Inside Chronic Diseases: COVID-19 and Diabetes

One of the hard truths about the COVID-19 pandemic is the disproportionate effect it has on people with diabetes, a group that includes more than 34 million in the United States, or roughly 10% of the population.

A study published in The Lancet: Diabetes & Endocrinology in August 2020 found that one-third of hospital COVID-19 deaths occurred among people with diabetes. Getting patients on a statin seems to help, according to a study published in the Journal of the American Heart Association. Researchers at Montefiore Medical Center in Bronx, New York, found that patients with diabetes who were hospitalized with COVID-19 experienced a 12% lower (adjusted) risk of in-hospital mortality if they were taking a statin.

Catherine Rolih, M.D., medical director at Novant Health’s Diabetes Center of Excellence in Winston-Salem, North Carolina, says that diabetes, coronary heart disease, obesity and chronic obstructive pulmonary disease are the top four comorbidities associated with mortality due to COVID-19. Among Novant Health’s patients, diabetes is the most prevalent chronic condition associated with mortality and COVID-19. Rolih tells her patients that the impact of diabetes starts with the immune system. Various organ systems are damaged as a result of poorly controlled diabetes — everything from blood vessels in the eyes to a person’s nerves — and that can lead to a greater likelihood of infection in general.

Paul Sherman, M.D., chief medical officer at Community Health Plan of Washington in Seattle, a nonprofit insurer that markets Medicaid and Medicare managed care plans, says that “providers and insurers face the probability of their patients (and) members with diabetes having a much higher disease burden, worse outcomes and greatly increased healthcare expenses. This will increase the burden on already overtaxed primary care systems and hospitals, including (intensive care units).”

Targeting the right patients for outreach is a good first step, says Robert Gabbay, M.D., Ph.D., chief scientific and medical officer for the American Diabetes Association. The first question to ask: “Which patients with diabetes haven’t been seen in the last six months?” Within that patient population, he recommends focusing resources on patients whose last glycated hemoglobin (A1C) level was greater than 9%. “If their diabetes was poorly controlled then, they really need help. Then staff at provider organizations need to hit the phones to set up video and telephone visits with patients,” Gabbay says. He also suggests providing free delivery of medications to patients.

Priority Health in Grand Rapids, which covers 1 million Michigan residents, embraced this approach early in the pandemic, says James Forshee, M.D., the insurer’s senior vice president of medical affairs and chief medical officer. In addition to eliminating copays and coinsurance on care related to COVID-19, the nonprofit health insurer coordinated with large pharmacy chains in the state to provide free delivery of medications to patients.

A role for payers

Many patients with diabetes have gained weight; Rolih calls it the “COVID 20.” That’s in addition to losing control of their diabetes and high blood pressure and missing screenings for complications. She says payers should maintain coverage for telehealth-based care and expand access to diabetes education for the duration of the pandemic.

Rolih has facts to back up her suggestions. In 2019, participants in Novant Health’s class for people with type 2 diabetes experienced a 1.4% reduction in their A1C levels, exceeding the 1% reduction typically seen with many medications. The health system’s diabetes education program includes an initial 60- to 90-minute assessment between a patient and a diabetes educator. Also included are eight hours in a group class that covers the ADA-specified curriculum. Before the pandemic, there were approximately 10 to 20 people in each in-person group, according to Rolih. Currently, patients participate in the program virtually, and there are fewer participants in each group. More than 2,000 patients completed at least part of Novant Health’s program in 2019. Participation is down this year, presumably due to the pandemic.

However, coverage by payers is iffy at best. Some payers may not continue with telehealth coverage except by arrangement with individual employers, says Rolih. “This may cause many issues, especially since it’s clear COVID-19 will be around for a while, and poor diabetes management is a big risk factor for poor COVID-19 outcomes.”

Education has gone virtual

Andrew Ahmann, M.D., director of the Harold Schnitzer Diabetes Health Center at Oregon Health & Science University, says that provider organizations should be assessed on their ability to track patients with prediabetes and diabetes and direct them to education programs in much the same way they’re held accountable for tracking patients’ cholesterol and blood pressure levels. The CDC defines prediabetes as a serious health condition in which blood sugar levels are higher than normal but not high enough to be diagnosed as type 2 diabetes. About one-third of Americans meet the criteria for prediabetes. Ahmann says managing prediabetes is especially important now because of the pandemic and the vulnerability of people with diabetes to serious cases and death. The pandemic may tip some people with prediabetes into full-blown diabetes because of lack of exercise and less healthful eating habits.

Ahmann says payers should waive copays for prediabetes and diabetes education after the pandemic. Gabbay at the ADA agrees, while praising diabetes educators: “Diabetes education specialists are worth their weight in gold. They’re underappreciated and underreferred to, but they’re a part of helping (patients) deal with the overwhelmingness of (managing their diabetes).”

Ahmann says the diabetes prevention education program at his facility follows the CDC’s National Diabetes Prevention Program. Educators teach the participants about caloric intake, healthy eating, increasing physical activity, managing negative thought patterns, healthy approaches when eating out, managing stress and staying motivated.

During the pandemic, patients have participated in education sessions on Zoom video calls. While class facilitators prefer in-person meetings, attendance and interaction have been successful on Zoom, says Ahmann, a contributor to the ADA’s “Standards of Medical Care in Diabetes,” a compilation of the association’s prevention, screening and treatment recommendations. Three separate groups of between 10 and 20 patients participate virtually in the diabetes prevention program, says Ahmann. Participants are required to upload reports from their insulin pumps, sensors and meters.

The pivot to virtual education for patients with prediabetes and diabetes first required training and certifying diabetes educators on the virtual platforms. During the pandemic, diabetes education has transitioned between virtual and face-to-face formats. For example, in late June, participants were moved to 25% face-to-face and 75% virtual interactions. Ahmann says he expects a hybrid of in-person and online sessions to be the model in the future.

Keeping the virtual platform “as simple as possible for patients” is important, says Ahmann. He’s confident that virtual delivery of diabetes education will increase access to care, while improving patient knowledge and adherence to care plans. Payers are currently covering virtual visits and diabetes education, but Ahmann says he doesn’t know if this will continue after the pandemic.

Aine Cryts is a healthcare writer in the Boston area.