During COVID-19, health care systems reorganized with less ambulatory care and a shift to virtual care.1  There was an increase in diabetic ketoacidosis (DKA), a preventable, life-threatening condition, at diabetes onset in children during COVID-19.2  DKA at diabetes onset has been attributed to delays in seeking care, missed diagnosis, or delays in referral after a primary health care contact.3  Reasons for the recent increase in DKA may relate to hesitancy to seek care, providers failing to recognize diabetes symptoms because of cognitive bias focusing on COVID-19, or limitations of virtual care. To explore these potential mechanisms, we compared in-person and virtual primary care and emergency department (ED) visits in children 4 weeks before diagnosis before and during COVID-19. If increased DKA rates during COVID-19 were due to more missed diagnoses, possibly related to virtual visits, children with DKA would be more likely to have visits during versus before COVID-19. If families were hesitant to seek or were unable to access care during COVID-19, then among those with no visits, there would be a higher proportion with DKA.

We conducted a cross-sectional population-based study of children <19 years in Ontario, Canada, diagnosed with diabetes between April 1, 2017, to September 30, 2021. We used administrative datasets, linked using unique encoded identifiers, held and analyzed at ICES. We included all individuals aged 1 to 17 years in Ontario annually on January 1 (2017 to 2020) with any ED or admissions for diabetes, with no previous record in the Ontario Diabetes Database (ODD) and no outpatient diabetes visits in the prior two years (excluding the four weeks prior). The Ontario Diabetes Database is a population-based, validated diabetes registry derived using administrative data (83% sensitivity, 99% specificity).4  Dataset descriptions are in the Supplemental Information. We defined pre-COVID-19 as being from April 1, 2017, to March 31, 2020, and COVID-19 starting April 1, 2020, 2 weeks after the beginning of the pandemic in Ontario. We compared the proportion with any primary care and ED visits 4 weeks before diagnosis among those with and without DKA before versus during COVID-19. Among those with no visits, we compared the proportion with DKA between time periods. We used the χ2 test for between-group comparisons.

A greater proportion of children diagnosed with diabetes had DKA during COVID-19 (44.9%) compared with before (33.1%) (P < .001). Among those with DKA, there was no difference in the proportion who had any visits within 4 weeks between time periods (P = .94) (Table 1A). Among individuals with any visits, 167/277 (60.3%) had at least 1 virtual primary care visit. Figure 1 shows that the proportion with any primary care visits was slightly higher and ED visits slightly lower during COVID-19 compared with pre-COVID-19, although these differences were only statistically significant for ED visit among those without DKA. Among those with no previous visits, the proportion with DKA was higher during vs. pre-COVID-19 (46.8% and 35.0%) (P < .001) (Table 1B). The proportion with DKA with a primary care visit was similar (about 40%) between periods.

FIGURE 1

None of the comparisons between pre-COVID-19 and COVID-19 in any of the panels are statistically significant except for those with any ED visits without DKA (as indicated with asterisks).

FIGURE 1

None of the comparisons between pre-COVID-19 and COVID-19 in any of the panels are statistically significant except for those with any ED visits without DKA (as indicated with asterisks).

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TABLE 1

Baseline Characteristics of Individuals With DKA at Diabetes Diagnosis, Proportion With Any Visit Before Diagnosis Pre- Versus During COVID, and Proportion With DKA Among Individuals Having No Primary Care or ED Visits Pre- and During COVID

Pre-COVIDDuring COVIDStandard Difference or P Value
Individuals with DKA at diabetes diagnosis (N = 1575) n = 895 n = 680  
 Age, y, mean (SD) 9.3 (4.5) 9.6 (4.4) 0.054 
 Age group, y, n (%)    
  1–5 199 (22.2) 148 (21.8) 0.011 
  6–12 455 (50.8) 326 (47.9) 0.058 
  13–18 241 (26.9) 206 (30.3) 0.075 
 Sex, female, n (%) 397 (44.4) 304 (44.7) 0.007 
 Geographic residence, urban, n (%) 786 (87.8) 619 (91.0) 0.104 
 Neighborhood deprivation quintile, n (%)    
  1 - least deprived 204 (22.8) 151 (22.2) 0.014 
  2 174 (19.4) 124 (18.2) 0.031 
  3 158 (17.7) 123 (18.1) 0.011 
  4 156 (17.4) 117 (17.2) 0.006 
  5 - most deprived 203 (22.7) 165 (24.3) 0.037 
 Any visits 4 weeks prior to diagnosis, PC or ED, n (%) 363 (40.6) 277 (40.7) 0.94 
Individuals having no visits 4 weeks prior to diabetes diagnosis (N = 2381) n = 1519 n = 862  
 DKA, n (%) 532 (35.0) 403 (46.8) <0.001a 
Pre-COVIDDuring COVIDStandard Difference or P Value
Individuals with DKA at diabetes diagnosis (N = 1575) n = 895 n = 680  
 Age, y, mean (SD) 9.3 (4.5) 9.6 (4.4) 0.054 
 Age group, y, n (%)    
  1–5 199 (22.2) 148 (21.8) 0.011 
  6–12 455 (50.8) 326 (47.9) 0.058 
  13–18 241 (26.9) 206 (30.3) 0.075 
 Sex, female, n (%) 397 (44.4) 304 (44.7) 0.007 
 Geographic residence, urban, n (%) 786 (87.8) 619 (91.0) 0.104 
 Neighborhood deprivation quintile, n (%)    
  1 - least deprived 204 (22.8) 151 (22.2) 0.014 
  2 174 (19.4) 124 (18.2) 0.031 
  3 158 (17.7) 123 (18.1) 0.011 
  4 156 (17.4) 117 (17.2) 0.006 
  5 - most deprived 203 (22.7) 165 (24.3) 0.037 
 Any visits 4 weeks prior to diagnosis, PC or ED, n (%) 363 (40.6) 277 (40.7) 0.94 
Individuals having no visits 4 weeks prior to diabetes diagnosis (N = 2381) n = 1519 n = 862  
 DKA, n (%) 532 (35.0) 403 (46.8) <0.001a 
a

P value.

DKA was more frequent during COVID-19; however, this was not associated with a difference in precedent visits, suggesting the mechanism is unlikely to be more missed diagnoses. The 40% visit rate representing a missed opportunity to prevent DKA is similar to a recent study reporting 43% of children who had a primary health care contact before hospital admission were not referred immediately to an ED.3  Given that the proportion with any previous visit was similar between periods and during COVID-19, 60% of those with any visits had at least 1 virtual visit, suggests that virtual care is unlikely to be an important driver of the increased risk of DKA; however, there are limited data about the safety and effectiveness of virtual primary care.5  Importantly, the higher DKA rate among those with no visits during COVID-19 and a pattern of fewer ED visits during COVID-19 may reflect hesitancy to seek or barriers to access emergency care. Hesitancy to seek emergency care for children has been higher in those living in areas with high COVID-19 positivity and may be an important factor in the increased risk of DKA.6  Public messaging should encourage families to seek care for their children urgently during this and future pandemics to prevent DKA.

The use of data in this project was authorized under section 45 of Ontario’s Personal Health Information Protection Act, which does not require review by a Research Ethics Board.

The opinions, results, and conclusions reported in this paper are those of the authors and are independent from the funding sources. No endorsement by ICES or the Ontario Ministry of Health is intended or should be inferred. Parts of this material are based on data and information compiled and provided by the Canadian Institute for Health Information. However, the analyses, conclusions, opinions, and statements expressed herein are those of the authors, and not necessarily those of CIHI.

Dr Shulman conceptualized and designed the study, contributed to the interpretation of data, drafted the initial manuscript, and reviewed and revised the manuscript. Drs Nakhla, Stukel, and Guttmann conceptualized and designed the study, contributed to the interpretation of data, and reviewed and revised the manuscript. Ms Diong carried out the initial analyses, contributed to the interpretation of data, and reviewed and revised the manuscript. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: This study was supported by ICES, which is funded by an annual grant from the Ontario Ministry of Health. This study was also supported by the Canadian Institutes of Health Research Grant No.VR4-172730 (Nominated Principal Applicant: Dr Guttmann). The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

CONFLICTS OF INTEREST: Dr Shulman has received speaking fees from Dexcom. The other authors have no reported conflicts of interest to declare.

DKA

diabetic ketoacidosis

ED

emergency department

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Supplementary data