The impact of the COVID-19 pandemic on the access to care for Type 2 Diabetic Patients

Background: Type 2 diabetic hemoglobin (HbA1c) A1c testing decreased substantially during the coronavirus (COVID-19) pandemic, resulting in gaps in care. Low socioeconomic populations may be affected in care received during the COVID-19 pandemic. The pandemic may have further amplified health disparities, such as inadequate HbA1c testing, and decreased resource availability, ultimately leading to potential health decline. The purpose of this study was to identify race/ethnicity predictors of gaps in care for HbA1c testing during the COVID-19 pandemic among patients with type 2 diabetes (T2DM).

Methods: This study included analysis of electronic health records from patients with T2DM at two healthcare systems (John Peter Smith Health Network and UNT Health). Times between HbA1c testing were compared pre COVID (March 1, 2019 – March 1, 2020) and during COVID (March 2, 2020 – March 1, 2021). Established patients (with two or more visits) at the two systems during the pre COVID period and at least one visit during the COVID period were included for analysis. Variables for analysis were selected using the Anderson Social Behavioral Model to assess the impact predisposing, enabling, and need factors had on gaps in HbA1c testing among different racial/ethnic groups during COVID-19. Data were analyzed using multilevel clustered survival models. Analyses were stratified by race/ethnicity (non-Hispanic White, non-Hispanic Black American, Hispanic, and other). Age, sex, BMI, visit modality (telemedicine or in-person), taking insulin (yes, no), at least one HbA1c above 8%, hypertension (yes, no), anxiety (yes, no), lipid metabolism disorder (yes, no), and private insurance (yes, no) were included in the models. Comparisons were made using multilevel clustered survival models to assess trends that occurred and the impact variables had in care gaps in type 2 diabetic patients during the COVID-19 pandemic.

Results: A total of 2,951 patients were included. Patients with HbA1c >8% pre-COVID had larger HbA1c testing gap times during COVID-19 for all race/ethnicities, compared with those with HbA1c <=8%. Larger testing gaps among patients with diabetic medications (oral and injectables) during COVID-19 were identified in Non-Hispanic Black Americans (p=0.02) and Hispanics (p=0.01), compared to those without diabetic medications. Men experienced larger gap times in HbA1c assessments compared to females among non-Hispanic Black Americans. Having at least one telemedicine appointment was associated with a decreased gap time among Hispanics.

Conclusions: Research demonstrates a reduction in access to care for underrepresented populations due to COVID. Patients with diabetic medications (excluding insulin) experienced decreased HbA1c assessments, potentially resulting in worsened health. Inconsistent chronic disease management is associated with increased risk of all-cause mortality. Implementation of telemedicine and increased HbA1c testing is known to correlate with positive health overall.