Review: COVID-19 Pandemic Impact on Clinical Outcomes in Patients With Diabetes

COVID-19-related disruptions in health care delivery generally increased diabetes-related morbidity and mortality, according to a study published in The Lancet Diabetes & Endocrinology.

The researchers explained that there is limited research on the indirect impacts of the COVID-19 pandemic and associated prevention measures on clinical outcomes in patients with diabetes. Consequently, the researchers reviewed evidence on the impact of COVID-19-related disruptions on clinical outcomes in those with diabetes, aiming to synthesize and describe the current body of evidence both in those with pre-existing diabetes and those presenting with diabetes for the first time during the pandemic. They hoped this study would minimize the negative consequences of the pandemic and help to inform responses to future pandemics or natural disasters.

To conduct this study, the researchers searched electronic databases MEDLINE and OVID for relevant articles published between January 1, 2020, and June 7, 2023. The researchers explained that they were interested in studies on patients diagnosed with any type of diabetes that focused on the following outcomes: hospital admissions, emergency hospital admissions, diabetic ketoacidosis, amputations, sight loss, foot ulcer presentations, renal failure, severe hypoglycemic events, and mortality.

The researchers screened 11,021 records. After closer examination, they included 138 publications (133 primary studies and 5 systematic reviews) in their analysis. The studies were conducted in Western Europe (n = 39 studies), North America (n = 39), Asia (n = 17), Eastern Europe (n = 14), Asia (n = 17), Eastern Europe (n = 14), South America (n = 4), Australia (n = 1), and Egypt (n = 1). The researchers noted that, overall, the studies analyzed all desired outcomes except renal failure.

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Across all studies, the researchers found that all-cause mortality, diabetes-related mortality, sight loss, and major amputations increased during the pandemic. Conversely, the remaining outcomes, namely diabetic ketoacidosis, all-cause hospital admissions, diabetes-related hospital admissions, foot ulcer presentations, emergency department admissions, and overall amputation rates, had mixed findings.

Of the 6 studies that examined all-cause mortality, all but 1 found an increase during the pandemic. Similarly, each of the 13 studies that analyzed diabetes-related mortality reported an increase. More specifically, 3 studies analyzed diabetes-related mortality data by subgroups and determined this rise to be most pronounced in younger adults (age range, 25-44 years) and patients who belong to a racial or ethnic minority group (P < .001).

Additionally, based on the 7 studies that explored sight loss in patients with diabetes during the pandemic, the researchers could not determine a pattern. Among these studies, there was 1 systemic review, which analyzed the impact of delayed antivascular endothelial growth factor injections on visual activity in various retinal diseases, including diabetic macular edema; it found a statistically significant decrease in visual acuity across all diseases. The researchers could not find a clear pattern across the other 6 primary studies as 3 reported an increase in sight loss, 2 did not detect a difference, and 1 found a decrease.

Also, the researchers identified 20 studies that provided data on amputations. Of the 9 that did not differentiate by amputation type, 4 indicated no difference in the number of amputations, 3 showed an increase, and 2 showed a decrease. For studies specifically on major amputations, 9 of 12 showed an increase, 2 showed a decrease, and 1 showed no difference. Conversely, for minor amputations, 3 of 4 relevant studies showed a decrease.

Additionally, compared to prepandemic foot ulcer incidence, the researchers found mixed results as 4 studies showed a decrease, another 4 showed an increase, and 1 showed no clear difference. Mixed findings were also found for the pandemic's impact on diabetic ketoacidosis. The researchers identified 4 related systemic reviews, 3 of which found an increase in diabetic ketoacidosis. An additional 69 primary studies included data on diabetic ketoacidosis. Of these, 3 found a decrease in diabetic ketoacidosis occurrence or severity among adult or mixed cohorts, 2 found an increase, and the remainder found no clear evidence of either.

Furthermore, by analyzing 30 studies on diabetes-related hospital admissions, the researchers concluded that there were mixed findings. They explained that this is due to each study’s different population and setting as the ones focused on children mostly found increases while those focused on adults mostly found no difference or an increase.

Most notably, 3 studies analyzed trends in diabetes-related hospitalizations by population groups. One found that more girls than boys aged under 18 (62.5%) were admitted to hospitals in 2020 due to diabetes diagnosis. On the other hand, another study reported no differences in trends based on sex, age, socioeconomic status, or comorbidities. Conversely, the third study noted an overall decrease in the number of diabetes-related hospitalizations between 2019 and 2020 among adults in Poland, particularly in women, patients with type 1 diabetes aged between 20 and 39 years, and those with type 2 diabetes aged between 40 and 49 years or 80 years and older.

The researchers identified 5 studies that provided data on all-cause hospital admissions, which had mixed results. They noted that 3 studies noted a decline in hospitalizations, while 2 observed no difference. As for emergency hospital admissions, 9 studies found mixed results as 2 of the studies did not detect any difference, 4 detected decreases, and 3 detected increases.

Lastly, 4 studies presented data on severe hypoglycemic events, yielding mixed findings. One study reported a significant reduction in the need for emergency department visits due to hypoglycemia in pediatric patients with type 1 diabetes during lockdown in Saudi Arabia. Another observed a nonsignificant decrease in severe hypoglycemia cases in Italian type 1 diabetes centers during lockdown in 2020. Conversely, an English study reported a significant increase in severe hypoglycemia incidence during pandemic waves; another study, which used data from a German registry, found similar rates of severe hypoglycemia during and before the pandemic.

The researchers acknowledged their study’s limitations, one being that most studies were in high-income countries, meaning their findings may not be generalizable to low- or middle-income countries. Despite any limitations, the researchers used their findings to make future suggestions to health care providers treating patients with diabetes; these included mental health support through virtual counseling and helplines, along with flexible medication delivery options from pharmacies. Conversely, they noted that further research is needed on this topic.

“Future research must investigate the impact of the pandemic on long-term condition incidence, management, and outcomes in order to support future preventative strategies, particularly in underserved communities,” the authors wrote.

Reference

Hartmann-Boyce J, Highton P, Rees K, et al. The impact of the COVID-19 pandemic and associated disruptions in health-care provision on clinical outcomes in people with diabetes: a systematic review. Lancet Diabetes Endocrinol. 2024;12(2):132-148. doi:10.1016/s2213-8587(23)00351-0