Urban–Rural Differences in Health Care Utilization and COVID-19 Outcomes in Patients With Type 2 Diabetes

Annemarie G. Hirsch, PhD; Cara M. Nordberg, MPH; Karen Bandeen-Roche; Jonathan Pollak, MPP; Melissa N. Poulsen, PhD; Katherine A. Moon, PhD; Brian S. Schwartz, MD


Prev Chronic Dis. 2022;19(7):e44 

In This Article


We evaluated how the COVID-19 pandemic influenced diabetes for both hospitalization outcomes and health care utilization, with a focus on whether these impacts differed by community features. We evaluated 5 hospitalization outcomes (death, ICU admission, ventilator use, elevated troponin levels, and elevated D-dimer levels) and 4 features of health care utilization (HbA1c tests, antihyperglycemic medication orders, ED visits, and outpatient and telehealth visits). We observed that persons with diabetes had higher odds of ICU admission and elevated troponin levels, but these associations were not modified by community features. In contrast, the impacts of the pandemic on the patterns of HbA1c tests and antihyperglycemic medication orders among individuals with diabetes showed important differences by community type, urbanicity, and CSD, providing evidence that clinical care for persons with diabetes during the pandemic was affected by residential setting.

Consistent with prior studies, we observed associations of diabetes with some, but not all, indicators of severe COVID-19 outcomes.[5–11] Specifically, patients with diabetes had increased risk of ICU admission and elevated troponin levels. Elevated troponin levels have been associated with mortality among patients with COVID-19, but we did not find an association between diabetes and mortality.[18] Elevated troponin among individuals with diabetes may be a marker of existing chronic heart damage rather than damage related to COVID-19 infection.[23]

Early in the pandemic, reports from China implicated diabetes as a risk factor for severe COVID-19 outcomes.[24] Thus, the elevated risk of ICU admission among persons with diabetes could be due to more severe disease in diabetes or because health systems were more proactively moving individuals with diabetes to ICU settings. Other conditions identified as high risk for poor outcomes early in the pandemic were not associated with ICU admission in our study, providing evidence that ICU admission may have been driven by a need for more intensive care among those with diabetes.

Community type, urbanicity, and CSD were not associated with COVID-19 hospitalization outcomes, nor did they modify associations between diabetes and these outcomes. Prior studies reported that the risk of severe COVID-19 outcomes was reduced in urban communities[2,3] and that the risk of severe COVID-19 was higher in more deprived communities[25] than in the general population. By studying patients hospitalized for COVID-19, our study sample was restricted to those experiencing more severe disease. The mechanisms through which community features influence risk of COVID-19 hospitalization and death in the general population (eg, better access to health care, walkable environments) may have less influence on hospitalization outcomes among those who already have serious disease (ie, are already hospitalized for COVID-19).

Consistent with prior studies,[13,14] we observed decreased HbA1c tests, ED and outpatient visits, and antihyperglycemic medication orders at the start of the pandemic, when mitigation measures were implemented at the health system and state level. Utilization was rebounding by May 2020, when mitigation measures were lifted. By July 2020, many mitigation measures had been eased, with all Pennsylvania counties moving to the green phase (lowest risk of infection) on July 3, 2020.[26] Yet we observed that the trend of increasing utilization slowed in July for antihyperglycemic medication orders and ED visits, and for HbA1c tests and outpatient visits, rates started to decline. This could potentially be explained by increased national infection rates starting in mid-July, with cases doubling in 19 US states,[27] news that may have influenced local care-seeking behaviors. Thus, individuals with diabetes experienced disruptions in care during multiple phases of the COVID-19 pandemic, including periods of strict mitigation policies and periods of elevated infection rates.

Changes in antihyperglycemic medication order rates differed by community type. The more gradual decline in medication orders in cities may be driven by the peak in medication order rates that occurred in townships and boroughs, but not cities, immediately before the pandemic. The peak in medication orders early in the pandemic has been previously attributed to "panic buying" because of concerns about possible medication shortages.[28] Individuals residing in townships and boroughs may have more proactively prepared for a potential disruption in medication supplies, obtaining medications in early March 2020.

ED utilization differences persisted by community type and urbanicity. In contrast with a national report of higher ED utilization in rural, versus urban, communities,[29] we found higher ED visits among patients in city census tracts (vs townships) and urbanized areas (vs rural). In prior work in our study region,[16] associations between urbanicity and diabetes onset have also differed from national trends, potentially reflecting geographic differences that indicate a need for more localized research on the impact that community features have on health.

This research had numerous strengths. First, our measure of CSD used a spatial scale that is behaviorally relevant, rather than suboptimal scales based on census tract or county boundaries.[20] Second, by studying a single health system serving a geographically diverse region, our findings were less vulnerable to confounding by health system factors (eg, treatment protocols) that could differ by community features.

This study had some limitations. First, the study population was predominately White individuals. Findings may not be generalizable to populations with different sociodemographic characteristics, though findings are likely generalizable to the region studied. Second, patients missing D-dimer or troponin measures were excluded from the analysis of these outcome measures. Third, the administrative community type is challenging to replicate in states without similar municipality boundaries.

In a large, geographically diverse region of Pennsylvania, diabetes was associated with more severe COVID-19 outcomes among individuals hospitalized for COVID-19. These outcomes did not differ by community features, and the higher odds of ICU admission and elevated troponin levels among persons with diabetes was not influenced by community features. Diabetes care was disrupted during periods when COVID-19 mitigation policies were in place and when infection rates were elevated nationally. Community features modified the trajectories of health care utilization during these phases of the pandemic and could be used to identify individuals at risk of gaps in diabetes care. It is important to evaluate the impact of these utilization differences on diabetes outcomes.