Abstract
Objectives
We aimed to estimate how rheumatology outpatient hospital attendances have changed since the COVID-19 pandemic and determine demographic characteristics associated with observed changes.
Methods
Using three primary and secondary care electronic health record datasets in England (with the approval of NHS England), Scotland, and Wales, we identified people with a diagnosis of rheumatoid arthritis (RA) before 01/04/2019. We determined the proportion of people with rheumatology hospital outpatient appointments each month (April 2019-December 2022 (Wales and Scotland), November 2023 (England)) and quantified changes using interrupted time-series analysis. We used logistic regression to determine characteristics associated with having fewer appointments compared to 2019.
Results
We identified 145,065, 3,813 and 13,637 people coded with RA in England, Scotland, and Wales, respectively. At the start of the COVID-19 pandemic the number of rheumatology outpatient appointments dropped sharply across all nations. In England and Scotland, the percentage of monthly appointments has continued to decline. In Wales, while there was a gradual recovery, rheumatology services have not returned to pre-pandemic levels. In contrast, the number of appointments for other specialties has recovered in all nations. People with no rheumatology outpatient appointments were more often aged over 80, male, and living in rural areas. Ethnic minorities, those living in more deprived, and urban areas had fewer appointments after the start of the pandemic compared to 2019.
Conclusion
For the first time, we compared healthcare use across three UK nations and found rheumatology outpatient appointments had not recovered to pre-COVID-19 pandemic levels, particularly in Scotland and England.
We aimed to estimate how rheumatology outpatient hospital attendances have changed since the COVID-19 pandemic and determine demographic characteristics associated with observed changes.
Methods
Using three primary and secondary care electronic health record datasets in England (with the approval of NHS England), Scotland, and Wales, we identified people with a diagnosis of rheumatoid arthritis (RA) before 01/04/2019. We determined the proportion of people with rheumatology hospital outpatient appointments each month (April 2019-December 2022 (Wales and Scotland), November 2023 (England)) and quantified changes using interrupted time-series analysis. We used logistic regression to determine characteristics associated with having fewer appointments compared to 2019.
Results
We identified 145,065, 3,813 and 13,637 people coded with RA in England, Scotland, and Wales, respectively. At the start of the COVID-19 pandemic the number of rheumatology outpatient appointments dropped sharply across all nations. In England and Scotland, the percentage of monthly appointments has continued to decline. In Wales, while there was a gradual recovery, rheumatology services have not returned to pre-pandemic levels. In contrast, the number of appointments for other specialties has recovered in all nations. People with no rheumatology outpatient appointments were more often aged over 80, male, and living in rural areas. Ethnic minorities, those living in more deprived, and urban areas had fewer appointments after the start of the pandemic compared to 2019.
Conclusion
For the first time, we compared healthcare use across three UK nations and found rheumatology outpatient appointments had not recovered to pre-COVID-19 pandemic levels, particularly in Scotland and England.
| Original language | English |
|---|---|
| Journal | Rheumatology |
| Publication status | Accepted/In press - 10 Oct 2025 |
Bibliographical note
We wish to thank Albasoft for access to primary care healthcare data in Scotland and the NHS Scotland electronic Data Research and Innovation Service Team (Public Health Scotland) for their involvement in obtaining approvals, provisioning, and linking data and the use of the secure analytical platform within the National Safe Haven. We are also very grateful for all the support received from the TPP Technical Operations team throughout this work, and for generous assistance from the information governance and database teams at NHS England and the NHS England Transformation Directorate. We would also like to thank Gary J Macfarlane (RHEUMAPS investigator) for comments on the manuscript, Laura Moir (project administrator for RHEUMAPS) and Michelle Stevenson (patient partner on the RHEUMAPS study) for supporting recruitment of general practices in Scotland.Data Availability Statement
In England, access to the underlying identifiable and potentially re-identifiable pseudonymised electronic health record data is tightly governed by various legislative and regulatory frameworks, and restricted by best practice. The data in the NHS England OpenSAFELY COVID-19 service is drawn from General Practice data across England where TPP is the data processorTPP developers initiate an automated process to create pseudonymised records in the core OpenSAFELY database, which are copies of key structured data tables in the identifiable records. These pseudonymised records are linked onto key external data resources that have also been pseudonymised via SHA-512 one-way hashing of NHS numbers using a shared salt. University of Oxford, Bennett Institute for Applied Data Science developers and PIs, who hold contracts with NHS England, have access to the OpenSAFELY pseudonymised data tables to develop the OpenSAFELY tools.
These tools in turn enable researchers with OpenSAFELY data access agreements to write and execute code for data management and data analysis without direct access to the underlying raw pseudonymised patient data, and to review the outputs of this code. All code for the full data management pipeline — from raw data to completed results for this analysis — and for the OpenSAFELY platform as a whole is available for review at github.com/OpenSAFELY.
Access to NHS Scotland health data is governed by the NHS Scotland Public Benefit and Privacy Panel for Health and Social Care (HSC-PBPP). Access to the underlying pseudonymised health data used in this study is by application to the HSC-PBPP panel. All data used in this study can be accessed by request to SAIL.
The data management and analysis code for this paper was led by Ruth E Costello in England and Michael Parker in Wales and Scotland.
Funding
In England, the OpenSAFELY platform is principally funded by grants from: • NHS England [2023-2025]; • The Wellcome Trust (222097/Z/20/Z) [2020-2024]; • MRC (MR/V015737/1) [2020-2021]. Additional contributions to OpenSAFELY have been funded by grants from: • MRC via the National Core Study programme, Longitudinal Health and Wellbeing strand (MC_PC_20030, MC_PC_20059) [2020-2022] and the Data and Connectivity strand (MC_PC_20058) [2021-2022]; • NIHR and MRC via the CONVALESCENCE programme (COV-LT-0009, MC_PC_20051) [2021-2024]; • NHS England via the Primary Care Medicines Analytics Unit [2021-2024]. Funding for the RHEUMAPS study and creation and analysis of the Scotland and Wales datasets used in this study was provided by the Nuffield Foundation Oliver Bird Fund (grant number OBF/44000).
| Funders | Funder number |
|---|---|
| NHS England | |
| Wellcome Trust | 222097/Z/20/Z |
| Medical Research Council | MR/V015737/1, MC_PC_20030, MC_PC_20059, MC_PC_20058 |
| National Institute for Health and Care Research | COV-LT-0009, MC_PC_20051 |
Keywords
- observational studies
- organisation of health care
- Rheumatoid Arthritis
- delivery of health care
- inequalities