Risk of Diabetic Ketoacidosis 4 Times Greater Among Black Patients with COVID-19 vs White Counterparts

Osagie Ebekozien, MD, MPH

An analysis of data from patients with type 1 diabetes and coronavirus disease 2019 (COVID-19) indicates Black individuals were 4 times more likely to be hospitalized for diabetic ketoacidosis than Non-Hispanic White individuals.

A cross-sectional analysis of data from 52 clinical sites in the US, results highlight the additional risk of negative outcomes with COVID-19 among Black individuals and underline the immediate need to address healthcare disparities.

"This is the first major study to examine racial-ethnic inequities for people with type 1 diabetes and COVID-19 that are brought on by structural and systemic racism," said lead investigator Osagie Ebekozien, MD, MPH, of the T1D Exchange in Boston, in a statement. “We used a diverse cohort of patients with type 1 diabetes and found there is a significantly increased risk of worse outcomes for Black and Hispanic patients with COVID-19 and diabetes."

With multiple studies demonstrating the increased risk of mortality associated with diabetes among patients with COVID-19, especially Non-Hispanic Black and Hispanic populations, Ebekozien and a team of colleagues sought to evaluate the incidence of diabetic ketoacidosis in patients with COVID-19. In August 2020, 52 clinical centers from across the US took part in a surveillance study conducted by the T1D Exchange and this information was used for the current analysis.

As part of the surveillance study, participating centers completed retrospective chart reviews and submitted information related to 33 patient and clinical attributes. Of note, each center identified a single team member for reporting to avoid duplicating patient information. All submissions were reviewed for potential errors or incomplete information.

For the purpose of the analysis, race/ethnicity information was defined according to US Census criteria. The primary outcome of the study was diabetic ketoacidosis, which was defined as blood glucose greater than 200 mg/dl, a venous pH less than 7.3 or bicarbonate less than 15 mmol/L, ketonemia, and ketonuria. Age, sex, insurance, and last HbA1c were used as confounding factors in multivariable analysis.

From April-August 2020, a total of 180 patients with type 1 diabetes and laboratory-confirmed COVID-19 from the 52 clinical sites. Of the 180, 79 (44%) identified as Non-Hispanic White, 55 (31%) were Non-Hispanic Black, and 46 (26%) were Hispanic. Investigators pointed out Non-Hispanic Black and Hispanic patients had a greater median HbA1c compared to White patients (IQR: 11.7 [4.7], P<.001) and 9.7 [3.1] vs 8.3 [2.4], P=.01).

Upon analysis, results indicated Non-Hispanic Black (55% vs 13%, P <.001) and Hispanic (33% vs 13%, P=.008) patients were more likely to present with diabetic ketoacidosis than White patients. After adjusting for potential confounders, results suggested Non-Hispanic Black patients were still at greater odds of presenting with diabetic ketoacidosis when compared to Non-Hispanic White patients (OR, 3.7; 95% CI, 1.4-10.6).

"Our findings of troubling and significant inequities call for urgent and targeted interventions, such as culturally appropriate diabetic ketoacidosis awareness campaigns, increased continuous glucose monitoring coverage for minority patients and health care provider participation in a Quality Improvement Collaborative," Ebekozien said.

This study, “Full Inequities in Diabetic Ketoacidosis among Patients with Type 1 diabetes and COVID-19: Data from 52 US Clinical Centers,” was published in the Journal of Clinical Endocrinology & Metabolism.