key: cord-0792563-dm36p113 authors: Lui, David Tak Wai; Lee, Chi Ho; Chow, Wing Sun; Fong, Carol Ho Yi; Woo, Yu Cho; Lam, Karen Siu Ling; Tan, Kathryn Choon Beng title: A Territory‐wide Study on the Impact of COVID‐19 on Diabetes‐Related Acute Care date: 2020-07-20 journal: J Diabetes Investig DOI: 10.1111/jdi.13368 sha: 8ad4ad960cd0c8b66eee2dbbb8f66f37a802498a doc_id: 792563 cord_uid: dm36p113 Diabetes is a risk factor for severity of coronavirus disease 2019 (COVID‐19). Little is known how the COVID‐19 pandemic has disrupted diabetes‐related acute care. We compared hospitalization rates for severe hyperglycemia or hypoglycemia during COVID‐19 outbreak in Hong Kong (study period: 25 January to 24 April 2020) with those during 25 January to 24 April 2019 (inter‐year control), and 25 October 2019 to 24 January 2020 (intra‐year control), using Poisson regression analysis. Hospitalization rates abruptly decreased after the first confirmed local COVID‐19 case on 23 January 2020, by 27% and 23% compared with inter‐year and intra‐year control periods respectively (incidence rate ratio 0.73 and 0.77, p<0.001). Hospitalizations were reduced for severe hyperglycemia and hypoglycemia, but not diabetic ketoacidosis. This significant reduction in hospitalization rates should alert endocrinologists to take proactive measures to optimize glycemic control of individuals with diabetes. The COVID-19 pandemic has overwhelmed health care systems globally, 1 with COVID-19 patients with diabetes having worse outcomes. 2 Hong Kong is one of the earliest regions involved. 3 Following the first confirmed local case on 23 January 2020, the Hong Kong Hospital Authority (HA) has implemented the Emergency Response Level since 25 January 2020. 4 Little is known how the COVID-19 pandemic has disrupted the diabetes-related acute care. We compared the hospitalization rates for severe hyperglycemia or hypoglycemia before and during COVID-19 outbreak in Hong Kong. We conducted a retrospective study using data extracted from the territory-wide anonymized electronic health records of the HA, the Clinical Data Analysis and Reporting System (CDARS). The HA is the only public-funded healthcare provider in Hong Kong, covering 90% of all secondary and tertiary care in the territory. 5 Accident and Emergency (A&E) services are provided at 18 public hospitals under the HA distributed among 7 clusters. 6 Our institute Queen Mary Hospital (QMH) provided A&E services in the Hong Kong West Cluster, serving a population of 530,000. 7 Our study period was from 25 January to 24 April 2020. Similar period in the previous year (25 January to 24 April 2019) was used as the inter-year control. The preceding 3 months (25 October 2019 and 24 January 2020) was used as the intra-year control. Principle diagnoses from discharge records were retrieved using the following ICD-9 codes. Severe hyperglycemia, During the study period, the mean age of all subjects admitted was 71.0±14.9 years and majority had long-standing type 2 diabetes (median 18.0 years) with median HbA1c 8.0% (64 mmol/mol). Those admitted with severe hyperglycemia during the study period had a longer duration of diabetes than those admitted during the two control periods (p<0.001) ( Table 1) . They also had a higher plasma glucose and HbA1c. For those admitted for severe hypoglycemia, no significant differences were observed in the mean age and duration of diabetes among different periods, except subjects admitted during the study period had more complex anti-diabetic regimens (18.6% were on ≥3 anti-diabetic agents, versus 14.2% and 17.2% inter and intra-year control respectively). They had lower HbA1c than the inter-year control but not significantly different from intra-year control. Less subjects admitted for severe hypoglycemia during the study period were aged <65 (17.0% versus inter-year 20.8%, p=0.030; intra-year 21.0%, p=0.025). In this first territory-wide study, we quantified the impact of the COVID-19 pandemic on diabetes-related acute care. We observed an abrupt drop in hospitalization rates by approximately 25% following the first confirmed local case of COVID-19 in late January and the reduction was maintained throughout the pandemic period. Similar collateral effect of COVID-19 on other acute conditions including myocardial infarction 7,9 and stroke 10 has also been reported. The Department of Veterans Affairs, the largest health system in the US, has observed a 42% reduction in overall This article is protected by copyright. All rights reserved hospitalization rates during the COVID-19 pandemic. The drop in admissions for conditions generally requiring emergency treatment parallels the decrease in overall hospitalization rates. 11 In our study, the reduction in hospitalization rates was mainly in admissions for severe hyperglycemia but not for DKA. This is presumably because the more pronounced symptoms of DKA would prompt these individuals to attend the A&E, 12 whereas those with less marked symptoms of hyperglycemia would try to avoid hospital attendance. Subjects in the severe hyperglycemia group in the study period had significantly higher plasma glucose and HbA1c than those admitted during the control periods, suggesting that many individuals might intentionally delay seeking medical care for fear of exposing themselves to potential COVID-19 infection. This may lead to a delay in treatment as subjects in the severe hyperglycemic group had unacceptably high HbA1c and they likely required hospitalization for insulin therapy 13 and exclusion of infections. 14 We do not have data on the proportion of subjects presenting with newly diagnosed diabetes in the severe hyperglycemic group and therefore cannot assess the potential impact on delayed diagnosis. A similar trend in reduction in admissions for severe hypoglycemia was also observed in the study period. The reduction in hospitalization rates was mainly observed in the younger age groups who were more likely to be able to manage their hypoglycemic episodes at home. The decline in emergency admissions may not be only due to individuals avoiding hospital to minimize the risk of COVID-19 infection. 11 Interviews with people with diabetes have suggested that some may be delaying treatment in order not to burden the health care system. Concern has been expressed regarding how "sick" one needs to be to call a paramedic and what can be done if the emergency services are overwhelmed. 15 People with chronic disorders like diabetes are faced with a number of difficulties in self-management in the time of COVID-19 pandemic. They also have to deal with postponement of clinic visits, suspension of treatment for diabetes-related issues, This article is protected by copyright. All rights reserved as well as lack of access and/or interruption of medications and supplies. Our study was limited by its retrospective nature. We relied on the diagnostic codes to capture the hospitalizations and miscoding or misdiagnosis cannot be ruled out. There may also be under-reporting in discharge diagnosis. Furthermore, we did not differentiate between symptomatic hyperglycemia and HHS. This study was based on the healthcare utilization pattern in Hong Kong and the results may not be generalizable to other countries. Nonetheless, our findings should help to raise awareness among endocrinologists to take proactive measures to maintain case detection and optimization of glycemia in those with poorly controlled diabetes who may not be seeking medical attention. With the interruption of routine clinical service, lockdown and restricted access, managing people with diabetes during the COVID-19 pandemic is challenging. 16 Approaches with telemedicine and digital medicine can be used to reach out to the at-risk individuals with diabetes and improve access and efficiency of medical care. 17 It remains to be seen how the observed reduction in acute admissions affects the health outcomes of individuals who would otherwise require in-patient care, and whether there will be a subsequent rebound in hospitalization rates after the COVID-19 outbreak. 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