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Introduction: The use of continuous glucose monitors (CGM) and insulin pumps (PUMP) have been associated with improved outcomes in type 1 diabetes (T1D) care. Therefore, disengaging from these devices represents a risk for worsening health outcomes. Objective(s): We sought to evaluate the effect of the COVID-19 pandemic on device disengagement rates by race and ethnicity. Method(s): This retrospective cohort study Pre-COVID-19 [n = 15,838] + peri-COVID-19 ([n = 14,799]) used EMR data from 15 sites (i.e., 3 adult and 12 pediatric diabetes centers) within the T1D Exchange Quality Improvement Collaborative. We identified individuals using at least one Advanced Diabetes Technology (ADT [PUMP or CGM]) at their most recent visit. Individuals who continued to use that technology for at least two subsequent visits were classified as engaged. Those who reported not using ADT in two subsequent visits were classified as disengaged. Result(s): Comparing pre-COVID-19 (January 2017-March 2020) to peri-COVID-19 (April 2020-2021) time periods, we observed increases in disengagement among non-Hispanic White (NHW;42% to 45%, p = 0.03) and Hispanic (12% to 19%, p < 0.001) individuals. We found no difference among NH Black (NHB;61% to 62%, p = 0.7) individuals. Conclusion(s): The pandemic has presented self-care challenges for individuals with T1D, including continued use of ADT. NHB individuals exhibited the highest disengagement rates overall, while NHW/Hispanic individuals experienced significant pandemic-related increases in disengagement. Future research should evaluate the relative impact of intrinsic (i.e., patient-level) versus extrinsic (i.e., family-, environment-, and system-level) factors associated with race-/ethnicity- based differences in rate of disengagement.
ABSTRACT
There have been remarkable innovations in diabetes management since the start of the COVID-19 pandemic, but these groundbreaking innovations are drawing limited focus as the field focuses on the adverse impact of the pandemic on patients with diabetes. This article reviews select population health innovations in diabetes management that have become available over the past 2 years of the COVID-19 pandemic from the perspective of the T1D Exchange Quality Improvement Collaborative, a learning health network that focuses on improving care and outcomes for individuals with type 1 diabetes (T1D). Such innovations include expanded telemedicine access, collection of real-world data, machine learning and artificial intelligence, and new diabetes medications and devices. In addition, multiple innovative studies have been undertaken to explore contributors to health inequities in diabetes, and advocacy efforts for specific populations have been successful. Looking to the future, work is required to explore additional health equity successes that do not further exacerbate inequities and to look for additional innovative ways to engage people with T1D in their health care through conversations on social determinants of health and societal structures. Copyright © 2022 Turner White Communications Inc.. All rights reserved.
ABSTRACT
Background: Patient outcomes of COVID-19 have improved throughout the pandemic. However, because it is not known whether outcomes of COVID-19 in the type 1 diabetes (T1D) population improved over time, we investigated differences in COVID-19 outcomes for patients with T1D in the United States. Methods: We analyzed data collected via a registry of patients with T1D and COVID-19 from 56 sites between April 2020 and January 2021. We grouped cases into first surge (April 9, 2020, to July 31, 2020, n = 188) and late surge (August 1, 2020, to January 31, 2021, n = 410), and then compared outcomes between both groups using descriptive statistics and logistic regression models. Results: Adverse outcomes were more frequent during the first surge, including diabetic ketoacidosis (32% vs 15%, P< .001), severe hypoglycemia (4% vs 1%, P= .04), and hospitalization (52% vs 22%, P< .001). Patients in the first surge were older (28 [SD,18.8] years vs 18.0 [SD, 11.1] years, P< .001), had higher median hemoglobin A1c levels (9.3 [interquartile range {IQR}, 4.0] vs 8.4 (IQR, 2.8), P< .001), and were more likely to use public insurance (107 [57%] vs 154 [38%], P< .001). The odds of hospitalization for adults in the first surge were 5 times higher compared to the late surge (odds ratio, 5.01;95% CI, 2.11-12.63). Conclusion: Patients with T1D who presented with COVID-19 during the first surge had a higher proportion of adverse outcomes than those who presented in a later surge.
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Introduction: An increase in newly diagnosed type 1 diabetes (T1D) has been posited during the COVID-19 pandemic, but data have been conflicting. Objectives: We aimed to determine trends in newly diagnosed T1D and severity of presentation at diagnosis for pediatric and adolescent patients during COVID-19 year (2020) as compared to the previous year (2019) in a multi-center data analysis across the United States. Methods: This retrospective multi-center study included data from seven large U.S. clinical centers recruited from the T1D Exchange Quality Improvement Collaborative (T1DX-QI). Data on diagnosis, diabetic ketoacidosis (DKA), and clinical characteristics were collected from January 1 to December 31, 2020, compared to the prior year. Chi-square tests were used to compare differences in patient characteristics during the pandemic compared to the pre-pandemic comparison group. Results: Across seven member sites, there were 1399 newly diagnosed patients with T1D in 2020, compared to 1277 in 2019 (p=0.007). Of the newly diagnosed patients, a greater number, presented in DKA in 2020 compared to 2019 (599/1399 (42.8%) v. 493/1277 (38.6%), p<0.001), and a higher proportion of these patients presented with severe DKA (p=0.01) as characterized by a pH<7.1 or bicarbonate of <5mmol/L. The mean age at diagnosis was not different, but there were fewer females (p=0.004), and fewer NH White youth diagnosed in 2020 (p<0.001). Newly diagnosed T1D patients in 2020 were less likely to have private insurance (p=0.001). Monthly data trends demonstrated a higher number of new diagnoses of T1D over the spring and summer months (April to September) of 2020 compared to 2019 (p=0.007). Conclusions: We found an increase in newly diagnosed T1D and a greater proportion of newly diagnosed T1D patients presenting in DKA at diagnosis during the COVID-19 pandemic compared to the prior year. Future longitudinal studies are needed to confirm these findings with population level data and determine the long-term impact of COVID-19 on diabetes trends.
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Introduction: Considerable research has addressed the impact and increased severity of coronavirus disease 2019 (COVID-19) in adult patients with type 2 diabetes (T2D). However, findings from older adult patients cannot be generalized to affected children and young adults. Objectives: In this retrospective cohort study, we examine whether race/ethnicity and other factors are associated with hospitalization in pediatric and young adult patients with T2D and COVID-19 infection. Methods: The de-identified COVID-19 patient cohort from the December 2020 release of Cerner Real-World Data™ includes longitudinal data for patients who received care at 87 US-based health systems between December 2019 and September 2020. A rigorous, multi-step algorithm was used to identify patients with T2D (n=229). Analysis was limited to patients <27 years old with a positive laboratory test or billing code consistent with COVID-19 infection. A generalized linear mixed model was used to evaluate race/ethnicity, gender, HbA1c, body mass index (BMI), mean blood glucose, age, payer, and Elixhauser comorbidity score as correlates of hospital admission. Results: In this cohort, 204 (89.1%) patients were 18-26 years old, and 133 (58.1%) were female. Fifty-two percent were Hispanic, 27.1% were non-Hispanic Black, and 12.2% were non-Hispanic White. Median BMI was 37.9 kg/m2 (IQR 32.3-45.1 kg/m2);median HbA1c was 9.25% (IQR 7.2-12.3%). Ninety-four patients (41.0%), including all 21 patients in diabetic ketoacidosis (DKA;9.2%) were hospitalized. Male gender (OR 2.46 [CI 1.23-4.91], p=0.011), HbA1c (OR 1.29 [CI 1.10-1.52], p=0.001), and BMI (OR 1.44 [CI 1.02-2.03], p=0.040) were associated with hospitalization. Conclusions: Male gender, increased HbA1c, and increased BMI are associated with hospitalization in youths and young adults with T2D and COVID-19 infection. Further study is needed to identify targeted interventions to prevent hospitalization in youths and young adults with T2D.
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Introduction: Health insurance coverage type differs significantly by socio-economic status and racial groups in the United States. There is limited data on the association between insurance and the risk of adverse outcomes for patients with pre-existing T1D and COVID19. Objectives: The aim of this study was to determine if publicly insured pediatric and adolescent patients with Type 1 Diabetes (T1D) were more likely to experience adverse outcomes compared to privately insured patients with acute COVID-19 infections. Methods: Data from 575 patients with previously established T1D aged <24 years with acute COVID-19 infections was analyzed from the T1DX-COVID-19 Surveillance Registry. Data for the registry was collected from 52 endocrinology clinics across the U.S, using an online survey tool. Each site completed the survey using electronic medical record (EMR) data between April 2020 and May 2021. Results: Privately insured patients were more likely to identify as Non-Hispanic White than publicly insured patients (63% vs 18%, p<0.001). T1D patients with COVID-19 that were on public insurance reported higher A1c (9.5% vs 7.9%, p<0.001), lower insulin pump use (29% vs 62%, p<0.001), as well as lower continuous glucose monitor (CGM) use (51% vs 77%, p<0.001) compared to privately insurance patients. Publicly insured patients with T1D and COVID-19 were three times more likely to be hospitalized than privately insured patients (Odds Ratio 3.4, 95% Confidence Interval: 2.1-5.4). Conclusions: Our data reveals a high rate of hospitalization and DKA among children and adolescents with T1D and COVID19 with public health insurance despite controlling for other potential confounders. This underscores that those on public health insurance are more vulnerable to adverse health outcomes during the COVID19 pandemic. (Table Presented).
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Introduction: The COVID-19 pandemic has had far-reaching consequences for individuals with type 1 diabetes (T1D) and has laid bare inequities in health care. Objectives: We sought to examine the United States (US) trends in diabetic ketoacidosis (DKA) across the lifespan during the COVID-19 pandemic and factors associated with these trends, compared to DKA rates the year prior to the pandemic. Methods: The T1D Exchange Quality Improvement Collaborative (T1DX-QI) collected aggregate data on the incidence of DKA among children and adults with established and new-onset T1D from 7 large medical centers in the US (total T1D population >15,000). We compared DKA rates during COVID-19 Wave 1 (March-May 2020) and COVID-19 Wave 2 (August-October 2020) to the same periods in 2019. Descriptive statistics were used to summarize data. Chi-square tests were used to compare differences in patient characteristics. Results: DKA rates were higher in patients with established T1D during COVID-19 Wave 1 compared to the same period in 2019 (6.15% vs 4.71%, p=<0.001). DKA rates were also higher in patients with established T1D during COVID-19 Wave 2 compared to 2019 (5.55% vs 4.90%, p=0.02). There were no differences in rates of DKA by age or DKA severity. DKA rates were lower among individuals on insulin pumps during both COVID-19 waves compared to 2019 (Wave 1: 6.43% vs 10.25%, p=0.008;Wave 2: 8.14% vs 11.21%, p=0.03). Consistent with known T1D inequities, DKA rates were exacerbated for NH Black patients in 2020, with 18% of NH Blacks with T1D experiencing DKA compared to 6% of NH Whites. Conclusions: DKA rates rose among patients with T1D during US COVID-19 Waves 1 and 2, with the highest rates among NH Blacks. These findings highlight the urgent need for improved strategies to decrease the risk of DKA in individuals with T1D under pandemic conditions, especially among populations most affected by health inequities.
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Introduction: While there is rapidly emerging information describing race or ethnicity outcome disparities of patients hospitalized with COVID-19, no such data is available for people with type 1 diabetes (T1D). Objectives: This U.S. based, multi-center surveillance study aimed to investigate racial disparities among presenting symptoms, and adverse outcomes of patients with T1D who tested positive for SARS CoV-2 (N = 26) or are suspected to have COVID-19. As a secondary objective, this study also reports differences in access to SARS CoV-2 testing by racial group (Non-Hispanic White versus Minority) by analyzing data among T1D patients with COVID-like symptoms (N = 24) who were unable to get tested. Methods: De-identified patient data was collected through T1D Exchange's Type 1 Diabetes-COVID-19 Registry. Patient information for people who tested positive for SARS CoV-2, and patients suspected to have COVID-19 were reported by healthcare providers from U.S. Endocrinology clinics. Racial groups were classified as Non- Hispanic White (NH White) or minority (all other races). Results: We analyzed 50 patients with T1D, of which 25 (50%) were reported NH White, 10 (20.0%) Hispanic, 10 (20.0%) Non-Hispanic Black, 1 (2%) Asian, and 2 (4.0%) other. The mean age of the NH White population was 19.2 years (SD = 12.25, Range = 6.0-61.0), and 44% were female. Among the NH White population (N = 25), the reported highest level of care at the time of reporting was ICU at 16.6%, compared to 26.1% of the minority population (N = 23). Of the NH White population, 60% were tested for SARS CoV-2, compared to 36% of the minority population. The most prevalent adverse T1D outcome was diabetic ketoacidosis in both NH White (16.67%) and minority (34.78%) populations. Two patient deaths were recorded, one with confirmed COVID-19, both of Hispanic origin. Conclusions: This study provides racial differences in clinical outcomes of patients with T1D with confirmed or suspected COVID-19 in the United States.
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Introduction: While there is rapidly emerging information describing characteristics of patients hospitalized with confirmed COVID-19, no such data is available for people with type 1 diabetes (T1D). Objective: This U.S. based, multi-center surveillance study aimed to investigate characteristics, presenting symptoms, and adverse outcomes of patients with T1D who tested positive for SARS CoV-2 (N = 26). As a secondary objective, this study also reports patient attributes and clinical outcomes among T1D patients with COVID-like symptoms (N = 24) who tested negative or were unable to get tested. Methods: De-identified patient data was collected through T1D Exchange's Type 1 Diabetes-COVID-19 Registry. Patient information for people who tested positive for SARS CoV-2, as well as patients suspected to have COVID-19 were reported by healthcare providers from Endocrinology clinics at participating sites in the US. Statistical analysis was completed using SAS Studio software (version 3.8). Results: We analyzed 50 patients with T1D, of which 26 tested positive for SARS CoV-2 by nasopharyngeal sample PCR, and 24 were reported to have COVID-19-like symptoms but no positive test. In the group that tested positive for SARS CoV-2 (N = 26), mean age was 25.5 years (SD = 17.98, range = 7.0-79.0, IQR = 14.0-28.0), 61.5% (16 of 26) were female, and 38.46% (10 of 26) were Non- Hispanic White. Among T1D patients who tested positive for SARS CoV-2, the most prevalent adverse type 1 diabetes outcome was diabetic ketoacidosis (42.3%). The highest level of care at the time of reporting was hospitalization (23.1% [6 of 26]) or ICU ((30.8% [8 of 26]) in this population. One patient with confirmed with COVID-19 and one patient with a suspected case (4.1%) died. Conclusions: This study provides patient characteristics and clinical outcomes of patients with type 1 diabetes who had either confirmed or suspected COVID-19 in the United States.