Trends Of Diabetic Ketoacidosis During COVID-19 Pandemic In Large Urban Public Emergency Department

Study Objectives: Diabetic ketoacidosis (DKA) is a common and serious endocrine emergency. Common triggers for diabetic ketoacidosis include infection, cardiovascular events, drug use, medication non-adherence, and new onset diabetes. Early evidence suggests a correlation between COVID-19 infection and DKA. Based on the limited data, it is unclear at this time if increases in DKA are triggered by acute COVID-19 infection, or secondary factors from the pandemic such as lack of access to care or acute stress. In this study, we examine trends in DKA prevalence among patients at an underserved urban public ED within the context of the COVID-19 pandemic. Methods: This is a retrospective study using administrative report data of all ED encounters. Cases of DKA, found using top 5 ICD10 ED diagnoses, were identified from 2019 and 2020. COVID-19 infection was pulled from laboratory data and merged to create one data set. Poisson regression was utilized to compare incidence rates of DKA (1) between 2019 and 2020 and (2) among COVID positive and COVID negative patients with DKA for the year of 2020. Yearly trends were examined month by month. Results: There were 180,158 patient visits in 2019 and 138,012 in 2020. Compared to 2019, incidence rates of DKA increased by 23% in 2020 (95% CI 4% to 42%, p=0.017). Among all those tested for COVID in 2020 (n=25,867), patients with positive COVID-19 tests trended to higher DKA rate (37% higher (95% CI -6% to 81% increase, p=0.098) than patients with negative COVID-19 tests. The increase was most prominent from April 2020 onward, with the largest increase in December 2020, correlating with the COVID surge at our hospital. (Figure 1). In December 2019, 20 out of 14,324 visits (0.14%) were coded as DKA, while in December 2020, 37 out of 10,942 visits (0.34%) were coded DKA. In December 2020, 11 DKA cases were COVID-19 positive and 26 were COVID-19 negative. When excluding the 11 cases of DKA with positive COVID-19 tests, the rate of DKA in 12/2020 would be 0.24%. Conclusions: We found the incidence rate ratio of DKA in 2020 increased compared to 2019, with an almost doubling of DKA rates in the month of December, the peak months of our pandemic surge. Our findings suggest a correlation between COVID-19 positivity and DKA, but is limited by small numbers at a single site. There is also limited data to suggest secondary factors may also play a role in increased rates. When removing COVID positive DKA cases in December 2020, the prevalence that month continued to 0.10% higher than in December 2019. While small numbers prevent firm conclusions, itis possible factors outside of COVID infection are attributing to higher rates. Various studies have shown reduced access to care for conditions managed in ambulatory settings during the COVID pandemic. Given this, decreased access to care for medication refill and titration may also be contributing to the rise in DKA rates. As more data becomes available, further research is required to establish the role of access to care versus inflammation from COVID-19 infection in triggering DKA. [Formula presented]