COVID-19 Pandemic Led to Worse Glycemic Control in Pediatric Medicaid Patients

In children with type 1 diabetes, the COVID-19 pandemic led to worsened glycemic control, particularly in those on public insurance such as Medicaid, according to research results published in Clinical Diabetes and Endocrinology.

Through a retrospective cohort study, researchers set out to determine the effect of stay-at-home orders in response to the COVID-19 pandemic on glycemic control in children with type 1 diabetes. The cohort included all insulin-dependent children receiving care at the University of South Alabama Pediatric Endocrinology Clinic from May 1 to July 31, 2020.

During the study period, 419 patients with either type 1 or type 2 diabetes were scheduled for a visit at the clinic; 30% of these patients either skipped or rescheduled their visits, primarily due to concerns about COVID-19, for a total of 316 in-person visits.

After applying exclusion criteria, 238 patients were included for analysis (45% girls; average age, 13.3 years; 34% Black); 4% had type 2 diabetes and were on insulin therapy, and the remaining 96% had type 1 diabetes. Insulin was administered via pump (45%) or multiple daily injections, and 29% wore a continuous glucose monitor.

Patients were either on public insurance or Medicaid (47%) or on private insurance (53%).

Researchers first analyzed prepandemic hemoglobin A_1c (HbA_1c) values from May 2019 to April 2020. Prior to quarantine, average HbA_1c was 9.2% (range, 5.8 to 15.0) with a median value of 8.9%. No significant differences were noted by gender or diabetes type, but patients with multiple daily injections demonstrated a significantly higher mean HbA_1c (9.6%) vs those using an insulin pump (8.8%). Medicaid patients also had significantly higher mean HbA_1c compared with the previous year vs patients on private insurance (9.8% vs 8.8%).

During the quarantine period, average HbA_1c for clinic patients was 9.5%, with no significant differences by sex or diabetes type. Patients receiving multiple daily injections had significantly higher mean HbA_1c compared with patients using a pump (9.9% vs 9.0%). Medicaid patients also showed significantly higher HbA_1c compared with private insurance patients (10.3% vs 8.8%). Compared with White patients, Black patients reported significantly higher mean HbA_1c (10.4% vs 9.0%).

Change in HbA_1c was evaluated from the prequarantine period to the quarantine period across clinical groups. No significant differences were seen by sex, mode of insulin administration, diabetes type, or race, but there was a significant difference by insurance type. An average increase in HbA_1c of 0.49% was seen in Medicaid patients and was significantly higher than the difference noted in patients with private insurance (0.03%).

During the prequarantine period, average HbA_1c was 9.2%, increasing to 9.5% during quarantine. A statistically significant increase of 0.24% in mean HbA_1c was seen between the time periods.

A total of 17% of patients were at the American Diabetes Association HbA_1c goal of 7.5% or less prior to the pandemic; 19% were at that goal during quarantine. A total of 56% of patients experienced some increase in HbA_1c, while 44% experienced either no change or a decrease. Among patients whose HbA_1c increased, 30% increased by less than 0.5% while 70% increased by 0.5% or more.

The direction of change was also analyzed. Overall, 44% of patients had a decrease or no change in HbA_1c level, while 17% had an increase of less than 0.5% and 39% had an increase of 0.5% or more. Of the 92 patients who had the largest HbA_1c increase, 12% were at an HbA_1c goal of 7.5% or less prior to quarantine.

There were no significant associations between the direction of change and sex, mode of insulin administration, or race, but a significant association was noted between the direction of change and the type of insurance coverage.

Study limitations include the 30% of patients who did not attend their clinic visit during quarantine, the availability of previous HbA_1c values for only 5% of patients for the previous year, and a lack of inclusion of continuous glucose monitoring data.

“Our study shows that the most at-risk population, Medicaid patients, had worse diabetes outcomes during the quarantine phase, which strengthens the conclusion that COVID has disproportionately affected minorities and other vulnerable populations such as those with chronic illness,” the researchers wrote. “It also…strengthens the hypothesis that being in school helped control diabetes among children.”

“Possible influential factors for worsening control include lack of routine, lack of school nurse oversight, family stressors, more snacking from staying home all day with little to do, and lack of exercise since everyone stayed indoors,” they concluded.

Reference

Gayoso M, Lim WY, Mulekar MS, Kaulfers AD. Effect of COVID-19 quarantine on diabetes care in children. Clin Diabetes Endocrinol. Published online May 21, 2021. doi:10.1186/s40842-021-00122-x