Abstract
Most studies reported reduced health care use among people with diabetes during the COVID-19 pandemic. This may be due to restricted medical services or people avoiding health care services because they fear being infected with COVID-19 in health care facilities. The aim of our study was to analyse hospitalisation and mortality in people with and without diabetes in Germany during the COVID-19 pandemic year 2020 compared to 2017–2019. The data were sourced from a German statutory health insurance company covering 3.2 million people. We estimated age-sex standardised rates of mortality, all-cause hospitalisation, hospitalisation due to coronary heart disease (CHD), acute myocardial infarction (AMI), stroke, diabetic foot syndrome (DFS), and major and minor amputations in people with and without diabetes. We predicted rates for 2020 using Poisson regression based on results from 2017–2019 and compared these with the observed rates.In people with diabetes, the hospitalisation rate for major amputation was significantly increased, while all-cause hospitalisation rate and hospitalisation due to CHD, AMI and DFS were significantly decreased compared to the previous period. Moreover, we found a significantly increased mortality and hospitalisation rate for minor amputation in people without diabetes while all-cause hospitalisation and hospitalisation due to CHD and AMI was significantly lower during the COVID-19 pandemic year 2020.We observed changes in health care utilisation and outcomes during the COVID-19 pandemic compared to previous years in people with and without diabetes. Concerning diabetes care, the increase of hospitalisations due to amputation in people with diabetes with a simultaneous reduction in DFS needs special attention.
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People with diabetes have a high risk of hospitalisation and mortality due to COVID-19 (coronavirus) infection [1]. However, a number of studies reported reduced health care use among people with non-communicable diseases, including diabetes, during the COVID-19 pandemic [2]. This may be due to restricted medical services or avoidance of health care use for fear of infection in health care facilities [3]. Nevertheless, the extent of this change and its impact on health outcomes in people with and without diabetes is unclear. The aim of our study was to analyse hospitalisation and mortality in people with and without diabetes in Germany during the COVID-19 pandemic year 2020 compared to 2017–2019.
Methods
We used data from one German statutory health insurance company (Allgemeine Ortskrankenkasse (AOK) Rheinland/Hamburg) covering 3.2 million insured people. We included data from all individuals who had continuously been insured for at least two subsequent calendar years between 2016 and 2020. The diabetes status of all people including incident cases was defined for each calendar year according to an established algorithm [https://www.wido.de/fileadmin/Dateien/Dokumente/Publikationen_Produkte/Gesundheitsatlas/wido_int_gesundheitsatlas_deutschland_1119.pdf]. We estimated age-sex standardised mortality rates, rates for all-cause hospitalisation, and hospitalisation rates due to coronary heart disease (CHD), acute myocardial infarction (AMI), stroke, diabetic foot syndrome (DFS), and major and minor amputations in people with and without diabetes using the German population 2019 as standard population. For each individual, hospitalisation per calendar year was defined as at least one hospitalisation in the respective year. We predicted rates for 2020 using Poisson regression based on age-sex standardised rates from 2017 to 2019 and compared these with the observed rates with estimation of relative risks (RR).
Results
The average prevalence of diabetes during the study period was 10.3%. In 2020, 42,117 people died (diabetes: 14,459) and 615,015 people had at least one hospitalisation (diabetes: 134,040). The observed hospitalisation rates in 2020 were significantly lower than predicted in people with diabetes for all-cause hospitalisation (RR 0.84 [95% confidence interval 0.84–0.85], p < 0.001), hospitalisation due to CHD (RR 0.88 [0.85–0.92], p < 0.001), AMI (RR 0.89 [0.83–0.95], p = 0.007) and DFS (RR 0.77 [0.71–0.83], p < 0.001), Table 1). In contrast, the hospitalisation rate due to major amputation was significantly higher than predicted (RR 1.36 [1.12–1.65], p = 0.002), Table 1). We did not find significant changes regarding mortality, stroke and minor amputation.
Rates observed in people without diabetes were significantly lower than predicted for all-cause hospitalisation (RR 0.86 [0.86–0.87], p < 0.001), hospitalisation due to CHD (RR 0.88 [0.86–0.90], p < 0.001) and AMI (RR 0.95 [0.92–0.99], p = 0.012), while mortality (RR 1.04 [1.02–1.05], p < 0.001) and hospitalisation rates due to minor amputations (RR 1.15 [1.02–1.30], p = 0.020) were significantly higher than predicted. Hospitalisation rates for stroke and for major amputation did not significantly differ from predicted rates. Age and sex stratified analysis in both people with and without diabetes revealed that findings regarding mortality, AMI and minor amputation were predominantly explained by changes in the older age groups. Increased rates of major amputation in people with diabetes were predominantly identified amongst the male population. The results for all other outcomes were consistent in age and sex strata (data not shown).
Discussion
Our study found a significantly lower hospitalisation rate than predicted for all-cause hospitalisation as well as hospitalisation due to CHD and AMI in both people with and without diabetes during the COVID-19 pandemic. In contrast, we observed an increased hospitalisation rate due to major amputation in 2020 in the population with diabetes. In the population without diabetes, this rate was not increased. The increase of hospitalisations due to amputation in people with diabetes with a simultaneous reduction in DFS is in line with results of other studies and needs special attention [3,4,5]. A number of underlying reasons can be assumed, including restricted medical services during the COVID-19 pandemic, fear of COVID-19 infection, refusal to attend clinics, unwillingness to be admitted to hospital, and inadequate diabetes self-management due to demotivation when socially distancing coupled with lacking or limited medical support. The increase of observed hospitalisations for minor amputations in people without diabetes might also be explained by reduced medical care during the COVID-19 pandemic.
A limitation of this study is that the data are based on a regional statutory health insurance company. Thus, future nationwide studies in this field are required.
Availability of data and material
The data that support the findings of this study are available from the authors upon reasonable request and with permission of the AOK Rheinland/Hamburg.
Code Availability
Not applicable.
References
Seiglie J, Platt J, Cromer SJ, et al. Diabetes as a Risk Factor for Poor Early Outcomes in Patients Hospitalized With COVID-19. Diabetes Care. 2020;43(12):2938–44. https://doi.org/10.2337/dc20-1506.
(2020) The impact of the COVID-19 pandemic on noncommunicable disease resources and services: results of a rapid assessment. Geneva: World Health Organization. Licence: CC BY-NC-SA 3.0 IGO. Available from https://www.who.int/publications/i/item/9789240010291. Accessed 10 June 2021.
Mariet AS, Benzenine E, Bouillet B, Vergès B, Quantin C, Petit JM. Impact of the COVID-19 Epidemic on hospitalization for diabetic foot ulcers during lockdown: A French nationwide population-based study. Diabet medicine: J Br Diabet Association: e14577. 2021. https://doi.org/10.1111/dme.14577.
Caruso P, Longo M, Signoriello S, et al. Diabetic Foot Problems During the COVID-19 Pandemic in a Tertiary Care Center: The Emergency Among the Emergencies. Diabetes Care. 2020;43(10):e123–4. https://doi.org/10.2337/dc20-1347.
Lipscomb D, Smith AS, Adamson S, Rezazadeh EM. Diabetic foot ulceration in COVID-19 lockdown: cause for concern or unexpected benefit? Diabet medicine: J Br Diabet Association. 2020;37(8):1409–10. https://doi.org/10.1111/dme.14340.
Acknowledgements
We thank Olga Dortmann (Department of Health Mangement, AOK Rheinland/Hamburg – die Gesundheitskasse, Düsseldorf, Germany) for her contributions with regard to the methodology, data collection and data analysis. We also thank Jeremy Groves for editing the paper and revising the English language used in this manuscript.
Funding
The work was supported by institutional funding (German Diabetes Center) of the Federal Ministry of Health and by the Ministry of Culture and Science of North-Rhine Westphalia. It was further funded by the Federal Ministry of Education and Research as part of the German Center of Diabetes Research. The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Open Access funding enabled and organized by Projekt DEAL.
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A.I. designed the study and co-drafted the first version of the article. M.S. collected and provided data. H.C., M.N., and T.K. contributed to the overall coordination, data collection and research data. S.M. provided clinical expertise. H.C., M.N. and J.R. analysed and interpreted the findings and drafted the first version of the article. All authors interpreted the analysis, reviewed and provided input for the final manuscript, and gave their final approval of the version to be published. A.I. is the guarantor of this work and, as such, had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
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Narres, M., Claessen, H., Kvitkina, T. et al. Hospitalisation rate and mortality among people with and without diabetes during the COVID-19 pandemic year 2020. Eur J Epidemiol 37, 587–590 (2022). https://doi.org/10.1007/s10654-022-00865-6
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DOI: https://doi.org/10.1007/s10654-022-00865-6