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. 2024 Aug;16(8):e13591.
doi: 10.1111/1753-0407.13591.

Trends in diabetic ketoacidosis- and hyperosmolar hyperglycemic state-related mortality during the COVID-19 pandemic in the United States: A population-based study

Xinyuan He  1 , Amy Huaishiuan Huang  2 , Fan Lv  3 , Xu Gao  1   4 , Yuxin Guo  1 , Yishan Liu  1 , Xiaoqin Hu  1 , Jingyi Xie  1 , Ning Gao  1 , Yang Jiao  5 , Yuan Wang  1 , Jian Zu  3 , Lei Zhang  6   7   8   9 , Fanpu Ji  1   10   11   12   13 , Yee Hui Yeo  14
Affiliations

Trends in diabetic ketoacidosis- and hyperosmolar hyperglycemic state-related mortality during the COVID-19 pandemic in the United States: A population-based study

Xinyuan He et al. J Diabetes. 2024 Aug.

Abstract

Background: During the pandemic, a notable increase in diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS), conditions that warrant emergent management, was reported. We aimed to investigate the trend of DKA- and HHS-related mortality and excess deaths during the pandemic.

Methods: Annual age-standardized mortality rates related to DKA and HHS between 2006 and 2021 were estimated using a nationwide database. Forecast analyses based on prepandemic data were conducted to predict the mortality rates during the pandemic. Excess mortality rates were calculated by comparing the observed versus predicted mortality rates. Subgroup analyses of demographic factors were performed.

Results: There were 71 575 DKA-related deaths and 8618 HHS-related deaths documented during 2006-2021. DKA, which showed a steady increase before the pandemic, demonstrated a pronounced excess mortality during the pandemic (36.91% in 2020 and 46.58% in 2021) with an annual percentage change (APC) of 29.4% (95% CI: 16.0%-44.0%). Although HHS incurred a downward trend during 2006-2019, the excess deaths in 2020 (40.60%) and 2021 (56.64%) were profound. Pediatric decedents exhibited the highest excess mortality. More than half of the excess deaths due to DKA were coronavirus disease 2019 (COVID-19) related (51.3% in 2020 and 63.4% in 2021), whereas only less than a quarter of excess deaths due to HHS were COVID-19 related. A widened racial/ethnic disparity was observed, and females exhibited higher excess mortality than males.

Conclusions: The DKA- and HHS-related excess mortality during the pandemic and relevant disparities emphasize the urgent need for targeted strategies to mitigate the escalated risk in these populations during public health crises.

Keywords: COVID‐19; diabetic ketoacidosis; disparities; excess mortality; forecast model; hyperosmolar hyperglycemic state.

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Conflict of interest statement

Fanpu Ji receives speaker fees from Gilead Sciences, MSD and Ascletis and is a consultant/advisory board member for Gilead, MSD. All other authors do not have any conflict of interest.

Figures

FIGURE 1
FIGURE 1
Temporal trends in diabetic ketoacidosis (DKA)‐related deaths and excess deaths during the coronavirus disease 2019 (COVID‐19) pandemic, by sex, further stratified by age. (A) Overall population, (B) female, (C) male, (D) aged 0–18 years in overall population, (E) aged 0–18 years in females, (F) aged 0–18 years in males, (G) aged 19–44 years in overall population, (H) aged 19–44 years in females, (I) aged 19–44 years in males, (J) aged 45–64 years in overall population, (K) aged 45–64 years in females, (L) aged 45–64 years in males, (M) aged 65 years and above in overall population, (N) aged 65 years and above in females, (O) aged 65 years and above in males. The observed mortality rates were above the predicted mortality rates (dashed horizontal line). DKA‐related death refers to multiple cause‐of‐death associated with DKA. *COVID‐19‐related death count less than nine persons.
FIGURE 2
FIGURE 2
Temporal trends of hyperosmolar hyperglycemic state (HHS)‐related mortality and excess mortality during the coronavirus disease 2019 (COVID‐19) pandemic, by sex, further stratified by age. (A) Overall population, (B) female, (C) male, (D) aged 19–44 years in overall population, (E) aged 19–44 years in females, (F) aged 19–44 years in males, (G) aged 45–64 years in overall population, (H) aged 45–64 years in females, (I) aged 45–64 years in males, (J) aged 65 years and above in overall population, (K) aged 65 years and above in females, (L) aged 65 years and above in males. HHS‐related mortality rates (per 100 000 persons) increased across all subgroups during the pandemic. The observed mortality rates were above the predicted mortality rates (dashed horizontal line). HHS‐related death refers to multiple cause‐of‐death associated with HHS. *COVID‐19‐related death count less than nine persons.
FIGURE 3
FIGURE 3
Monthly age‐standardized mortality for diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) in the United States in 2018–2021. (A) Overall mortality for decedents with DKA, (B) overall mortality for decedents with HHS.
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