Diabetes related emergency department visits among adults during the COVID-19 pandemic - an analysis of data from the New York City syndromic surveillance system (preprint)

ObjectiveNew York City was an early epicenter of the COVID-19 pandemic. We aim to describe population level epidemiological trends in diabetes related emergency department (ED) visits among adults in New York City, for the period prior to and encompassing the first four waves of the pandemic. Research Design and MethodsWe used data from the New York City ED syndromic surveillance system during December 30, 2018 through May 21, 2022. This system captures all visits from EDs in the city in near-real time. We matched these visits to laboratory confirmed COVID-19 positivity data beginning with February 15, 2020. ResultsCompared to pre-pandemic baseline levels, diabetes related ED visits noticeably increased during the first wave in spring 2020, though this did not necessarily translate to net increases overall during that period. Visits for diabetic ketoacidosis, particularly among adults with type 2 diabetes, sharply increased before returning to pre-pandemic levels, most notably during wave 1 and wave 4 in winter 2021-2022. Trajectories of diabetes-related ED visits differed by diabetes type, age, and sex. Some ED visit trends did not return to pre-pandemic baseline levels. ConclusionsThe COVID-19 pandemic, especially the first wave in the spring of 2020, coincided with a dramatic shift in diabetes related ED utilization in New York City. Our findings highlight the importance of on-going surveillance of health care utilization for chronic diseases during population-level emergencies like pandemics. A robust syndromic surveillance system that includes infectious and non-infectious syndromes is useful to better prepare, mitigate, and respond to population-level events. Article HighlightsO_LIDiabetes related emergency department (ED) visits in New York City increased dramatically with the emergence of the COVID-19 pandemic in spring 2020. C_LIO_LIThe trajectory of diabetes-related ED visits differed by diabetes type, age, sex, and pandemic wave. C_LIO_LIThe diabetes complication of diabetic ketoacidosis among adults with type 2 diabetes showed sharp increases in the first and fourth waves of the pandemic, respectively its initial emergence in spring 2020 and the Omicron variant in winter 2021-2022. C_LIO_LIOur findings highlight the importance of on-going surveillance of health care utilization for chronic diseases during population-level emergencies like pandemics. C_LI SummaryData from NYCs syndromic surveillance system showed major increases in #type2diabetes complications (e.g. diabetic ketoacidosis) during #COVID-19 waves 1 and 4 (Omicron) - this tool may be useful for population-level monitoring of chronic disease complications during emergencies

Hospital segregation, critical care strain, and inpatient mortality during the COVID-19 pandemic in New York City (preprint)

Background: Hospital segregation by race, ethnicity, and health insurance coverage is prevalent, with some hospitals providing a disproportionate share of undercompensated care. We assessed whether New York City (NYC) hospitals serving a higher proportion of Medicaid and uninsured patients pre-pandemic experienced greater critical care strain during the first wave of the COVID-19 pandemic, and whether this greater strain was associated with higher rates of in-hospital mortality. Methods: In a retrospective analysis of all-payer NYC hospital discharge data, we examined changes in admissions and inpatient mortality, stratified by use of intensive care unit (ICU), from the baseline period in early 2020 to the first COVID-19 wave across hospital quartiles (265,329 admissions and 23,032 inpatient deaths), based on the proportion of Medicaid or uninsured admissions from 2017-2019 (quartile 1 lowest to 4 highest). Logistic regressions were used to assess the cross-sectional association between ICU strain, defined as ICU volume in excess of the baseline average, and patient-level mortality. Results: ICU admissions in the first COVID-19 wave were 84%, 97%, 108%, and 123% of the baseline levels by hospital quartile 1-4, respectively. The age-adjusted mortality rates for ICU admissions were 269%, 353%, 375%, and 387%, and those for non-ICU admissions were 355%, 500%, 633%, and 843% of the baseline rates by hospital quartile 1-4, respectively. Compared with the reference group of 100% or less of the baseline weekly average, ICU admissions on a day for which the ICU volume was 101-150%, 151-200%, and > 200% of the baseline weekly average had odds ratio of 1.17 (95% CI=1.10, 1.26), 2.63 (95% CI=2.31, 3.00), and 3.26 (95% CI=2.82, 3.78) for inpatient mortality, and non-ICU admissions on a day for which the ICU volume was 101-150%, 151-200%, and > 200% of the baseline weekly average had odds ratio of 1.28 (95% CI=1.22, 1.34), 2.60 (95% CI=2.40, 2.82), and 3.44 (95% CI=3.11, 3.63) for inpatient mortality. Conclusions: Our findings are consistent with hospital segregation as a potential driver of COVID-related mortality inequities and highlight the need to desegregate health care to address structural racism, advance health equity, and improve pandemic resiliency.

Direct and indirect mortality impacts of the COVID-19 pandemic in the US, March 2020-April 2021 (preprint)

Excess mortality studies provide crucial information regarding the health burden of pandemics and other large-scale events. Here, we used time series approaches to separate the direct contribution of SARS-CoV-2 infections on mortality from the indirect consequences of pandemic interventions and behavior changes in the United States. We estimated deaths occurring in excess of seasonal baselines stratified by state, age, week and cause (all causes, COVID-19 and respiratory diseases, Alzheimer’s disease, cancer, cerebrovascular disease, diabetes, heart disease, and external causes, including suicides, opioids, accidents) from March 1, 2020 to April 30, 2021. Our estimates of COVID-19 excess deaths were highly correlated with SARS-CoV-2 serology, lending support to our approach. Over the study period, we estimate an excess of 666,000 (95% Confidence Interval (CI) 556000, 774000) all-cause deaths, of which 90% could be attributed to the direct impact of SARS-CoV-2 infection, and 78% were reflected in official COVID-19 statistics. Mortality from all disease conditions rose during the pandemic, except for cancer. The largest direct impacts of the pandemic were seen in mortality from diabetes, Alzheimer’s, and heart diseases, and in age groups over 65 years. In contrast, the largest indirect consequences of the pandemic were seen in deaths from external causes, which increased by 45,300 (95% CI 30,800, 59,500) and were statistically linked to the intensity of non-pharmaceutical interventions. Within this category, increases were most pronounced in mortality from accidents and injuries, drug overdoses, and assaults and homicides, while the rate of death from suicides remained stable. Younger age groups suffered the brunt of these indirect effects. Overall, on a national scale, the largest consequences of the COVID-19 pandemic are attributable to the direct impact of SARS-CoV-2 infections; yet, the secondary impacts dominate among younger age groups, in periods of stricter interventions, and in mortality from external causes. Further research on the drivers of indirect mortality is warranted to optimize interventions in future pandemics.