Hospitalization Risk Four Times Higher in Blacks With T1D, COVID-19

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Among people with type 1 diabetes (T1D) who contract COVID-19, Black individuals are four times more likely than Whites to be hospitalized with diabetic ketoacidosis (DKA), new data suggest.

The findings, from 180 patients at 52 T1D Exchange clinical network sites, were published online January 7 in the Journal of Clinical Endocrinology & Metabolism by T1D Exchange vice president Osagie Ebekozien, MD, and colleagues.

After adjustment for health insurance status and other potential confounders, the difference in DKA rates in COVID-19 was a significant fourfold higher in Black versus White patients with type 1 diabetes. For Hispanic patients with type 1 diabetes the DKA risk was double that seen in White patients, but that difference didn't achieve statistical significance. All patients with DKA were hospitalized.

"This study is the first systematic examination of racial-ethnic disparities for people with T1D and COVID-19 infection, using a diverse cohort, with equal representation from both Black and Hispanic groups," say the authors.

"Our findings demonstrate that Black patients with COVID-19 and T1D have an additional risk of DKA beyond the risk already conferred from having longstanding diabetes or being of minority status."

In an interview, study co-lead author Shivani Agarwal, MD, Albert Einstein College of Medicine, New York City, said: "This is kind of a whistleblower paper. COVID-19 has obviously magnified racial and ethnic inequities across all arenas, medical or nonmedical."

"But in the type 1 diabetes space we're really uncovering a potentially fatal complication. We really need to pay more attention to this issue and the underlying systemic factors that may be leading to [worse] outcomes."

Ebekozien noted that these data also point to a concern as COVID-19 vaccination rolls out.

"The same type of systemic inequities we've seen...are also likely to rear their ugly head with vaccine distribution [and may] get in the way of these patients getting the vaccine," he told Medscape Medical News.

As such, it will be important to ensure "equitable distribution" of any vaccines, so "that minority patients are not being left out of being protected from COVID-19," he stressed.

What's Behind the High DKA Rate, and What Can Clinicians Do?

Socioeconomic issues are the major driver of the increased DKA rate in minority populations, which was already apparent prior to the COVID-19 pandemic, Ebekozien said.

"We know that lack of insulin and lack of food are really critical things that can drive people into DKA...Food insecurity is a big problem that we don't talk enough about in the type 1 space and is more prominent among minority patients."

"We can't ignore the direct social and economic and structural problems that have led us to where we are now, and with COVID they're way over-amplified."

Clinicians should ask patients about these issues, as well as about housing insecurity, Agarwal said.

"Another social determinant of health that people don't think as much about is housing insecurity, as opposed to homelessness, which is easier to identify. Movement between houses is really an issue. I practice in the Bronx, and I've learned over time to ask, 'Do you have a stable home?' How are you supposed to tote around your insulin and actually pay attention to anything else besides where you're going to sleep the next week?"

Concrete steps clinicians can take include ensuring that patients have ketone test strips at home and educating them about their use and the signs and symptoms of DKA, Ebekozien emphasized.

"Don't assume they already know. Our results are telling us otherwise, that not everyone knows this if we're seeing these huge disparities in who presents with DKA."

Agarwal added that clinicians need to keep in mind the vulnerability of minority patients, which might include flagging the charts of those who haven't been seen in a long time and following up if they miss an appointment.

"There's only so much we can do to bring patients to us, but of those we do see among racial and ethnic minority groups that may be vulnerable…we can be more cognizant of their increased risk for DKA and have a stronger connection with them."

One previously reported finding also observed in the current study is that Black and Hispanic patients were far less likely to use insulin pumps or continuous glucose monitors (CGMs) than White patients, Agarwal noted.

This is one way in which clinicians can try to help, he added.

"If there's no insurance coverage that's a harder modifiable factor from a provider perspective but prescription for CGM is extremely modifiable if it's covered…This is our wheelhouse. This is something we can do, and also provides better monitoring of the patient, better ability to monitor for issues that come up quickly and prevent DKA, across the board. It's not only an equity issue, it's just better medical management."

Among Those With T1D and COVID-19, DKA Hits Black Patients Hardest

Of the 180 patients with type 1 diabetes and a confirmed COVID-19 diagnosis during April to August 2020, 34% (62) were White, 24% (44) were Black, and 20% (36) were Hispanic. One third overall were younger than 19 years of age.

Black and Hispanic patients were significantly more likely than Whites to be publicly insured (78% Black, 72% Hispanic, and 30% White). A1c levels were also significantly higher for Black and Hispanic patients compared with White patients, with median levels of 11.0%, 9.8%, and 8.3%, respectively.

The difference in device use was dramatic. While 62% and 54% of White patients were using CGMs and insulin pumps, respectively, those proportions were just 13% and 7%, respectively, for Black patients and 37% and 22%, respectively, for Hispanics.

Compared with White patients, Black patients were significantly more likely to present with DKA (55% vs 13%; P = .001). The proportion was 33% among Hispanics (P = .008 vs Whites).

New-onset type 1 diabetes among those with COVID-19 was also more common among Black and Hispanic patients (13% and 12%, respectively, versus 1% in Whites; P = .001).

The question of whether COVID-19 is directly attacking the pancreas and destroying the insulin-producing beta cells is still under investigation, Agarwal noted.

After adjustment for age, sex, A1c, and insurance status, the odds ratio for DKA with COVID-19 among Black versus White patients with known type 1 diabetes was 3.7, a significantly increased risk. For Hispanics, the odds ratio was 1.9, which did not achieve significance.

The Helmsley Charitable Trust funds the T1D Exchange QI Collaborative. The T1D Exchange received financial support for this study from Abbott Diabetes, JDRF, Dexcom, Medtronic, Insulet Corporation, Lilly, and Tandem Diabetes Care. Agarwal has reported receiving funding from the National Institute of Diabetes and Digestive and Kidney Diseases.

J Clin Endocrinol Metab. Published online January 7, 2021. Abstract

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