Frequency of Ketoacidosis at Diagnosis of Pediatric Type 1 Diabetes Associated With Socioeconomic Deprivation and Urbanization: Results From the German Multicenter DPV Registry

Urban-rural disparities in interfacility transfers for children during COVID-19

PURPOSE

We aimed to identify temporal trends and differences in urban and rural pediatric interfacility transfers (IFTs) before and during the COVID-19 pandemic.

METHODS

We conducted a cross-sectional analysis of IFT among children <18 years from January 2019 to June 2022 using the Pediatric Health Information System. The primary outcome was IFTs from general hospitals to referral children's hospitals. The primary exposure was patient rurality, defined by Rural-Urban Commuting Area codes. We categorized IFTs into medical, surgical, and mental health diagnoses and analyzed trends by month. We calculated observed-to-expected (O-E) ratios of pre-pandemic (March 2019-Feb 2020) transfers compared to pandemic year 1 (March 2020-Feb 2021) and year 2 (March 2021-February 2022) using Poisson modeling.

FINDINGS

Of 419,250 IFTs, 18.8% (n = 78,751) were experienced by rural-residing children. The O-E ratio of IFT in year 1 for urban children was 14.0% (95% confidence interval [CI] 13.8, 14.2) and 14.8% (95% CI 14.4, 15.3) for rural children compared to pre-pandemic (P = .0001). In year 2, transfers rebounded with IFTs for rural-residing children increasing more than urban-residing children (101.7% [95% CI 100.1, 103.4] compared to 90.7% [95% CI 89.0, 90.4], P < .0001). For mental-health indications in year 2, rural transfer ratios were higher than urban, 126.8% (95% CI, 116.7, 137.6) compared to 113.7% (95% CI 109.9, 117.6), P = .0168.

CONCLUSIONS

Pediatric IFTs decreased dramatically during pandemic year 1. In year 2, while medical and surgical transfers continued to lag pre-pandemic volumes, transfers for mental health indications significantly exceeded pre-pandemic levels, particularly among rural-residing children.

Race- and Neighborhood-Related Disparities Spanning the COVID-19 Pandemic: Trajectories of Combined Glycemic Control and BMI in Youth With Diabetes

OBJECTIVE

To use combined glycemic (HbA1c) and BMI z-score (BMIZ) trajectories spanning the coronavirus disease 2019 (COVID-19) pandemic to identify high-risk subgroups of adolescents with diabetes.

RESEARCH DESIGN AND METHODS

Retrospective cohort of adolescents 10-19 years old with type 1 and type 2 diabetes with one or more visits at a large pediatric hospital from January 2018 through February 2020 (prepandemic) and April 2020 through August 2021 (pandemic). Group-based trajectory models were used to identify latent classes of combined BMIZ and HbA1c trajectories. Multinomial logistic regression was used to evaluate predictors of class membership, including Area Deprivation Index (ADI) (socioeconomic status proxy).

RESULTS

The cohort included 1,322 youth with type 1 diabetes (93% White and 7% Black) and 59 with type 2 diabetes (53% Black and 47% White). For type 1 diabetes, six trajectory classes emerged. Black youth were more likely to be in the class with worsening glycemic control and concurrent BMIZ decrease at pandemic onset (relative risk ratio [RRR] vs. White: 3.0 [95% CI 1.3-6.8]) or in the class with progressively worsening glycemic control and obesity (RRR 3.0 [95% CI 1.3-6.8]), while those from the most deprived neighborhoods (RRR ADI tertile 3 vs. 1: 1.9 [95% CI 1.2-2.9]) were more likely to be in the class with stable obesity and glycemic control. For type 2 diabetes, three distinct trajectories emerged, two of which experienced worsening glycemic control with concurrent BMIZ decline at pandemic onset.

CONCLUSIONS

Race and neighborhood deprivation were independently associated with distinct glycemic and BMIZ trajectory classes in youth with diabetes, highlighting persistent and widening disparities associated with the COVID-19 pandemic.