DKA more common for Black vs. white people with type 1 diabetes before, during pandemic
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Black people with type 1 diabetes were more likely to have a diabetic ketoacidosis event before the COVID-19 pandemic in 2019 than other racial-ethnic groups, and that disparity persisted in 2020, according to study findings.
In an analysis of data from seven medical centers in the T1D Exchange Quality Improvement Collaborative, no significant difference was observed in the total number of DKA cases from 2019 to 2020, but Black people with type 1 diabetes had significantly more DKA events in both years than white and Hispanic people. Andrew Lavik, MD, PhD, clinical fellow in the division of endocrinology at Cincinnati Children’s Hospital Medical Center; Osagie Ebekozien, MD, MPH, CPHQ, population health researcher and vice president of quality improvement and population health at T1D Exchange; and Nana-Hawa Yayah Jones, MD, pediatric endocrinologist at Cincinnati Children’s Hospital Medical Center, said the data show that DKA racial disparities present before the COVID-19 pandemic did not improve during the pandemic’s first year.
“As distressing as this pandemic has been for all of us, racial inequities in type 1 diabetes existed before the COVID-19 pandemic, they were starkly visible during the pandemic, and they will continue to exist after the pandemic unless we systematically identify and address them,” Lavik, Ebekozien and Yayah Jones told Healio.
Researchers collected data on DKA events among children and adults with type 1 diabetes for 2019 and 2020. DKA events from March to May 2020 were labeled as taking place during the first COVID-19 surge, and events from August to October 2020 were categorized as happening during the second COVID-19 surge. Data on age, HbA1c at the time of DKA, sex, self-reported race and ethnicity, and diabetes device use were also collected.
DKA events increase during COVID-19 surges
The analysis included 15,267 people with type 1 diabetes in 2019 and 15,176 in 2020. No difference was observed in the total number of DKA events in 2020 compared with 2019. A higher percentage of adults aged 60 years or older had DKA in 2020 compared with 2019 (32.2% vs. 29.4%; P = .02). A lower percentage of people using continuous glucose monitors (13.2% vs. 15%; P < .001) and insulin pumps (8% vs. 10.6%; P < .001) had DKA in 2020 compared with 2019. A higher percentage of people with type 1 diabetes had DKA during the first COVID-19 surge (7.1% vs. 5.4%; P < .001) and the second COVID-19 surge (6.6% vs. 5.7%; P = .001) compared with the same respective periods in 2019. Among insulin pump users, the percentage of people with DKA was lower during the first COVID-19 surge (6.4% vs. 10.3%; P = .008) and the second COVID-19 surge (8.1% vs. 11.2%; P = .03) compared with 2019.
DKA more common among non-Hispanic Black people
Among those in the 2019 cohort, 71.4% were non-Hispanic white, 8.7% were Hispanic and 6.4% were non-Hispanic Black. Of the 2020 cohort, 69.6% were non-Hispanic white, 9.5% were Hispanic and 6.3% were non-Hispanic Black.
In 2019, a higher proportion of Black participants experienced a DKA event compared with white participants (44.6% vs. 16%; P < .001) and Hispanic participants (44.6% vs. 17.2%; P = .001). The findings were similar in 2020, as the percentage of Black people with type 1 diabetes with DKA was higher than what was observed among white people (48.6% vs. 18.4%; P < .001) and Hispanic people (48.6% vs. 13.7%; P = .001).
“The COVID-19 pandemic just laid bare these ever-present disparities that we have been failing to adequately address,” Lavik, Ebekozien and Yayah Jones said. “What’s especially disheartening is that, despite the increased focus on racial health inequities during COVID-19 and efforts made to address them, DKA frequency didn’t improve among non-Hispanic Black patients as the first year of the pandemic progressed. This feeling of alarm is a call to action.”
The researchers wrote that systemic changes are needed to reverse disparities in DKA rates. Some strategies to address health inequities include gathering insights from real-world data, addressing provider bias, embedding quality improvement into practice, engaging stakeholders, partnering with centers serving a diverse patient population and benchmarking and tracking performance.
“Real-world implementation strategies in this area should be tested and amplified,” Lavik, Ebekozien and Yayah Jones said. “Ongoing work by T1D Exchange Quality Improvement Network and collaborators includes additional practical solutions that can improve equity using a comprehensive database. Our team is also testing the role of the electronic medical record in automated functions and shared decision-making.”
Reference:
Ebekozien O, et al. J Diabetes. 2021;doi:10.1111/1753-0407.13235.
For more information:
Osagie Ebekozien, MD, MPH, CPHQ, can be reached at oebekozien@t1dexchange.org.
Andrew Lavik, MD, PhD, can be reached at andrew.lavik@cchmc.org.
Nana-Hawa Yayah Jones, MD, can be reached at nana.jones@cchmc.org.
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