitted to different levels of care (such as hospital admissions) were also excluded. Articles that focused solely on the care of COVID-19 patients or the development of the disease were excluded. In terms of study type, we excluded grey literature, dissertations, commentaries, and conference proceedings. Qualitative studies were also excluded. The references were processed via the bibliographic manager Mendeley and later exported to Rayyan software for data management and duplicate removal. Articles were included if they met the inclusion criteria and excluded if they did not. Two independent reviewers (I.B-U. and S.M.) screened titles and abstracts to select studies related to the population, intervention, and outcomes. In cases of disagreement, a third reviewer (I.A.-P.) resolved the discrepancy. Collection of data During this screening phase, we searched for studies whose full texts potentially met the inclusion criteria. Any full-text studies that did not meet the inclusion criteria were excluded, and the reasons for exclusion were reported. The final search results are presented in a PRISMA flowchart. After identifying the papers that met the defined criteria, we thoroughly read and classified them on the basis of their characteristics and relevant information. This allowed us to draw conclusions about the care of patients with T2D in PC during the COVID-19 pandemic. The following data were collected for the different studies: author, year, title, journal, country, type of study, sources of information, objective, duration of study, population, indicators measured, results, conclusions and limitations. Data summary and synthesis of results First, all the information extracted from each article was presented in tables to compare the general characteristics of the articles included in the scoping. Then, the main quantitative outcomes of each article were extracted (primary care visits, follow-up activities, constant measurements, laboratory measurements, referrals...) and grouped into service use and disease control. After being classified and summarised, the results were interpreted and discussed. Patient and public involvement Patients and the public were not involved in the design or completion of this study. RESULTS After removing duplicates, 441 articles were identified for review selection. Following the review of titles and abstracts, 105 articles met the inclusion criteria. Once we had access to the full-text articles, we read and screened them and found that 19 focused on the care of patients with T2D in PC during the pandemic (Fig. 1). The main characteristics of the studies are summarised in Table 1. Europe had the highest number of publications (63.2%). The United States and Canada were the only countries from the Americas included in the review, accounting for 21.1% of the publications. Two studies represented Asia, and none from Africa. Most of the studies (61.9%) were retrospective cohort studies, followed by retrospective cross-sectional studies. The most commonly used source of data was electronic health records. The results were obtained from a single collection period in 9 of the articles, while the remaining 9 compared prepandemic periods with those during or after the pandemic, and one was a systematic review. After the results of the 19 articles were analysed, two topics of interest were identified: access to healthcare services and results regarding disease management. Table 2 presents the main results. Regarding the collection of outcomes measured in the studies, follow-up activities such as recording vital signs, screening for retinopathy and diabetic foot, and activities during visits were the most common, followed by laboratory measures. Follow-up support and the frequency of visits were also frequently analysed, while prescriptions, referrals and control targets were mentioned in 4 articles each. Access to healthcare services During the pandemic, there was an overall decrease in face-to-face visits to PC, with a corresponding increase in virtual and telephone consultations ( 10 – 21 ). Some studies suggested that patient follow-up decreased during the pandemic( 11 , 14 , 19 , 22 ). This decrease in the number of GP visits during the pandemic had a slow recovery afterwards but without reaching prepandemic levels ( 23 – 25 ). Most studies reported differences in the use of health services, with an increase in virtual visits and a greater proportion of virtual visits than face-to-face visits, which decreased in all studies ( 10 , 13 – 15 , 20 , 21 , 23 ). Only van den Berg described an increase in total visits during the pandemic at the expense of virtual visits ( 10 ) in a retrospective study in the Netherlands. A reduction in referrals from PC to other specialists of 17% ( 26 ) to 18.7% ( 12 ) were described in some studies and a reduction in emergency assistance and access to hospital specialist have also been reported ( 13 , 21 ). Disease management Overall, fewer controls for HbA1c, blood pressure (BP), BMI and diabetic foot screening and retinography were described ( 10 , 12 , 13 , 15 – 17 , 19 , 22 – 24 , 27 , 28 ). In some cases, the results were worse than those reported before the COVID-19 pandemic. The prevalence of HbA1c controls was reduced by 4.5% ( 22 ) to 20–28% ( 13 , 17 , 19 ), with contradictory results. Some studies reported worse results than previously described ( 10 , 19 , 25 , 29 , 30 ). However, in most studies, the results were not significant or were similar to previous findings. There were also fewer BP recordings ( 10 – 13 , 19 , 22 , 23 ) with a decrease in the degree of compliance with therapeutic goals in some studies ( 19 , 25 ). With regard to BMI, there was a decrease in recordings during the pandemic period, but there was no clear change in the results obtained ( 12 , 16 , 25 , 28 , 31 ). DISCUSSION The 19 articles included and analysed in this scoping review revealed that access to healthcare in PC to patients with DM2 declined during the COVID-19 pandemic, with fewer follow-up visits to these patients and, in some cases, worse outcomes. The COVID-19 pandemic highlighted disparities in access to healthcare, being the low-income communities and geriatric patients the most vulnerable population groups ( 14 , 21 , 32 , 33 ). The decrease in both PC and hospital visits was attributed not only to increased access difficulties ( 18 ) but also to fear of possible infection. In addition, chronically ill patients, such as those with T2D, experienced disruptions in care and medication adherence, further exacerbating health inequalities ( 31 , 34 ). Several studies included in this review reported changes in healthcare use during the pandemic, with reductions in both GP visits, consultations and prescription rates for chronic medications ( 13 , 19 , 34 ) and prescribing patterns (Kowall et al., 2023). Difficulties with medication adherence were observed, particularly for those requiring specialist visits or new prescriptions, reflecting barriers to accessing health services ( 34 ). Telemedicine, while beneficial, presented challenges for vulnerable groups such as inadequate internet connectivity and difficulty using electronic devices, exacerbating existing health inequalities ( 30 , 35 ). Some studies showed that women, black patients and those with Medicare/Medicaid coverage faced barriers to care, such as delays in scheduling appointments and reluctance to return to medical facilities ( 35 , 36 ). These findings contrast with those of other studies ( 11 , 15 , 21 ), which reported higher rates of medical visits among older people and women and better follow-up outcomes. Although virtual consultations appear to have been beneficial for patient follow-up during the pandemic ( 16 , 18 , 20 , 21 ), some difficulties in accessing this tool have been highlighted. These include inadequate internet connectivity and practical difficulties in examining patients ( 37 ). Virtual consultations have many advantages, particularly for young working people, for administrative purposes or for the follow-up of conditions previously seen in person, however, these virtual consultations cannot replace regular face-to-face care. This is particularly true for old people ( 38 ), for whom telephone communication is difficult, or for processes that have just started or require a physical examination. Additional efforts to maintain continuity of care for chronic patients during the pandemic included the involvement of community pharmacists and the implementation of home medication programs ( 30 , 31 ). These strategies helped to mitigate disruptions in care while complying with COVID-19 containment measures. However, a significant proportion of patients reported delays or avoidance of care, citing reasons such as provider cancellations, safety concerns, and loss of employment or insurance ( 36 ). The implementation of accessible, patient-centred interventions remains critical to address health care disparities and ensure the continuity of care for vulnerable populations. Some studies showed a reduction in the incidence of diabetes ( 18 , 29 ), with slightly higher HbA1c at diagnosis ( 29 ), which may be due to a reduction in the number of patients receiving health services and a delay in diagnosis. Poorer health outcomes with increased HbA1c, BP or BMI in some cases ( 19 , 39 ) were reported. This may be due to the fear of going to the clinic during the pandemic for fear of infection or the convenience of not having to travel to the health centre for care ( 30 ). Patients with uncontrolled diabetes (HbA1c > 9%) were more likely to attend virtual visits ( 33 ), although they may have been less effective than those who attended face-to-face follow-up ( 28 ). It is possible that face-to-face visits by both GPs and nurses may help patients become more aware of their true follow-up numbers and the importance of taking lifestyle measures. In a significant number of cases, there was no difference in outcomes such as HbA1c, BP or BMI compared with the previous period. The likelihood of achieving guideline-recommended HbA1c levels before the pandemic was the strongest predictor of adherence during the pandemic ( 17 ). The worst results were observed in patients with a previously documented worse mean HbA1c ( 22 ). In other cases, increases in HbA1c and other parameters were more pronounced in lower-risk patients (young, with controlled HbA1c) ( 10 ). A statistically significant, although small, inverse association was found between face-to-face visits and HbA1c ( 15 , 19 ). This may be because people who were more aware of their disease were also those who requested more consultations ( 11 , 15 ). Patient empowerment is associated with better glycaemic control, psychosocial functioning and perceived access to person-centred chronic disease care( 40 , 41 ). These findings raise questions about the usefulness of health education strategies for chronic patients or whether they are being provided adequately. Some patient profiles, particulary those who are younger and with high educational levels, know how to manage and control their disease. We may have had a paternalistic attitude, and during the pandemic period, with less strict follow-up, many patients may have neglected their self-care and therefore had worse outcomes. Strengths and limitations of this study Although this review followed a specific strategy for searching for and synthesising articles, there are certain limitations. The search was conducted only in English and Spanish, which may have excluded other relevant articles. The use of a defined search strategy may have resulted in some articles being excluded, despite the use of MeSH and natural language terms. The exclusion of articles in preprint or conference communication may have ignored interesting results under different experimental conditions. Furthermore, the review did not include grey literature. In this review, certain studies have acknowledged their lack of representativeness ( 16 , 20 , 27 , 30 , 42 ) due to the small number of participants from racial minorities or the specific and underrepresentation of some geographical areas. Some studies do not differentiate between types of diabetes among their patients ( 22 , 42 ). Importantly, synthesising the results of studies conducted in such different populations and health contexts is challenging. Furthermore, it is not possible to determine the effect on health outcomes of those who did not have access to the healthcare system during this period because of pandemic restrictions ( 16 ). These patients may represent the group with the worst outcomes. Finally, the impact of the smaller number of controls and the results reported on the quality of life of patients with T2D was not analysed. This review has several strengths. An important one is that a comprehensive search strategy was implemented to ensure the identification of relevant studies across multiple databases and sources. In addition, it is broad in scope because it includes a variety of study designs. This increases the validity of the findings and provides valuable insights for future research, practice and policy development. CONCLUSIONS The COVID-19 pandemic significantly affected access to PC for patients with T2D, resulting in fewer follow-up visits and, in some cases, poorer health outcomes. Vulnerable populations, including low-income and elderly patients, faced the greatest barriers. While telemedicine helped to reduce some barriers, it also presented challenges such as limited internet access and difficulties in conducting thorough virtual examinations. The findings highlight the need for targeted interventions based on patient characteristics to ensure continuity of care for chronically ill patients during and after medical crises. Although some studies reported worse health outcomes, others found no significant differences in key measures such as HbA1c, BP or BMI compared with the pre-pandemic period. This review highlights the importance of maintaining face-to-face consultations for effective disease management and of providing PC with the necessary resources in terms of time and staff, in order to ensure that professionals can work in an appropriate environment and patients receive equitable and high quality care. Abbreviations T2D: type 2 diabetes PC: primary care HbA1c: glycated haemoglobin GP: general practitioners BP: blood pressure BMI: body mass index LDL: low-density lipoprotein-cholesterol HDL: high-density lipoprotein-cholesterol Declarations Ethics approval and consent to participate: not applicable. Consent for publication: not applicable. Data availability statement: All data relevant to the study are included in the article or uploaded as online supplemental information. Competing interests: The authors declare that they have no competing interests. Funding: This study was funded by Health Institute Carlos III (ISCIII) ‘PI22/01193’ and by the European Regional Development Fund (EDRF) “A way of making Europe” . Authors’ contributions: IBU screened the literature and extracted the data. IBU and SM screened titles and abstracts to select studies, and IAP resolved discrepancies. IBU was responsible for drafting the manuscript. SM and IAP were responsible for supervision of the research and critical revision of the manuscript. SM acted as guarantor. MJ and MA reviewed the manuscript and contributed to the discussion and formatting of the text. All the authors helped with critical review of the manuscript for important improvement of its content. Acknowledgements : to Montse Salas Valero. Documentalist - Coordinator of the Virtual Library of Health Sciences of Aragón. Institute for Health Sciences in Aragon (IACS) for her help during the definition of the search strategies. References Internacional Diabetes Federation. Vol. 1, IDF Diabetes Atlas. 2023 [cited 2024 Feb 14]. p. 31–88 IDF Diabetes Atlas 10th edition 537 million people worldwide have diabetes. Available from: www.diabetesatlas.org Yeh HC, Duncan BB, Schmidt MI, Wang NY, Brancati FL. Smoking, smoking cessation, and risk for type 2 diabetes mellitus: a cohort study. Ann Intern Med. 2010 Jan;152(1):10–7. World Health Organization. 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NATIONAL ONLINE SURVEY Coronavirus and Its Impact on US Healthcare Providers. 2020;1–6. Available from: https://pos.org/wp-content/uploads/2020/04/Jarrard-POS-National-Survey-Exec-Summary-4-29-2020.pdf Matenge S, Sturgiss E, Desborough J, Hall Dykgraaf S, Dut G, Kidd M. Ensuring the continuation of routine primary care during the COVID-19 pandemic: a review of the international literature. Fam Pract. 2022 Jul;39(4):747–61. Koh ZWJ, Sim SZ, Lew KJ, Lee PSS, Lee ES. Evaluation of the clinical effectiveness of telephone consultation compared to face-to-face consultation in terms of glycaemic control among patients with suboptimally controlled type 2 diabetes: a retrospective cohort study. BMJ Open. 2023;13(5). Strumann C, Blickle PG, von Meißner WCG, Steinhäuser J. The use of routine data from primary care practices in Germany to analyze the impact of the outbreak of SARS-CoV-2 on the utilization of primary care services for patients with type 2 diabetes mellitus. BMC Prim care. 2022 Dec;23(1):327. Rossi MC, Lucisano G, Funnell M, Pintaudi B, Bulotta A, Gentile S, et al. Interplay among patient empowerment and clinical and person-centered outcomes in type 2 diabetes. The BENCH-D study. Patient Educ Couns [Internet]. 2015 Sep;98(9):1142–9. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0738399115002335 Lambrinou E, Hansen TB, Beulens JW. Lifestyle factors, self-management and patient empowerment in diabetes care. Eur J Prev Cardiol [Internet]. 2019 Dec 26;26(2_suppl):55–63. Available from: https://academic.oup.com/eurjpc/article/26/2_suppl/55-63/5925416 Moin JS, Troke N, Plumptre L, Anderson GM. Impact of the COVID-19 Pandemic on Diabetes Care for Adults With Type 2 Diabetes in Ontario, Canada. Can J Diabetes [Internet]. 2022;46(7):715–21. Available from: https://doi.org/10.1016/j.jcjd.2022.04.009 Tables Tables 1 and 2 are available in the Supplementary Files section. Additional Declarations The authors declare no competing interests. Supplementary Files Tables.xlsx Additionalfile1.docx Search strategies Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6255075","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":430616492,"identity":"c2a8b487-e241-42e4-987f-110b335175c1","order_by":0,"name":"Irantzu Bengoa-Urrengoechea","email":"","orcid":"https://orcid.org/0000-0001-7283-7713","institution":"Grupo de Investigación en Servicios Sanitarios de Aragón (GRISSA), Fundación Instituto de Investigación Sanitaria de Aragón (IIS Aragón), Zaragoza, Spain","correspondingAuthor":false,"prefix":"","firstName":"Irantzu","middleName":"","lastName":"Bengoa-Urrengoechea","suffix":""},{"id":430620357,"identity":"aa01f2da-08a1-4ab5-85ba-ae941cc86795","order_by":1,"name":"Sara Malo","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAtUlEQVRIiWNgGAWjYHACxgMMFQwMbCTpOcBwhmQtjG2kKJefdvjBgY/zDufx8R9+9oGhoo6wFoPbaQYHZ247XMzGcMx4BsOZw0RokU4wOMy77XBiG2ODMQNj2wEiHDY7/cNh3jlALczsnxkY/xHhMIbbOUBbGoBa2HiAtjQwE+Gw2zkFB2ccS09s4+EpZkg4RoRfgA7b+OBDjXXi/P7jmxk+1BDjMBSQQKqGUTAKRsEoGAXYAQBFkTn/b3lPbgAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0000-0002-7194-8275","institution":"Grupo de Investigación en Servicios Sanitarios de Aragón (GRISSA), Fundación Instituto de Investigación Sanitaria de Aragón (IIS Aragón), Zaragoza, Spain","correspondingAuthor":true,"prefix":"","firstName":"Sara","middleName":"","lastName":"Malo","suffix":""},{"id":430620358,"identity":"9acbc05f-468b-4e48-b75b-f4c92938f3c3","order_by":2,"name":"Mª José Rabanaque","email":"","orcid":"https://orcid.org/0000-0002-6671-5661","institution":"Grupo de Investigación en Servicios Sanitarios de Aragón (GRISSA), Fundación Instituto de Investigación Sanitaria de Aragón (IIS Aragón), Zaragoza, Spain","correspondingAuthor":false,"prefix":"","firstName":"Mª","middleName":"José","lastName":"Rabanaque","suffix":""},{"id":430620359,"identity":"eae8531b-e679-4e01-b8f3-ce9acc37fea2","order_by":3,"name":"Mª Antonia Sánchez-Calavera","email":"","orcid":"https://orcid.org/0000-0001-8756-114X","institution":"Network for Research on Chronicity, Primary Care and Health Promotion (RICAPPS), ISCIII, Madrid, 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16:33:11","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-6255075/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6255075/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":79764663,"identity":"b97050d7-09dd-4643-8ef4-c0828839eb8a","added_by":"auto","created_at":"2025-04-02 12:01:18","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":43698,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSee image above for figure legend\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-6255075/v1/ef687559ae1dae507a90f19d.png"},{"id":79872166,"identity":"6d70610b-57a3-46c1-b7dc-32d25a534b96","added_by":"auto","created_at":"2025-04-03 22:41:37","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":688008,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6255075/v1/2d646bbc-b223-4f84-8a91-925193b92a61.pdf"},{"id":79764657,"identity":"33a1518e-7906-45d6-9758-b30c9ff12acc","added_by":"auto","created_at":"2025-04-02 12:01:17","extension":"xlsx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":20864,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-6255075/v1/6192785503b14ec68e0ca4ee.xlsx"},{"id":79764658,"identity":"bb9a1ed0-d864-4f94-825c-50c2a7f480c4","added_by":"auto","created_at":"2025-04-02 12:01:18","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":13740,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSearch strategies\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Additionalfile1.docx","url":"https://assets-eu.researchsquare.com/files/rs-6255075/v1/1c5aeb515fd424836fbf0597.docx"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eExploring the impact of the COVID-19 pandemic on patients with type 2 diabetes and primary care utilisation: a scoping review\u003c/p\u003e","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003eDiabetes mellitus is a chronic condition characterised by elevated blood glucose levels. According to the International Diabetes Federation, diabetes is one of the fastest-growing global health emergencies of the 21st century. In 2021, it was estimated that 537\u0026nbsp;million people worldwide had diabetes. This number is projected to reach 643\u0026nbsp;million by 2030 and 783\u0026nbsp;million by 2045 (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Type 2 diabetes (T2D) accounts for more than 90% of diabetes cases worldwide. It has significant individual and social consequences due to the increased risk of acute and chronic complications, particularly chronic macrovascular and microvascular complications, resulting from abnormal and sustained high blood glucose levels. To prevent the onset of T2D, controlling risk factors and maintaining a healthy lifestyle through diet, physical activity, and smoking cessation are crucial (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). These goals should be achieved mainly through primary care (PC) services.\u003c/p\u003e \u003cp\u003eThe COVID-19 pandemic has caused a substantial decrease in access to PC services in some areas, which has had a particularly negative impact on chronic patients who depend on regular healthcare for disease management(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). This limited access led to deterioration in the control of chronic conditions and increased vulnerability among those affected (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Some studies have shown that a reduction in follow-up care has resulted in poorer outcomes and fewer resources for patients with T2D, which has significantly worsened the results of the monitoring indicators, screening and vaccination of patients in PC (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) and potentially exacerbated their health issues and increased complications (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eUnderstanding the attention received by patients with T2D from PC during the COVID-19 pandemic is crucial for understanding the impact of the pandemic on these patients in terms of control and follow-up. Therefore, the objective of this scoping review is to summarise how people with T2D access and use PC during the COVID-19 pandemic and how their disease was monitored and controlled. Our findings will be valuable in suggesting measures to improve the care of these patients in any future comparable scenarios.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003e\u003cstrong\u003eProtocol design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA scoping review was conducted according to the approach described by Arksey and O'Malley (2005)(8). The approach comprises five steps: (1) formulation of the research question, (2) identification of relevant studies, (3) selection of eligible studies, (4) collection of data and (5) data summary and synthesis of results.\u003c/p\u003e\n\u003cp\u003eThe review protocol has been included in the international platform for the registration of systematic reviews and meta-analysis protocols INPLASY® (INPLASY registration number: INPLASY202360057) (9), which provides an online database where protocols are maintained as permanent public records and whose website (www.inplasy.com) can be accessed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFormulation of\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003ethe\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eresearch question\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe used an iterative process, as recommended by Arksey and O’Malley(8), to develop the research question. The main research question aimed to understand how patients with T2D accessed PC services during the pandemic and how this affected their follow-up and disease management.\u003c/p\u003e\n\u003cp\u003eThe following questions guided the review:\u003c/p\u003e\n\u003cp\u003e-\u0026nbsp; \u0026nbsp;\u0026nbsp;Did patients with T2D continue to attend PC appointments during the COVID-19 pandemic?\u003c/p\u003e\n\u003cp\u003e- During the COVID-19 pandemic, did general practitioners (GPs) continue monitoring and reviewing patients with T2D?\u003c/p\u003e\n\u003cp\u003e-\u0026nbsp; \u0026nbsp;\u0026nbsp;Have the results of follow-up care been maintained for patients who received it during the pandemic?\u003c/p\u003e\n\u003cp\u003e-\u0026nbsp; \u0026nbsp;\u0026nbsp;What are the limitations, gaps, and opportunities of these types of studies?\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIdentification of relevant studies\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo identify relevant studies, structured search strategies were developed for each of the selected databases (PubMed, EMBASE and Web of Science). The strategy in PubMed included the MeSH terms “diabetes mellitus, type 2”, “hypoglycemic agents”, “primary health care”, “primary nursing”, “primary care nursing”, “physicians, primary care”, and “covid-19”. To increase the sensitivity of the search, additional general terms were added to title and abstract such as to make the search more sensitive, generic terms such as “non-insulin dependent diabetes mellitus” or \"ambulatory care facilities\" were added to the title and abstract. This search was adjusted for all other sources of information in accordance with their own specific search criteria. The search strategies for each of the databases used can be found in Additional file 1.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSelection of eligible studies\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInclusion criteria\u003c/p\u003e\n\u003cp\u003eThe inclusion criteria for this study were published manuscripts that evaluated healthcare for patients with T2D in\u0026nbsp;PC during the pandemic. The review included observational studies published in English or Spanish between January 1, 2020, and November 30, 2024.\u003c/p\u003e\n\u003cp\u003eExclusion criteria\u003c/p\u003e\n\u003cp\u003eStudies that did not collect data within the specified timeframe or reported the impact of the COVID-19 pandemic on healthcare were excluded. Additionally, studies that did not provide PC-specific data or included patients with T2D were excluded. Studies that focused on adults admitted to different levels of care (such as hospital admissions) were also excluded. Articles that focused solely on the care of COVID-19 patients or the development of the disease were excluded. In terms of study type, we excluded grey literature, dissertations, commentaries, and conference proceedings. Qualitative studies were also excluded.\u003c/p\u003e\n\u003cp\u003eThe references were processed via the bibliographic manager Mendeley and later exported to Rayyan software for data management and duplicate removal. Articles were included if they met the inclusion criteria and excluded if they did not. Two independent reviewers (I.B-U. and S.M.) screened titles and abstracts to select studies related to the population, intervention, and outcomes. In cases\u0026nbsp;of disagreement, a third reviewer (I.A.-P.) resolved the discrepancy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCollection of data\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDuring this screening phase, we searched for studies whose full texts potentially met the inclusion criteria. Any full-text studies that did not meet the inclusion criteria were excluded, and the reasons for exclusion were reported. The final search results are presented in a PRISMA flowchart.\u003c/p\u003e\n\u003cp\u003eAfter identifying the papers that met the defined criteria, we thoroughly read and classified them on the basis of their characteristics and relevant information. This allowed us to draw conclusions about the care of patients with T2D in PC during the COVID-19 pandemic.\u003c/p\u003e\n\u003cp\u003eThe following data were collected for the different studies: author, year, title, journal, country, type of study, sources of information, objective, duration of study, population, indicators measured, results, conclusions and limitations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData summary and synthesis of results\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFirst, all the information extracted from each article was presented in tables to compare the general characteristics of the articles included in the scoping. Then, the main quantitative outcomes of each article were extracted (primary care visits, follow-up activities, constant measurements, laboratory measurements, referrals...) and grouped into service use and disease control. After being classified and summarised, the results were interpreted and discussed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatient and public involvement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients and the public were not involved in the design or completion of this study.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eAfter removing duplicates, 441 articles were identified for review selection. Following the review of titles and abstracts, 105 articles met the inclusion criteria. Once we had access to the full-text articles, we read and screened them and found that 19 focused on the care of patients with T2D in PC during the pandemic (Fig.\u0026nbsp;1).\u003c/p\u003e \u003cp\u003eThe main characteristics of the studies are summarised in Table\u0026nbsp;1. Europe had the highest number of publications (63.2%). The United States and Canada were the only countries from the Americas included in the review, accounting for 21.1% of the publications. Two studies represented Asia, and none from Africa. Most of the studies (61.9%) were retrospective cohort studies, followed by retrospective cross-sectional studies. The most commonly used source of data was electronic health records. The results were obtained from a single collection period in 9 of the articles, while the remaining 9 compared prepandemic periods with those during or after the pandemic, and one was a systematic review.\u003c/p\u003e \u003cp\u003eAfter the results of the 19 articles were analysed, two topics of interest were identified: access to healthcare services and results regarding disease management. Table\u0026nbsp;2 presents the main results.\u003c/p\u003e \u003cp\u003eRegarding the collection of outcomes measured in the studies, follow-up activities such as recording vital signs, screening for retinopathy and diabetic foot, and activities during visits were the most common, followed by laboratory measures. Follow-up support and the frequency of visits were also frequently analysed, while prescriptions, referrals and control targets were mentioned in 4 articles each.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eAccess to healthcare services\u003c/h2\u003e \u003cp\u003eDuring the pandemic, there was an overall decrease in face-to-face visits to PC, with a corresponding increase in virtual and telephone consultations (\u003cspan additionalcitationids=\"CR11 CR12 CR13 CR14 CR15 CR16 CR17 CR18 CR19 CR20\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Some studies suggested that patient follow-up decreased during the pandemic(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThis decrease in the number of GP visits during the pandemic had a slow recovery afterwards but without reaching prepandemic levels (\u003cspan additionalcitationids=\"CR24\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Most studies reported differences in the use of health services, with an increase in virtual visits and a greater proportion of virtual visits than face-to-face visits, which decreased in all studies (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Only van den Berg described an increase in total visits during the pandemic at the expense of virtual visits (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) in a retrospective study in the Netherlands.\u003c/p\u003e \u003cp\u003eA reduction in referrals from PC to other specialists of 17% (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e) to 18.7% (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e) were described in some studies and a reduction in emergency assistance and access to hospital specialist have also been reported (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eDisease management\u003c/h2\u003e \u003cp\u003eOverall, fewer controls for HbA1c, blood pressure (BP), BMI and diabetic foot screening and retinography were described (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan additionalcitationids=\"CR23\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). In some cases, the results were worse than those reported before the COVID-19 pandemic.\u003c/p\u003e \u003cp\u003eThe prevalence of HbA1c controls was reduced by 4.5% (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e) to 20\u0026ndash;28% (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e), with contradictory results. Some studies reported worse results than previously described (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). However, in most studies, the results were not significant or were similar to previous findings.\u003c/p\u003e \u003cp\u003eThere were also fewer BP recordings (\u003cspan additionalcitationids=\"CR11 CR12\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e) with a decrease in the degree of compliance with therapeutic goals in some studies (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). With regard to BMI, there was a decrease in recordings during the pandemic period, but there was no clear change in the results obtained (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe 19 articles included and analysed in this scoping review revealed that access to healthcare in PC to patients with DM2 declined during the COVID-19 pandemic, with fewer follow-up visits to these patients and, in some cases, worse outcomes.\u003c/p\u003e \u003cp\u003eThe COVID-19 pandemic highlighted disparities in access to healthcare, being the low-income communities and geriatric patients the most vulnerable population groups (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). The decrease in both PC and hospital visits was attributed not only to increased access difficulties (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e) but also to fear of possible infection.\u003c/p\u003e \u003cp\u003eIn addition, chronically ill patients, such as those with T2D, experienced disruptions in care and medication adherence, further exacerbating health inequalities (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Several studies included in this review reported changes in healthcare use during the pandemic, with reductions in both GP visits, consultations and prescription rates for chronic medications (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e) and prescribing patterns (Kowall et al., 2023). Difficulties with medication adherence were observed, particularly for those requiring specialist visits or new prescriptions, reflecting barriers to accessing health services (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTelemedicine, while beneficial, presented challenges for vulnerable groups such as inadequate internet connectivity and difficulty using electronic devices, exacerbating existing health inequalities (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). Some studies showed that women, black patients and those with Medicare/Medicaid coverage faced barriers to care, such as delays in scheduling appointments and reluctance to return to medical facilities (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). These findings contrast with those of other studies (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e), which reported higher rates of medical visits among older people and women and better follow-up outcomes.\u003c/p\u003e \u003cp\u003eAlthough virtual consultations appear to have been beneficial for patient follow-up during the pandemic (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e), some difficulties in accessing this tool have been highlighted. These include inadequate internet connectivity and practical difficulties in examining patients (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). Virtual consultations have many advantages, particularly for young working people, for administrative purposes or for the follow-up of conditions previously seen in person, however, these virtual consultations cannot replace regular face-to-face care. This is particularly true for old people (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e), for whom telephone communication is difficult, or for processes that have just started or require a physical examination.\u003c/p\u003e \u003cp\u003eAdditional efforts to maintain continuity of care for chronic patients during the pandemic included the involvement of community pharmacists and the implementation of home medication programs (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). These strategies helped to mitigate disruptions in care while complying with COVID-19 containment measures. However, a significant proportion of patients reported delays or avoidance of care, citing reasons such as provider cancellations, safety concerns, and loss of employment or insurance (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). The implementation of accessible, patient-centred interventions remains critical to address health care disparities and ensure the continuity of care for vulnerable populations.\u003c/p\u003e \u003cp\u003eSome studies showed a reduction in the incidence of diabetes (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e), with slightly higher HbA1c at diagnosis (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e), which may be due to a reduction in the number of patients receiving health services and a delay in diagnosis.\u003c/p\u003e \u003cp\u003ePoorer health outcomes with increased HbA1c, BP or BMI in some cases (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e) were reported. This may be due to the fear of going to the clinic during the pandemic for fear of infection or the convenience of not having to travel to the health centre for care (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Patients with uncontrolled diabetes (HbA1c\u0026thinsp;\u0026gt;\u0026thinsp;9%) were more likely to attend virtual visits (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e), although they may have been less effective than those who attended face-to-face follow-up (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). It is possible that face-to-face visits by both GPs and nurses may help patients become more aware of their true follow-up numbers and the importance of taking lifestyle measures.\u003c/p\u003e \u003cp\u003eIn a significant number of cases, there was no difference in outcomes such as HbA1c, BP or BMI compared with the previous period. The likelihood of achieving guideline-recommended HbA1c levels before the pandemic was the strongest predictor of adherence during the pandemic (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). The worst results were observed in patients with a previously documented worse mean HbA1c (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). In other cases, increases in HbA1c and other parameters were more pronounced in lower-risk patients (young, with controlled HbA1c) (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). A statistically significant, although small, inverse association was found between face-to-face visits and HbA1c (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). This may be because people who were more aware of their disease were also those who requested more consultations (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePatient empowerment is associated with better glycaemic control, psychosocial functioning and perceived access to person-centred chronic disease care(\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). These findings raise questions about the usefulness of health education strategies for chronic patients or whether they are being provided adequately. Some patient profiles, particulary those who are younger and with high educational levels, know how to manage and control their disease. We may have had a paternalistic attitude, and during the pandemic period, with less strict follow-up, many patients may have neglected their self-care and therefore had worse outcomes.\u003c/p\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations of this study\u003c/h2\u003e \u003cp\u003eAlthough this review followed a specific strategy for searching for and synthesising articles, there are certain limitations. The search was conducted only in English and Spanish, which may have excluded other relevant articles. The use of a defined search strategy may have resulted in some articles being excluded, despite the use of MeSH and natural language terms. The exclusion of articles in preprint or conference communication may have ignored interesting results under different experimental conditions. Furthermore, the review did not include grey literature. In this review, certain studies have acknowledged their lack of representativeness (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e) due to the small number of participants from racial minorities or the specific and underrepresentation of some geographical areas. Some studies do not differentiate between types of diabetes among their patients (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). Importantly, synthesising the results of studies conducted in such different populations and health contexts is challenging. Furthermore, it is not possible to determine the effect on health outcomes of those who did not have access to the healthcare system during this period because of pandemic restrictions (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). These patients may represent the group with the worst outcomes. Finally, the impact of the smaller number of controls and the results reported on the quality of life of patients with T2D was not analysed.\u003c/p\u003e \u003cp\u003eThis review has several strengths. An important one is that a comprehensive search strategy was implemented to ensure the identification of relevant studies across multiple databases and sources. In addition, it is broad in scope because it includes a variety of study designs. This increases the validity of the findings and provides valuable insights for future research, practice and policy development.\u003c/p\u003e \u003c/div\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003eThe COVID-19 pandemic significantly affected access to PC for patients with T2D, resulting in fewer follow-up visits and, in some cases, poorer health outcomes. Vulnerable populations, including low-income and elderly patients, faced the greatest barriers. While telemedicine helped to reduce some barriers, it also presented challenges such as limited internet access and difficulties in conducting thorough virtual examinations. The findings highlight the need for targeted interventions based on patient characteristics to ensure continuity of care for chronically ill patients during and after medical crises.\u003c/p\u003e \u003cp\u003eAlthough some studies reported worse health outcomes, others found no significant differences in key measures such as HbA1c, BP or BMI compared with the pre-pandemic period. This review highlights the importance of maintaining face-to-face consultations for effective disease management and of providing PC with the necessary resources in terms of time and staff, in order to ensure that professionals can work in an appropriate environment and patients receive equitable and high quality care.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eT2D: type 2 diabetes\u003c/p\u003e\n\u003cp\u003ePC: primary care\u003c/p\u003e\n\u003cp\u003eHbA1c: glycated haemoglobin\u003c/p\u003e\n\u003cp\u003eGP: general practitioners\u003c/p\u003e\n\u003cp\u003eBP: blood pressure\u003c/p\u003e\n\u003cp\u003eBMI: body mass index\u003c/p\u003e\n\u003cp\u003eLDL: low-density lipoprotein-cholesterol\u003c/p\u003e\n\u003cp\u003eHDL: high-density lipoprotein-cholesterol\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/strong\u003enot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003enot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement:\u003c/strong\u003e All data relevant to the study are included in the article or uploaded as online supplemental information.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e This study was funded by Health Institute Carlos III (ISCIII) \u0026lsquo;PI22/01193\u0026rsquo; and by the European Regional Development Fund (EDRF) \u0026ldquo;A way of making Europe\u0026rdquo;\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions:\u003c/strong\u003e IBU screened the literature and extracted the data. IBU and SM screened titles and abstracts to select studies, and IAP resolved discrepancies. IBU was responsible for drafting the manuscript. SM and IAP were responsible for supervision of the research and critical revision of the manuscript. SM acted as guarantor. MJ and MA reviewed the manuscript and contributed to the discussion and formatting of the text. All the authors helped with critical review of the manuscript for important improvement of its content.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e: to Montse Salas Valero. Documentalist - Coordinator of the Virtual Library of Health Sciences of Arag\u0026oacute;n. Institute for Health Sciences in Aragon (IACS) for her help during the definition of the search strategies.\u003c/p\u003e\n"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eInternacional Diabetes Federation. Vol. 1, IDF Diabetes Atlas. 2023 [cited 2024 Feb 14]. p. 31\u0026ndash;88 IDF Diabetes Atlas 10th edition 537 million people worldwide have diabetes. Available from: www.diabetesatlas.org\u003c/li\u003e\n\u003cli\u003eYeh HC, Duncan BB, Schmidt MI, Wang NY, Brancati FL. Smoking, smoking cessation, and risk for type 2 diabetes mellitus: a cohort study. Ann Intern Med. 2010 Jan;152(1):10\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eWorld Health Organization. The impact of the COVID-19 pandemic on noncommunicable disease resources and services: results of a rapid assessment. World Health Organization. 2020. 1\u0026ndash;32 p. \u003c/li\u003e\n\u003cli\u003eStokes EK, Zambrano LD, Anderson KN, Marder EP, Raz KM, El Burai Felix S, et al. Coronavirus Disease 2019 Case Surveillance - United States, January 22-May 30, 2020. 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Diabetes Res Clin Pract. 2021 Dec;182:109127. \u003c/li\u003e\n\u003cli\u003eKhmour HY, Al-Rabeei Y, Deen NZ, Elnour S, Al-Karbi K, Rashed MH, et al. Type 2 Diabetes Mellitus Control during COVID 19 Pandemic in Qatar 2020: A Retrospective Data Analysis. World Fam Med J /Middle East J Fam Med. 2022;20(1). \u003c/li\u003e\n\u003cli\u003eInglin L, Wikstr\u0026ouml;m K, Lamidi ML, Laatikainen T. The adverse effect of the COVID-19 pandemic on health service usage among patients with type 2 diabetes in North Karelia, Finland. BMC Health Serv Res. 2022 Jun;22(1):725. \u003c/li\u003e\n\u003cli\u003eDi Gangi S, L\u0026uuml;thi B, Diaz Hernandez L, Zeller A, Zechmann S, Fischer R. Quality outcome of diabetes care during COVID-19 pandemic: a primary care cohort study. Acta Diabetol. 2022 Sep;59(9):1189\u0026ndash;200. \u003c/li\u003e\n\u003cli\u003eSenthinathan A, Tu K, Stephenson E, O\u0026rsquo;Neill B, Lipscombe L, Ji C, et al. A comparison between different patient groups for diabetes management during phases of the COVID-19 pandemic: a retrospective cohort study in Ontario, Canada. Covid [Internet]. 2024;16(1):1\u0026ndash;10. Available from: https://doi.org/10.1016/j.aprim.2023.102815\u003c/li\u003e\n\u003cli\u003eFernandez FC, Lopez OTG, Espineira MD, Villalba SF, Leon AC de, Aguirre-Jaime A. Follow-up of patients with type 2 diabetes during the COVID-19 pandemic: A multicentre study in Primary Care. Med Fam. 2023;49(8). \u003c/li\u003e\n\u003cli\u003eStrumann C, Blickle PG, von Mei\u0026szlig;ner WCG, Steinh\u0026auml;user J. The use of routine data from primary care practices in Germany to analyze the impact of the outbreak of SARS-CoV-2 on the utilization of primary care services for patients with type 2 diabetes mellitus. BMC Prim Care [Internet]. 2022;23(1):1\u0026ndash;11. Available from: https://doi.org/10.1186/s12875-022-01945-y\u003c/li\u003e\n\u003cli\u003eCheng AYY, Harris S, Krawchenko I, Tytus R, Rph JH, Liu A, et al. Impact of the COVID-19 Pandemic on Adults With Type 2 Diabetes Care and Clinical Parameters in a Primary Care Setting in Ontario, Canada: A Cross-sectional Study. Can J DIABETES. 2023;47(4):345\u0026ndash;51. \u003c/li\u003e\n\u003cli\u003eCarr MJ, Wright AK, Leelarathna L, Thabit H, Milne N, Kanumilli N, et al. Impact of COVID-19 restrictions on diabetes health checks and prescribing for people with type 2 diabetes: a UK-wide cohort study involving 618 161 people in primary care. BMJ Qual Saf [Internet]. 2022 Jul;31(7):503\u0026ndash;14. Available from: https://qualitysafety.bmj.com/lookup/doi/10.1136/bmjqs-2021-013613\u003c/li\u003e\n\u003cli\u003eKowall B, Kostev K, Landgraf R, Hauner H, Bierwirth R, Rathmann W. Effects of the COVID-19 lockdown on primary health care for persons with type 2 diabetes - Results from the German Disease Analyzer database. Diabetes Res Clin Pract. 2021 Sep;179:109002. \u003c/li\u003e\n\u003cli\u003eKowall B, Kostev K, Landgraf R, Hauner H, Bierwirth R, Rathmann W. Routine care for people with newly diagnosed type 2 diabetes before and during the SARS-CoV-2 pandemic - results from the German Disease Analyzer database. Prim Care Diabetes. 2023;17(4):321\u0026ndash;6. \u003c/li\u003e\n\u003cli\u003eDavid NJ, Bresick G, Moodaley N, Von Pressentin KB. Measuring the impact of community-based interventions on type 2 diabetes control during the COVID-19 pandemic in Cape Town - A mixed methods study. South African Fam Pract Off J South African Acad Fam Pract Care. 2022 Aug;64(1):e1\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eCuevas Fern\u0026aacute;ndez FJ, Guti\u0026eacute;rrez Galeote JC, Garc\u0026iacute;a Marrero MR, Iglesias Gir\u0026oacute;n MJ, Cabrera de Le\u0026oacute;n A, Aguirre-Jaime A. Impacto de la alteraci\u0026oacute;n de la continuidad asistencial en los pacientes con diabetes tipo 2 durante la pandemia de COVID-19. Med Fam Semer [Internet]. 2022 Jul;48(5):308\u0026ndash;15. Available from: https://linkinghub.elsevier.com/retrieve/pii/S1138359322000788\u003c/li\u003e\n\u003cli\u003eAirhihenbuwa CO, Tseng TS, Sutton VD, Price LS. Global Perspectives on Improving Chronic Disease Prevention and Management in Diverse Settings. Prev Chronic Dis. 2021;18(December 2020):1\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eZhu Y, Liu Y, Jiang H. Geriatric Health Care During the COVID-19 Pandemic: Managing the Health Crisis. Clin Interv Aging. 2022;17(August):1365\u0026ndash;78. \u003c/li\u003e\n\u003cli\u003eCarr MJ, Wright AK, Leelarathna L, Thabit H, Milne N, Kanumilli N, et al. Impact of COVID-19 on diagnoses, monitoring, and mortality in people with type 2 diabetes in the UK. Lancet Diabetes Endocrinol [Internet]. 2021 Jul;9(7):413\u0026ndash;5. Available from: https://www.embase.com/search/results?subaction=viewrecord\u0026amp;id=L2012278986\u0026amp;from=export\u003c/li\u003e\n\u003cli\u003eMisra-Hebert AD, Hu B, Pantalone KM, Pfoh ER. Primary Care Health Care Use for Patients With Type 2 Diabetes During the COVID-19 Pandemic. Diabetes Care [Internet]. 2021 Sep 1;44(9):e173\u0026ndash;4. Available from: https://diabetesjournals.org/care/article/44/9/e173/138836/Primary-Care-Health-Care-Use-for-Patients-With\u003c/li\u003e\n\u003cli\u003eJarrard Phillips Cate \u0026amp; Hancock. NATIONAL ONLINE SURVEY Coronavirus and Its Impact on US Healthcare Providers. 2020;1\u0026ndash;6. Available from: https://pos.org/wp-content/uploads/2020/04/Jarrard-POS-National-Survey-Exec-Summary-4-29-2020.pdf\u003c/li\u003e\n\u003cli\u003eMatenge S, Sturgiss E, Desborough J, Hall Dykgraaf S, Dut G, Kidd M. Ensuring the continuation of routine primary care during the COVID-19 pandemic: a review of the international literature. Fam Pract. 2022 Jul;39(4):747\u0026ndash;61. \u003c/li\u003e\n\u003cli\u003eKoh ZWJ, Sim SZ, Lew KJ, Lee PSS, Lee ES. Evaluation of the clinical effectiveness of telephone consultation compared to face-to-face consultation in terms of glycaemic control among patients with suboptimally controlled type 2 diabetes: a retrospective cohort study. BMJ Open. 2023;13(5). \u003c/li\u003e\n\u003cli\u003eStrumann C, Blickle PG, von Mei\u0026szlig;ner WCG, Steinh\u0026auml;user J. The use of routine data from primary care practices in Germany to analyze the impact of the outbreak of SARS-CoV-2 on the utilization of primary care services for patients with type 2 diabetes mellitus. BMC Prim care. 2022 Dec;23(1):327. \u003c/li\u003e\n\u003cli\u003eRossi MC, Lucisano G, Funnell M, Pintaudi B, Bulotta A, Gentile S, et al. Interplay among patient empowerment and clinical and person-centered outcomes in type 2 diabetes. The BENCH-D study. Patient Educ Couns [Internet]. 2015 Sep;98(9):1142\u0026ndash;9. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0738399115002335\u003c/li\u003e\n\u003cli\u003eLambrinou E, Hansen TB, Beulens JW. Lifestyle factors, self-management and patient empowerment in diabetes care. Eur J Prev Cardiol [Internet]. 2019 Dec 26;26(2_suppl):55\u0026ndash;63. Available from: https://academic.oup.com/eurjpc/article/26/2_suppl/55-63/5925416\u003c/li\u003e\n\u003cli\u003eMoin JS, Troke N, Plumptre L, Anderson GM. 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Available from: https://doi.org/10.1016/j.jcjd.2022.04.009\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 and 2 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Diabetes mellitus, Type 2, Primary health care, COVID-19 pandemic","lastPublishedDoi":"10.21203/rs.3.rs-6255075/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6255075/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eDuring the coronavirus disease 2019 (COVID-19) pandemic, changes in healthcare organisation may have affected the management of chronic patients, such as those with type 2 diabetes (T2D), who require close monitoring. Although there are studies that analyse the access and management of patients with T2D in Primary Care (PC) during the pandemic, there is no synthesis of the results that inform us about the care provided. The aim of this study is to summarise the existing evidence on the care provided in PC settings to patients with T2D during the COVID-19 pandemic, as well as their follow-up care and outcomes, in order to understand the impact of the pandemic on their management.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eA scoping review was conducted according to the approach described by Arksey and O'Malley. Structured search strategies were developed for each of the selected databases (PubMed, EMBASE and Web of Science). We included articles published in English and Spanish up to 30 November 2024 on access to care for patients with T2D in PC during the pandemic. Two independent reviewers screened titles and abstracts to select studies related to the population, intervention, and outcomes of interest. In cases of disagreement, a third reviewer resolved the discrepancy. One of the reviewers extracted data and summarised them.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eFrom a total of 441 articles, 19 full-text articles were finally selected for inclusion. Europe had the highest number of publications. The majority of the studies were retrospective cohort studies and the most commonly used source of data was electronic health records. The two topics of interest were identified: access to healthcare services and results regarding disease management.\u003c/p\u003e\n\u003cp\u003eThere was a general decrease in face-to-face visits made by patients with T2D, with reduced checks of laboratory parameters, blood pressure and weight. The results of monitoring during and after the pandemic were not always worse that the results previously obtained.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eDuring the COVID-19 pandemic, face-to-face care for patients with T2D in PC was reduced without a clear impact on control outcomes, highlighting the importance of virtual visits to ensure continuity of care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eProtocol registration number \u003c/strong\u003eINPLASY202360057.\u003c/p\u003e","manuscriptTitle":"Exploring the impact of the COVID-19 pandemic on patients with type 2 diabetes and primary care utilisation: a scoping review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-02 12:01:13","doi":"10.21203/rs.3.rs-6255075/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"259dae15-d907-43c9-89f4-32a23f5c8700","owner":[],"postedDate":"April 2nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-04-03T22:33:57+00:00","versionOfRecord":[],"versionCreatedAt":"2025-04-02 12:01:13","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6255075","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6255075","identity":"rs-6255075","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}