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A qualitative study led by UNC School of Medicine student Lily Hale details what primary care providers and endocrine specialty clinicians reported about their patients’ self-management of diabetes during the pandemic and the effectiveness of providers’ support.

CHAPEL HILL, NC – In a qualitative study published in Frontiers in Clinical Diabetes in Healthcare led by third-year UNC School of Medicine student Lily Hale, primary care providers and endocrine specialty clinicians reported that people with diabetes experienced increased mental health symptoms, increased financial challenges, and positive and negative changes in self-care routines due to COVID-19.

Early in the pandemic, many ambulatory practices halted their in-person visits in favor of virtual appointments. This posed a problem for the management of diabetes, which typically requires routine in-office monitoring, lab testing, and medication management. In the first two months of the pandemic, rates of HbA1c tests fell by as much as 66%. There was concern among the diabetes healthcare community that the pandemic would result in poor diabetes outcomes, as interruptions in appointments and HbA1c testing have previously been associated with worsened glycemic control.

This study was conducted in the context of a larger study, Re-Think the Strip (RTS), which aims to promote the de‐adoption of daily self‐monitoring of blood glucose (SMBG) among non‐insulin treated patients with controlled type 2 diabetes, given the lower utility of this practice. Rethink the Strip involves 20 primary care clinics in North Carolina. Researchers were concerned that decreases in access to A1c test results during the pandemic would lead patients and providers to question the wisdom of de‐adopting SMBG during the pandemic.

To address this concern, researchers conducted interviews with staff members within the existing RTS clinics and expanded the interviews to endocrinologists in North Carolina to obtain a more complete picture of diabetes care during the pandemic. The study population comprised of 24 diabetes clinicians and staff. This included nine primary care clinicians and five primary care ancillary staff members from the existing RTS practices, and 10 endocrine specialty clinicians. Primary care providers focused their discussions on patients with type 2 diabetes, while endocrinologists commented on their experience treating patients with type 1 and type 2 diabetes.

“Disruptions during the pandemic made it logistically challenging to stay active and eat healthily, two key components of diabetes self-management. On top of that, people with diabetes were at a higher risk for severe COVID-19 infection, which created an additional layer of stress,” said Hale.

Primary care and endocrine providers reported patients had increased mental health symptoms, mainly depression, anxiety, and general stress. These symptoms presented challenges to diabetes self-management. Providers noted patients also had trouble affording diabetes supplies, medications, or healthy food due to job or insurance loss or new expenses.

Providers discussed the ways that COVID-19 restrictions disrupted patient self-care routines, including new family responsibilities and changes to diet and exercise habits. People with diabetes struggled to find safe ways to exercise and obtain healthy foods while protecting themselves from the virus.

More endocrine providers than primary care providers noted that for some patients, lockdowns allowed more time for self-management, encouraged healthier routines, and improved patient participation in care.

Primary care and endocrine providers discussed the strategies used to help patients maintain optimal self-care during the pandemic. To offer support, providers focused discussions on lifestyle management and utilized telemedicine to connect with patients. Additionally, endocrine specialty clinicians helped patients access financial assistance programs.

“Our findings emphasize the challenges people with diabetes face daily” said the study’s senior author Laura Young, MD, PhD, associate professor in the Department of Medicine. “Adding additional stressors like a pandemic can amplify the effect of these stressors, although for some patients working from home allowed for more time for self-care. Interviewing patients directly will help us understand the factors that predict whether a specific patient will likely struggle or possibly thrive during times of increased psychological stress.”

Thomas Cameron, MD, a second-year Endocrine fellow in the Department of Medicine, and Katrina Donahue, MD, MPH, professor and vice chair of research in the Department of Family Medicine, as well as various other UNC researchers contributed to this study.