COVID-19 and Diabetes: Strategies to Catch Up

J Clin Pathways. 2021; 7(8):20-21. doi:10.25270/jcp.2021.10.3

The COVID-19 pandemic has led to increased morbidity and mortality, both from direct effects of the disease and indirect effects, including access to medical care. Research has confirmed the association of poor outcomes in persons with diabetes who develop COVID-19; however, the harmful interplay between diabetes and COVID-19 extends beyond active infection. While new diagnoses of diabetes in adults have slowed in recent years, the pandemic may reverse this trend. Physicians, payers, and pharmaceutical companies all can play a part in mitigating the long-term effects on persons with diabetes. Pharmaceutical companies, in particular, can employ strategies in concert with payers and physicians to reduce the burden of COVID-19 on persons with diabetes.

Type 2 diabetes incidence in adults has slowed in recent years, although there has been a rising incidence of type 1 and 2 diabetes in persons aged <20 years. Currently, 1 in 10 US adults have diabetes, and 1 in 3 American adults have prediabetes. Persons with diabetes require intensive management with pharmaceuticals and regular monitoring. For example, physicians measure Hemoglobin A_1c (HbA_1c) levels at least twice a year in addition to yearly screening for proteinuria and neuropathy. Finally, persons with diabetes should receive yearly diabetic self-management education, which unfortunately has a low referral rate.¹ COVID-19 has affected persons with diabetes due to active infection, limited access to care, and accelerated the onset or worsening of diabetes symptoms.

Active COVID-19 infection does not account for the entire increase in diabetes mortality. In one study, mortality was 50% higher than previously reported; however, up to 80% of that mortality rate is not due to COVID-19.² Another study showed an increase in mortality in 24 of 39 states, particularly in Mississippi and New Jersey, mainly during the first phase of the pandemic when access to care was severely limited.³ What has caused this excess in mortality? There are two potential reasons: access to care and accelerated diabetes.

Multiple studies have described the barriers to in-person visits. One study showed that in-person visits were less likely in persons with uncontrolled diabetes. Black persons and patients on Medicare/Medicaid did participate in virtual visits but were less likely to have HbA_1c testing.⁴ In the UK, a study noted 70% fewer diagnoses of diabetes and a 30% reduction in HbA_1c testing in the early part of the pandemic. After 6 months, these discrepancies were resolved.² In summary, the transition to telehealth took time, resulting in delayed care with significant effects, and did not resolve gaps in care. One could postulate that the pandemic caused physicians to miss opportunities to prevent diabetes and long-term complications from delayed therapeutic intensification.

Not only did reduced access to care accelerate diabetes, but the COVID-19 infection may precipitate new diabetes diagnoses and exacerbate existing diabetes. Physicians have reported worsening diabetes after COVID-19 infection has resolved. Leading diabetic professionals developed the CoviDiab Registry (CoviDiab.e-dendrite.com) to monitor possible associations.⁵ In addition, researchers have identified a potential mechanism for B-cell death secondary to COVID-19 infection in pancreatic cells.⁶ While this theory of a COVID-19 and diabetes bidirectional relationship requires more research, it may undoubtedly affect disease monitoring in the near term.

The advances in diabetes screening and prevention have potentially slowed the incidence of diabetes, and the COVID-19 pandemic threatens to reverse that trend. However, there are several ways that payers, providers, and pharmaceutical companies can collaborate to mitigate future damage. First and foremost, payers and large health systems can share data to quantify the impact of delayed diabetes care. These results can inform federal and state policy and benefit design. In addition, physicians can screen patients with a history of COVID-19 for diabetes or monitor for worsening diabetes until more literature supports or refutes a potential bidirectional relationship. Pharmaceutical companies can assist physician groups and payers in adding appropriate pharmacologic therapies to meet diabetes care goals through the following initiatives:

• Develop programs around electronic health record platforms to identify members who have stopped medication or have not had a recent HbA_1c or microalbumin. Create workflows to schedule labs and in-person or telemedicine visits.
• Collaborate with large retail pharmacies to advertise convenient lab drawing services to supplement free-standing testing laboratories.
• Develop education campaigns to help persons with diabetes plan their quarterly visits either in person or by telemedicine. Collaborate with payers to ensure coverage and parity for telemedicine visits and develop partnerships with telemedicine companies.
• Develop physician resource tools or treatment protocols to supplement clinical guidelines on specific patient characteristics and recommended medications.

Waiting until the pandemic is over to act is not an option, especially given the rise in recent cases and the potential for additional variants. We must begin to recuperate our health losses to prevent further morbidity and mortality from COVID-19.

References

1. Centers for Disease Control and Prevention. National Diabetes Statistics Report 2020. Accessed October 6, 2021. https://www.diabetesresearch.org/file/national-diabetes-statistics-report-2020.pdf

2. Gregg E, Sophiea M, Weldegiorgis M. Diabetes and COVID-19: population impact 18 months into the pandemic. Diabetes Care. 2021;44(9):1916-1923. doi:10.2337/dci21-0001

3. Ran J, Zhao S, Han L, et al. Increase in diabetes mortality associated with COVID-19 pandemic in the U.S. Diabetes Care. 2021;dc210213. doi:10.2337/dc21-0213

4. Misra-Herbert A, Bo H, Pantalone K, Pfoh E. Primary care health use for patients with type 2 diabetes during the COVID-19 pandemic. Diabetes Care. 2021;44(9):e173-e174. doi:10.2337/dc21-0853

5. Dendrite Clinical Systems Ltd. COVIDIAB Registry. Accessed October 6, 2021. http://covidiab.e-dendrite.com/

6. Wu CT, Lidsky PV, Xiao Y, et al. SARS-CoV-2 infects human pancreatic β cells and elicits β cell impairment. Cell Metab. 2021;33(8):1565-1576.e5.doi: 10.1016/j.cmet.2021.05.013

Author Information

Author: Cynthia Miller, MD, MPH, FACP

Affiliation: Access Experience Team, PRECISIONvalue

Disclosures: Dr Miller has no disclosures to report.