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COVID-19 Disease in People with Diabetes in Scotland: Incidence, Severity and Risk Stratification Using Matched Case-Control and Prospective Cohort Studies
Background: The risks of, and risk factors for, COVID-19 disease associated with diabetes are poorly quantified.
Methods: We identified as cases all those in Scotland with a positive SARS-CoV-2 nucleic acid test in the national laboratory database and anyone else with a death certificate mentioning COVID-19. Seven controls matched for age, sex and general practice were selected per case. Data were linked to the national diabetes register, hospitalisation and critical care unit (CCU) databases. Analyses focused on those with COVID-19 requiring critical care or dying. Analyses were by conditional and unconditional logistic regression.
Findings: 0.3% (n=845) of those with diabetes had developed severe or fatal COVID-19, representing rate ratios of 3.86 (2.74, 5.45) in type 1 and 1.69 (1.56, 1.84) in type 2 diabetes. Rates were almost threefold in the most versus least socioeconomically deprived quintiles of the population. Most (77%) cases had another recognised co-morbidity such as heart or lung disease (OR 2.6). Diabetes specific factors associated with increased risk included; HbA1c odds ratio (OR) >85 mmol/mol versus <53: 1.96(1.55,2.48);p-value <0.001, prior diabetic ketoacidosis: OR 2.44(1.41,4.20);p-value 0.001 and hypoglycaemia hospitalisations: OR 3.28(2.41,4.46);p-value <0.001. Chronic retinal and renal complications were also associated with increased risk. A cross-validated predictive model of severe or fatal disease had a C-statistic of 0.83.
Interpretations: Relative risks of severe or fatal COVID-19 are substantially elevated in both types of diabetes. Risk scores based on prior clinical history should be useful for identifying those with diabetes needing tailored protective measures.
Funding Statement: There was no specific funder for this study.
Declaration of Interests: The authors declare no conflicts of interest.
Ethics Approval Statement: This research was conducted with approval from the Public Benefit Privacy Protection Panel (PBPP ref. 1617- 0147), originally set up under PAC 33/11, with approval from the Scotland A Research Ethics Committee (ref. 11/AL/0225). All datasets were de-identified before analysis.
McGurnaghan, Stuart J and Weir, Amanda and Bishop, Jen and Kennedy, Sharon and Blackbourn, Luke AK and Hutchinson, Sharon and Caparrotta, Thomas M and Mellor, Joseph and Jeyam, Anita and O’Reilly, Joseph E and Wild, Sarah and Hatam, Sara and Höhn, Andreas and Colombo, Marco and Robertson, Chris and Lone, Nazir I. and Murray, Janet and Butterly, Elaine and Petrie, John and Kennon, Brian and McCrimmon, Rory and Lindsay, Robert and Pearson, Ewan and Sattar, Naveed and McKnight, John and Samuel, Ashirwad Philip and Collier, Andrew and McMenamin, Jim and Smith-Palmer, Alison and Goldberg, David and McKeigue, Paul M and Colhoun, Helen M and Group, Public Health Scotland COVID-19 Health Protection Study and Group, Scottish Diabetes Research Network Epidemiology, COVID-19 Disease in People with Diabetes in Scotland: Incidence, Severity and Risk Stratification Using Matched Case-Control and Prospective Cohort Studies (6/29/2020). The Lancet Diabetes & Endocrinology, Volume 9, ISSUE 2, P82-93, February 01, 2021, https://doi.org/10.1016/S2213-8587(20)30405-8, Available at SSRN: https://ssrn.com/abstract=3640560 or http://dx.doi.org/10.2139/ssrn.3640560