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Abstract
Introduction Regular blood glucose/A1c, blood pressure (BP), and cholesterol (ABC) testing is important for diabetes management. It is unknown whether pandemic-related disruptions in medical care were negatively associated with ABC testing among US adults with diagnosed diabetes.
Research design and methods A cross-sectional analysis was conducted among adults ≥18 years with diagnosed diabetes who participated in the 2019 or 2021 National Health Interview Survey (n=3355 and n=3127, respectively). Adults with diabetes self-reported sociodemographic and diabetes-related characteristics, ABC testing in the past year, and delays or not getting medical care due to the pandemic (2021 only). Descriptive statistics were used to determine differences in ABC testing in 2019 vs 2021. Logistic regression models were used to assess the association between delays or not getting medical care due to the pandemic and ABC testing, adjusting for sociodemographic characteristics, diabetes duration, and diabetes medication use.
Results Overall, the prevalence of having a blood glucose/A1c or a BP test in the past year was high (>90%) but it was significantly lower in 2021 compared with 2019 (A1c: 94.2% vs 96.8%, p<0.001; BP: 96.8% vs 98.4%, p=0.002, respectively). Cholesterol testing remained stable (93.0% in 2021 vs 94.5% in 2019, p=0.053). In logistic regression analysis, after full adjustment, adults who reported delaying or not getting medical care when needed due to the pandemic were 50% less likely to get an ABC test in the past year compared with those who promptly received medical care (A1c: adjusted OR (aOR)=0.44, 95% CI 0.29–0.68; BP: aOR=0.48, 95% CI 0.27–0.85; cholesterol: aOR=0.48, 95% CI 0.31–0.75).
Conclusions Disruptions in medical care during the pandemic were associated with a decrease in ABC testing. Future research is needed to assess whether blood glucose/A1c and BP testing returns to prepandemic levels and if reductions in these tests result in excess diabetes-related complications.
- COVID-19
- Disease Management
- Epidemiology
Data availability statement
Data are available in a public, open access repository. Data are publicly available at: https://www.cdc.gov/nchs/nhis/data-questionnaires-documentation.htm.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
Medical care delivery and utilization was substantially disrupted by the COVID-19 pandemic but the magnitude of disruptions and the association with diabetes management is less known among the total US population.
WHAT THIS STUDY ADDS
In 2021, nearly one-quarter of adults with diabetes reported delaying medical care or not getting medical care due to the pandemic with blood glucose and blood pressure testing significantly decreasing between 2019 and 2021. Adults with diabetes who reported disruptions in medical care were 50% less likely to get an A1c, blood pressure, and cholesterol (ABC) test in the past year, even after full adjustment for potential confounders.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
Future research needs to determine whether blood glucose and blood pressure testing returns to prepandemic levels and whether reductions in ABC testing result in excess comorbidities and complications among adults with diabetes.
Introduction
Medical care delivery and utilization was substantially disrupted by the COVID-19.1 2 The disruption in care led to temporary cancellation of surgeries and procedures, a reduction in regular check-ups and preventive care, an increase in telehealth visits, and elective avoidance of medical care due to risk of contracting COVID-19.1 2 Delayed medical care among persons with diabetes may be higher than average since those with diabetes or complications of diabetes are known to have more adverse outcomes from COVID-19 than persons without diabetes.3 Literature on the potential impact of the COVID-19 pandemic on healthcare utilization and diabetes-related testing among adults is growing with some studies showing reductions in A1c testing4–6 and outpatient visits5 7 in selected populations. However, it is unclear whether disruptions to medical care are associated with diabetes management, including regular recommended testing for A1c, blood pressure (BP), and cholesterol (ABC).
Using a nationally representative US sample, this study assesses the prevalence of ABC testing in the past year before and during the pandemic and delaying or forgoing medical care due to the pandemic among adults with diagnosed diabetes that participated in the National Health Interview Study (NHIS). Further, the association between a self-reported disruption in medical care due to the pandemic and having an ABC test in the past year was evaluated.
Research design and methods
Data source and population
The NHIS is a nationally representative, cross-sectional household survey of the civilian non-institutionalized US population that has been conducted since 1957 by the National Center for Health Statistics. The NHIS is designed as a complex, multistage probability sample that incorporates stratification and clustering to provide nationally representative estimates for the civilian non-institutionalized US population. Interviews are conducted at the respondent’s home; follow-ups to completed interviews may be conducted by telephone. We used data collected in 2019 (prepandemic) and in 2021 (during the pandemic). Most interviews were conducted by phone in 2020 due to the pandemic and are not included herein. All information is self-reported. Detailed information about the survey methods, which remained the same in 2019 and 2021, has been described elsewhere.8–10
Participants included in our analytic sample were adults aged ≥18 years with diagnosed diabetes. Diabetes diagnosis was determined if participants answered ‘yes’ to the following question: ‘Other than during pregnancy, have you ever been told by a doctor or health professional that you have diabetes or sugar diabetes?’. There were 3355 adults in 2019 and 3127 in 2021 with diagnosed diabetes that participated in the NHIS. Among participants in the 2019 or 2021 survey, 99% had complete information on ABC testing in the past year. Additionally, 99% of participants with diabetes in 2021 completed questions about delays in or not receiving medical care due to the pandemic.
Main dependent variables
Having an ABC test in the past year was based on participants’ response to questions about blood glucose (2019), A1c (2021), BP (both years), and cholesterol testing (both years) in the past year. Response options were ‘never, within the past year, greater than 1 year but less than 2 years ago, 2 years but less than 3 years ago, 3 years but less than 5 years ago, 5 years but less than 10 years ago, and 10 years ago or more’. Participants responding ‘within the past year’ were considered to have test in the past year. In 2019, all participants were asked whether they had a blood test for high blood sugar or diabetes in the past year. In 2021, those who reported a diagnosis of diabetes were asked whether they had an A1c testing in the past year but the item on a blood test for high blood sugar or diabetes was intentionally omitted. Participants were asked about the last time their cholesterol and BP were checked by a doctor, nurse, or other health professional.
Main independent variables
First, study year (2019, prepandemic and 2021, during pandemic) was the main independent variable that was associated with ABC testing prevalence (main dependent variable). Second, disruptions in healthcare due to the pandemic were the main independent variable that was associated with ABC testing. In 2021, participants were asked whether they (1) delayed getting non-COVID medical care because of the pandemic or (2) needed non-COVID medical care but did not get it because of the pandemic. Responses to these questionnaire items were yes or no and combined to determine any healthcare disruption.
Covariates
Participants self-reported demographic characteristics (age, sex, race and ethnicity, education, family income to determine poverty income ratio (PIR), health insurance coverage), duration of diabetes, and medication use to treat diabetes (insulin, oral hypoglycemic agents).
Statistical analysis
Prevalence (SEs) of ABC testing was determined overall and by demographic characteristics, diabetes duration, and glycemic medication use for 2019 and 2021. In addition, the adjusted prevalence of ABC testing was determined using predicted margins; estimates were adjusted for demographic characteristics, diabetes duration, and glycemic medication use. Significance testing (two-sided t-tests, p<0.05) was conducted to determine significant differences in ABC testing between 2019 (prepandemic) and 2021 (during the pandemic).
To determine the percent change in the number of adults with diabetes who did not get an ABC test in 2019 vs 2021, the percentage of adults with diagnosed diabetes in 2019 and 202111 was applied to the US census adult population12 in each of these years to determine the number of adults with diagnosed diabetes, respectively. The estimate for the percent who did not get an ABC test in 2019 and 2021 was applied to the corresponding number of adults with diagnosed diabetes to determine the number of adults who did not get an ABC test. The percent change was calculated using the following equation with the number of adults with diagnosed diabetes who did not get an ABC test: % change=[(2021 estimate–2019 estimate)/2019 estimate]*100.
The 2021 data were used to examine the prevalence of ABC testing stratified by reported delays in medical care and not getting medical care due to the pandemic. Logistic regression (OR, 95% CI) was used to assess the associations between delayed medical care or not receiving medical care due to the pandemic and ABC testing. Regression models were (1) unadjusted, (2) adjusted for age, sex, race/ethnicity, (3) additionally adjusted for education, PIR, and health insurance, and (4) additionally adjusted for diabetes duration and diabetes medication use. Models were adjusted sequentially to show how the OR estimates changed with sequential adjustment for demographic characteristics, socioeconomic characteristics, and diabetes care factors. Each of the covariates included in the model was considered a confounder of the relationship between delays in or not receiving medical care and having an ABC test in the past year (online supplemental figure S1).
Supplemental material
All statistical analyses used sample weights provided by the NHIS and accounted for the cluster design using SUDAAN (SUDAAN User’s Manual, Release 11, 2012; Research Triangle Institute).
Results
There were no significant differences in participant characteristics between the 2019 and 2021 NHIS survey years (online supplemental table S1). For both years, 45% of adults with diabetes were aged ≥65 years and about half were female. The distribution of race and ethnicity in descending order was non-Hispanic white (58%–61%), Hispanic (18%–19%), non-Hispanic black (16%–17%), and non-Hispanic Asian (6%). Over half had a duration of diabetes ≥10 years (55%–56%) and were only taking oral hypoglycemic agents (56%).
Supplemental material
Overall, the prevalence of having a blood glucose/A1c test or a BP test in the past year was high (in the mid-90% range) but significantly lower in 2021 compared with 2019 (A1c: 94.2% (SE=0.6) vs 96.8% (SE=0.5), p<0.001; BP: 96.8% (SE=0.4) vs 98.4% (SE=0.3), p=0.002, respectively) (table 1). Cholesterol testing remained stable (93.0% (0.6) in 2021 vs 94.5% (0.6) in 2019, p=0.053). The number of adults with diabetes who did not get an ABC test in 2021 was estimated to be 1.44 million for blood glucose/A1c, 794 000 for BP, and 1.74 million for cholesterol, which represents a 90%, 109%, and 33% increase compared with 2019, respectively (online supplemental table S2).
Supplemental material
Unadjusted prevalence of ABC testing among adults aged ≥18 years with diagnosed diabetes by demographic characteristics, NHIS 2019 and 2021
When stratified by sociodemographic characteristics, blood glucose/A1c testing significantly decreased for older adults (aged 50–64 or ≥65 years), for both men and women, non-Hispanic white adults, adults with a high school education or greater, and regardless of PIR, type of health insurance coverage, except for those with Medicaid for which there was no change, and duration of diabetes (table 1). BP testing significantly decreased for older adults (≥65 years), both men and women, non-Hispanic white and non-Hispanic Asian, high school graduates, adults with a PIR ≥1.0, and regardless of health insurance type, except for those with Medicaid for which there was no change, and duration of diabetes. Cholesterol testing significantly decreased for non-Hispanic white adults and high school graduates, and regardless of health insurance type, except for those with Medicaid for which there was no change.
After adjustment for all covariates, the prevalence of ABC testing in the past year was significantly lower in 2021 vs 2019 (online supplemental table S3). The adjusted prevalence of ABC testing by sociodemographic characteristics was robust. Significant differences in ABC testing between 2019 and 2021 were largely the same in unadjusted versus adjusted estimates when stratified by socioeconomic characteristics.
Supplemental material
In 2021, 21.1% of adults with diabetes reported delaying non-COVID medical care, 15.0% reported not getting medical care when needed due to the pandemic, and 23.5% reported a delay or no medical care (table 2). ABC testing was significantly lower among adults with diabetes who delayed medical care due to the pandemic or did not get non-COVID medical care when needed due to the pandemic.
Unadjusted prevalence (SE) of self-reported disruptions in medical care due to the pandemic and having an ABC test in the past year by disruptions in medical care, NHIS 2021
Adults with diabetes reporting that they delayed getting medical care or did not get medical care due to the pandemic were significantly less likely to have an ABC test in the past year (unadjusted OR=0.50, 95% CI 0.34–0.75 for A1c; OR=0.51, 95% CI 0.30–0.87 for BP; OR=0.51, 95% CI 0.34–0.75 for cholesterol) (data not shown). After stepwise adjustment for (1) age, sex, race/ethnicity, and additionally (2) education, PIR, health insurance, and additionally (3) diabetes duration and diabetes medication, the association remained significant and largely unchanged (fully adjusted OR (aOR)=0.44, 95% CI 0.39–0.68 for A1c; aOR=0.48, 95% CI 0.27–0.85 for BP; aOR=0.48, 95% CI 0.41–0.75 for cholesterol) (figure 1).
Adjusted OR (95% CI) for having an A1c, blood pressure, and cholesterol (ABC) test in the past year associated with delayed or no medical care due to the pandemic among adults aged ≥18 years with diagnosed diabetes, National Health Interview Study (NHIS) 2021.
Conclusion
In a national sample of adults with diagnosed diabetes, the prevalence of ABC testing decreased between 2019 and 2021 which represents the year before and first complete year of the COVID-19 pandemic. In addition, delaying or not receiving medical care due to the pandemic was significantly associated with the lower odds of having an ABC test in the past year, even after adjustment for sociodemographic characteristics, diabetes duration, and diabetes medication use.
Recent research has highlighted the medical care challenges associated with the pandemic for persons with chronic disease.13 14 A UK survey found that 80% of healthcare professionals who deliver diabetes care felt that the COVID-19 pandemic had a moderate to severe impact on their practice ability to provide routine health checks.15 A longitudinal insurance study of healthcare claims in Tokyo found a significant increase in delayed clinic visits among persons with diabetes during the pandemic after adjustment for age, sex, income, and medication.16 A US study conducted in April 2020 determined that 40% of participants’ diabetes-related appointments were cancelled or postponed.7 Another US study found that, among adults with diabetes taking insulin and/or secretagogues, the pandemic was associated with an increase in therapeutic non-adherence and difficulty in testing and monitoring blood glucose.6 Another US study based on laboratory data from Quest Diagnostics reported a reduced A1c testing volume by as much as 66% in March and April 2020 compared with testing volumes between January 2019 and February 2020.4
The results of the present study contribute to the overall literature on poorer diabetes management during the pandemic. An Italian study among adults with well-controlled type 2 diabetes showed that a quarter had a significant worsening of glycemic control during the 8-week country-wide lockdown.17 Among enrollees in the US Taking Control of Your Diabetes Research Registry, 20% reported increases in glucose variability.7 A Turkish study found that patients with diabetic foot ulcers hospitalized during the pandemic had higher A1c levels and more advanced grades of foot ulcers than during the prepandemic period.18 An Iranian study among adults with type 2 diabetes using insulin found a decrease in physician visits, self-monitoring blood glucose, adhering to medication, and performing regular foot care.19 A study conducted in a family medicine clinic of a southeastern US academic health center found that A1c control was significantly worse during May 2020 versus May 2019 among adults with a baseline A1c ≥5.5%.20 Lastly, another US study using Optum Health data showed that adults with type 2 diabetes had large reductions in physician visits and A1c testing early in the pandemic with a rebound to baseline levels by week 48 of the pandemic; A1c levels were similar during the pandemic period versus 2019.5
This is the first nationally representative US study to assess delays in medical care due to the pandemic and its association with diabetes management. Since the study was cross-sectional, causality cannot be implied and a temporal relationship between the independent and dependent variables cannot be determined. The main dependent variables (ABC testing) may be constitutive of the main independent variable (delays in medical care). Although these items are asked in separate questionnaire sections, we can speculate that participants with diabetes may think about their ABC testing in the past year and report delays in medical care based on these routine laboratory visits for diabetes management; persons with diabetes may have better recall of delays in care since they are accustomed to the importance of regular medical care. Unadjusted prevalence estimates are nationally representative of the non-institutionalized US population but do not account for participant characteristics that may affect the outcome (eg, age, race/ethnicity). To account for this, estimates are shown stratified by and adjusted for participant characteristics to provide a more complete picture of differences in ABC testing in 2019 vs 2021. Diabetes management among the NHIS participants was quite high so the OR evaluated relatively small differences in prevalence of ABC testing. Finally, the prevalence of having an ABC test in the past year was high among our sample of adults with diabetes. Since these tests are recommended at least annually for adults with diabetes, there may be social desirability bias in self-reporting an ABC test in the past year.
It is not known if poorer ABC management during the pandemic, even if temporary, may predispose adults with diabetes to greater risks of microvascular and macrovascular complications. Future research is needed to assess whether delays in medical care after pandemic are reduced over time and if, in turn, ABC testing returns to prepandemic levels. As the USA emerges from pandemic-related medical restrictions, some people with diabetes may need additional support to resume routine medical care. Public health messages should emphasize that delaying routine medical care, including ABC testing, will increase the risk of chronic disease complications.
Data availability statement
Data are available in a public, open access repository. Data are publicly available at: https://www.cdc.gov/nchs/nhis/data-questionnaires-documentation.htm.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and was approved by the Ethics Review Board (ERB) of the National Center for Health Statistics (protocol numbers: 2019-09 and 2018-06). Participants gave informed consent to participate in the study before taking part.
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Contributors SSC was involved with the conception, design, and conduct of the study, and the analysis and interpretation of the results. SSC wrote the first draft of the manuscript and JML edited, reviewed, and approved the final version of the manuscript. SSC is the guarantor of this work and, as such, had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Funding This study was supported by a contract from the National Institute of Diabetes and Digestive and Kidney Diseases (Contract No 75N94022F00050).
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.