Increased risk of diabetic ketoacidosis in an Urban, United States, safety-net emergency department in the COVID-19 era

Aims: The incidence of diabetic ketoacidosis (DKA) increased during the COVID-19 pandemic but estimates from low-resource settings are limited. We examined the odds of DKA among emergency department (ED) visits in the Los Angeles County Department of Health Services (DHS) (1) during the COVID-19 pandemic compared to the pre-COVID era, ( 2) without active COVID infections, and (3) stratified by effect modifiers to identify impacted sub-groups. Methods: We estimated the odds of DKA from 400,187 ED visits pre-COVID era (March 2019-Feb 2020) and 320,920 ED visits during the COVID era (March 2020-Feb 2021). Our base model estimated the odds of DKA based on the COVID era. Additional specifications stratified by effect modifiers, controlled for confounders, and limited to visits without confirmed COVID-19 disease. Results: After adjusting for triage acuity and interaction terms for upper respiratory infections and payor, the odds of DKA during the COVID era were 27% higher compared to the pre-COVID era (95%CI 14-41%, p < 0.001). In stratified analyses, visits with private payors had a 112% increased odds and visits with Medicaid had a 20% increased odds of DKA during the COVID era (95%CI 7-36%, p = 0.003). Conclusions: We identified increased odds of DKA during the COVID pandemic, robust to a variety of specifications. We found differential effects by the payor; with increased odds during COVID for privately-insured patients.