Incremental Risk of Developing Severe COVID-19 Among Mexican Patients With Diabetes Attributed to Social and Health Care Access Disadvantages

Abstract

Objective: Diabetes is an important risk factor for severe coronavirus disease 2019 (COVID-19), but little is known about the marginal effect of additional risk factors for severe COVID-19 among individuals with diabetes. We tested the hypothesis that sociodemographic, access to health care, and presentation to care characteristics among individuals with diabetes in Mexico confer an additional risk of hospitalization with COVID-19.

Research design and methods: We conducted a cross-sectional study using public data from the General Directorate of Epidemiology of the Mexican Ministry of Health. We included individuals with laboratory-confirmed severe acute respiratory syndrome coronavirus 2 between 1 March and 31 July 2020. The primary outcome was the predicted probability of hospitalization, inclusive of 8.5% of patients who required intensive care unit admission.

Results: Among 373,963 adults with COVID-19, 16.1% (95% CI 16.0-16.3) self-reported diabetes. The predicted probability of hospitalization was 38.4% (37.6-39.2) for patients with diabetes only and 42.9% (42.2-43.7) for patients with diabetes and one or more comorbidities (obesity, hypertension, cardiovascular disease, and chronic kidney disease). High municipality-level of social deprivation and low state-level health care resources were associated with a 9.5% (6.3-12.7) and 17.5% (14.5-20.4) increased probability of hospitalization among patients with diabetes, respectively. In age-, sex-, and comorbidity-adjusted models, living in a context of high social vulnerability and low health care resources was associated with the highest predicted probability of hospitalization.

Conclusions: Social vulnerability contributes considerably to the probability of hospitalization among individuals with COVID-19 and diabetes with associated comorbidities. These findings can inform mitigation strategies for populations at the highest risk of severe COVID-19.

Figure 1

Predicted probability of hospitalization according to comorbidities of obesity, hypertension (HTN), CVD, and CKD among 373,963 patients with COVID-19 in Mexico. Four groups according to comorbidity status (A) and according to diabetes and each comorbidity (B) are shown on the x axis, and the predicted probability of hospitalization is presented on the y axis. The model is adjusted for age, sex, indigenous language spoken, municipality social deprivation level, health care provider type, state-level health care resource index, month of presentation to care, days from symptom onset to presentation to care, COPD, and asthma. Among patients that required hospitalization, 8.5% of patients required ICU-level care.

Figure 2

Incremental probability of hospitalization according to sociodemographic characteristics, health care resources, and presentation to care characteristics among 373,963 patients with COVID-19 and diabetes in Mexico, with and without one or more comorbidities. The incremental probability is calculated with respect to the overall adjusted probability of being hospitalized among individuals with diabetes as shown in Fig. 1. Model adjusted for all characteristics listed. Comorbidities included are as follows: obesity, hypertension, CVD, and CKD. Model additionally adjusted for COPD and asthma. Among patients that required hospitalization, 8.5% of patients required ICU-level care. *Ministry of Health and Social Security refer to health care provider type.

Figure 3

Case scenarios of the predicted probability of hospitalization according to social vulnerability, health care resources, and presentation to care characteristics for men (top panels) and for women (bottom panels). A and C: Case scenarios for patients with COVID-19 and diabetes. B and D: Case scenarios for patients with COVID-19 and diabetes with comorbidities. Model adjusted for all characteristics listed in addition to health care provider type and month of presentation to care. Comorbidities included are as follows: obesity, hypertension, CVD, and CKD. Model additionally adjusted for COPD and asthma. Among patients that required hospitalization, 8.5% of patients required ICU-level care. A sensitivity analysis of case scenarios that excluded timing of presentation to care did not appreciably change these estimates (Supplementary Appendix 4).