RESUMO
BACKGROUNDIn 2020, Mexico experienced one of the highest rates of excess mortality globally. However, the extent to which non-COVID deaths contributed to excess mortality, its regional characterization, and the association between municipal-and individual-level sociodemographic inequality has not been characterized. METHODSWe conducted a retrospective municipal an individual-level study using death certificate data in Mexico from 2016-2020. We analyzed mortality related to COVID-19 and to non-COVID-19 causes using ICD-10 codes to identify cause-specific mortality. Excess mortality was estimated as the increase in deaths in 2020 compared to the average of 2016-2019, disaggregated by primary cause of death, death setting (in-hospital and out-of-hospital) and geographical location. We evaluated correlates of non-COVID-19 mortality at the individual level using mixed effects logistic regression and correlates of non-COVID-19 excess mortality in 2020 at the municipal level using negative binomial regression. RESULTSWe identified 1,069,174 deaths in 2020 (833.5 per 100,000 inhabitants), which was 49% higher compared to the 2016-2019 average (557.38 per 100,000 inhabitants). Overall excess mortality (276.11 deaths per 100,000 inhabitants) was attributable in 76.1% to COVID-19; however, non-COVID-19 causes comprised one-fifth of excess deaths. COVID-19 deaths occurred primarily in-hospital, while excess non-COVID-19 deaths decreased in this setting and increased out-of-hospital. Excess non-COVID-19 mortality displayed geographical heterogeneity linked to sociodemographic inequalities with clustering in states in southern Mexico. Municipal-level predictors of non-COVID-19 excess mortality included levels of social security coverage, higher rates of COVID-19 hospitalization, and social marginalization. At the individual level, lower educational attainment, blue collar workers, and lack of medical care assistance were associated with non-COVID-19 mortality during 2020. CONCLUSIONNon-COVID-19 causes of death, largely chronic cardiometabolic conditions, comprised up to one-fifth of excess deaths in Mexico during 2020. Non-COVID-19 excess deaths occurred disproportionately out-of-hospital and were associated with both individual-and municipal-level sociodemographic inequalities. These findings should prompt an urgent call to action to improve healthcare coverage and access to reduce health and sociodemographic inequalities in Mexico to reduce preventable mortality in situations which increase the stress of healthcare systems, including the ongoing COVID-19 pandemic.
RESUMO
BACKGROUNDExcess all-cause mortality rates in Mexico in 2020 during the COVID-19 pandemic were among the highest globally. Recent reports suggest that diabetes-related deaths were also higher, but the contribution of diabetes as a cause of excess mortality in Mexico during 2020 compared to prior years has not yet been characterized. METHODSWe conducted a retrospective, state-level study using national death registries from Mexican adults [≥]20 years for the 2017-2020 period. Diabetes-related deaths were classified using ICD-10 codes that listed diabetes as the primary cause of death, excluding certificates which listed COVID-19 as a cause of death. Excess mortality was estimated as the increase in diabetes-related mortality in 2020 compared to average rates in 2017-2019. Analyses were stratified by diabetes type, diabetes-related complication, and in-hospital vs. out-of-hospital death. We evaluated the geographic distribution of diabetes-related excess mortality and its socio-demographic and epidemiologic correlates using spatial analyses and negative binomial regression models. RESULTSWe identified 148,437 diabetes-related deaths in 2020 (177/100,000 inhabitants), 41.6% higher than the average for 2017-2019, with the excess occurring after the onset of the COVID-19 pandemic. In-hospital diabetes-related deaths decreased by 17.8% in 2020 compared to 2017-2019, whereas out-of-hospital deaths increased by 89.4%. Most deaths were attributable to type 2 diabetes and type 1 diabetes (129.7 and 4.0/100,000 population). Diabetes-related emergencies as contributing causes of death also increased in 2020 compared to 2017-2019 for hyperglycemic hyperosmolar state (128%), and ketoacidosis (116%). Diabetes-related excess mortality clustered in southern Mexico and was highest in states with higher social lag, higher rates of COVID-19 hospitalization, and higher prevalence of HbA1c [≥]7.5%. INTERPRETATIONDiabetes-related mortality increased among Mexican adults by 41.6% in 2020 after the onset of the pandemic compared to 2017-2019, largely attributable to type 2 diabetes. Excess diabetes-related deaths occurred disproportionately out-of-hospital, clustered in southern Mexico, and were associated with higher state-level marginalization, rates of COVID-19 hospitalizations, and higher prevalence of suboptimal glycemic control. Urgent policies to mitigate mortality due to diabetes in Mexico are needed, particularly given the ongoing challenges in caring for people with diabetes posed by the COVID-19 pandemic. Research in contextO_ST_ABSEvidence before this studyC_ST_ABSWe searched PubMed and Google Scholar for research articles published up to February 15, 2022, using the terms [("diabetes-related mortality" OR ("excess mortality" AND "diabetes"))]. No language restriction was applied. This search revealed few international studies evaluating nationwide diabetes-related mortality in general. In Mexico, only one unpublished study evaluated diabetes-related mortality up to 2019. We identified no studies which evaluated diabetes-related excess mortality in Mexico or elsewhere during 2020 or which explored correlates of diabetes-related excess mortality in 2020. Added value of this studyThis is the first report and characterization of an excess in diabetes-related mortality in Mexico during 2020 compared to recent years. Diabetes as a primary cause of death in Mexico was higher in 2020 compared to 2017-2019, particularly for people living with type 2 diabetes, starting in March 2020 with the onset of the COVID-19 pandemic. Compared to the 2017-2019 period, most of these excess deaths occurred out of hospital, with a concurrent decrease in in-hospital diabetes-related mortality. Hyperosmolar hyperglycemic state and ketoacidosis as primary causes of diabetes-related deaths also increased in 2020 compared to prior years. Our study also identified substantial geographic variation in diabetes-related excess mortality in Mexico, with southern, poorer States bearing a disproportionate burden. Finally, we report that diabetes-related excess mortality was associated with higher marginalization, suboptimal glycemic control, and higher rates of COVID-19 hospitalization, which were clustered in southern Mexico. Implications of the available evidenceReadily treatable, high morbidity diabetes-related conditions were likely untreated due to the constraints of the health care system during the COVID-19 pandemic, leading to diabetes-related excess mortality. This is a problem for Mexico, but it is likely to be generalizable to other countries and other conditions, as seen even in high-income countries. Given the ongoing challenges posed by the COVID-19 pandemic on healthcare systems, policies that can strengthen care for diabetes and other chronic conditions are urgently needed to mitigate the dramatic rise in diabetes-related mortality occurring in the out-of-hospital setting and its disproportionate burden on populations with high levels of marginalization.
