Temporal trends in emergency admissions for diabetic ketoacidosis in people with diabetes in England before and during the COVID-19 pandemic: a population-based study

Abstract

Background: Diabetic ketoacidosis (DKA) has been reported to be increasing in frequency during the COVID-19 pandemic. We aimed to examine the rates of DKA hospital admissions and the patient demographics associated with DKA during the pandemic compared with in prepandemic years.

Methods: Using a comprehensive, multiethnic, national dataset, the Secondary Uses Service repository, we extracted all emergency hospital admissions in England coded with DKA from March 1 to June 30, 2020 (first wave of the pandemic), July 1 to Oct 31, 2020 (post-first wave), and Nov 1, 2020, to Feb 28, 2021 (second wave), and compared these with DKA admissions in the equivalent periods in 2017-20. We also examined baseline characteristics, mortality, and trends in patients who were admitted with DKA.

Findings: There were 8553 admissions coded with DKA during the first wave, 8729 during the post-first wave, and 10 235 during the second wave. Compared with preceding years, DKA admissions were 6% (95% CI 4-9; p<0·0001) higher in the first wave of the pandemic (from n=8048), 6% (3-8; p<0·0001) higher in the post-first wave (from n=8260), and 7% (4-9; p<0·0001) higher in the second wave (from n=9610). In the first wave, DKA admissions reduced by 19% (95% CI 16-21) in those with pre-existing type 1 diabetes (from n=4965 to n=4041), increased by 41% (35-47) in those with pre-existing type 2 diabetes (from n=2010 to n=2831), and increased by 57% (48-66) in those with newly diagnosed diabetes (from n=1072 to n=1681). Compared with prepandemic, type 2 diabetes DKA admissions were similarly common in older individuals and men but were higher in those of non-White ethnicities during the first wave. The increase in newly diagnosed DKA admissions occurred across all age groups and these were significantly increased in men and people of non-White ethnicities. In the post-first wave, DKA admissions did not return to the baseline level of previous years; DKA admissions were 14% (11-17) lower in patients with type 1 diabetes (from n=5208 prepandemic to n=4491), 30% (24-36) higher in patients with type 2 diabetes (from n=2011 to n=2613), and 56% (47-66) higher in patients with newly diagnosed diabetes (from n=1041 to n=1625). During the second wave, DKA admissions were 25% (22-27) lower in patients with type 1 diabetes (from n=5769 prepandemic to n=4337), 50% (44-56) higher in patients with type 2 diabetes (from n=2608 to n=3912), and 61% (52-70) higher in patients with newly diagnosed diabetes (from n=1234 to n=1986).

Interpretation: Our results provide evidence for differences in the numbers and characteristics of people presenting with DKA during the COVID-19 pandemic compared with in the preceding 3 years. Greater awareness of risk factors for DKA in type 2 diabetes and vigilance for newly diagnosed diabetes presenting with DKA during the COVID-19 pandemic might help mitigate the increased impact of DKA.

Funding: None.

Figure 1

Number of emergency hospital admissions in England coded with DKA by type of diabetes from March, 2017, to February, 2021 DKA=diabetic ketoacidosis.

Figure 2

Incidence rates of emergency hospital admissions coded with DKA during the first wave, post-first wave, and second wave of the COVID-19 pandemic, and the mean in equivalent time periods in 2017–20 by age group and diabetes type (A) Type 1 diabetes. (B) Type 2 diabetes. (C) Newly diagnosed diabetes. Incidence rates are per 100 000 population with diabetes for type 1 and type 2 diabetes and per 100 000 general population for newly diagnosed diabetes. The first wave was defined as from March 1 to June 30, 2020, the post-first wave was from July 1 to Oct 31, 2020, and the second wave was from Nov 1, 2020, to Feb 28, 2021. Error bars indicate 95% CI. DKA=diabetic ketoacidosis.