Health Care Use Prior to Diabetes Diagnosis in Children Before and During COVID.

During COVID-19, healthcare systems reorganized with less ambulatory care and a shift to virtual care (1). There was an increase in diabetic ketoacidosis (DKA), a preventable, life-threatening condition, at diabetes onset in children during COVID-19 (2). DKA at diabetes onset has been attributed to delays in seeking care, missed diagnosis or delays in referral following a primary healthcare contact (3). Reasons for the recent increase in DKA may relate to hesitancy to seek care, providers failing to recognize diabetes symptoms due to cognitive bias focusing on COVID-19, or limitations of virtual care. To explore these potential mechanisms, we compared in-person and virtual primary care and emergency department (ED) visits in children four weeks prior to diagnosis, before and during COVID-19. If increased DKA rates during COVID-19 were due to more missed diagnoses, possibly related to virtual visits, children with DKA would be more likely to have visits during vs. pre-COVID-19. If families were hesitant to seek or unable to access care during COVID-19, then among those with no visits, there would be a higher proportion with DKA.