Abstract and Introduction
Introduction: Two studies in Pennsylvania aimed to determine whether community type and community socioeconomic deprivation (CSD) 1) modified associations between type 2 diabetes (hereinafter, diabetes) and COVID-19 hospitalization outcomes, and 2) influenced health care utilization among individuals with diabetes during the COVID-19 pandemic.
Methods: The hospitalization study evaluated a retrospective cohort of patients hospitalized with COVID-19 through 2020 for COVID-19 outcomes: death, intensive care unit (ICU) admission, mechanical ventilation, elevated D-dimer, and elevated troponin level. We used adjusted logistic regression models, adding interaction terms to evaluate effect modification by community type (township, borough, or city census tract) and CSD. The utilization study included patients with diabetes and a clinical encounter between 2017 and 2020. Autoregressive integrated moving average time-series models evaluated changes in weekly rates of emergency department and outpatient visits, hemoglobin A1c (HbA1c) laboratory tests, and antihyperglycemic medication orders from 2018 to 2020.
Results: In the hospitalization study, of 2,751 patients hospitalized for COVID-19, 1,020 had diabetes, which was associated with ICU admission and elevated troponin. Associations did not differ by community type or CSD. In the utilization study, among 93,401 patients with diabetes, utilization measures decreased in March 2020. Utilization increased in July, and then began to stabilize or decline through the end of 2020. Changes in HbA1c tests and medication order trends during the pandemic differed by community type and CSD.
Conclusion: Diabetes was associated with selected outcomes among individuals hospitalized for COVID-19, but these did not differ by community features. Utilization trajectories among individuals with diabetes during the pandemic were influenced by community type and CSD and could be used to identify individuals at risk of gaps in diabetes care.
Despite early concerns of elevated risk of COVID-19 infection in urban communities, studies of infection rates adjusted for socioeconomic factors have shown either no differences or reduced risks between urban and rural areas. Urban communities have also been found to have lower risk of severe COVID-19 outcomes, attributed to multiple factors, including better access to health care, healthy food, and walkable environments that reduce the risk of severe COVID-19 outcomes.[3,4] These same mechanisms may also mitigate risk of severe COVID-19 associated with type 2 diabetes (hereinafter, diabetes).
Reports of associations between diabetes and COVID-19 outcomes have been mixed. Some studies have reported associations with severe COVID-19 (eg, intensive care unit [ICU] admission) and postacute COVID-19 sequelae,[5–7] while others have not.[8,9] Conversely, most, but not all, studies have reported no association between diabetes and COVID-19 mortality.[5,6,9–11] These differences may be due to variation in study design or in study settings from diverse locations around the world. The extent to which community features modify associations between diabetes and COVID-19 outcomes remains unexplored.
The impact of COVID-19 on individuals with diabetes goes beyond COVID-19 infection. Mitigation strategies during the pandemic (eg, suspension of nonurgent care, stay-at-home orders) resulted in diabetes care disruptions.[13,14] Health systems serving urban communities have been better able to adapt to COVID-19 mitigation strategies through telehealth technology. Thus, gaps in care could be exacerbated in rural communities, which are more likely to have limited access to broadband internet service and greater distances to clinical care settings. The objectives of this study, conducted in geographically diverse communities across 37 Pennsylvania counties, were to determine whether community type and community socioeconomic deprivation (CSD) 1) modified associations between diabetes and COVID-19 hospitalization outcomes, and 2) influenced health care utilization among individuals with diabetes during the COVID-19 pandemic.
Prev Chronic Dis. 2022;19(7):e44 © 2022 Centers for Disease Control and Prevention (CDC)