Coronavirus disease 2019 (COVID-19) has mandated substantive changes in health care provision to minimize the risk of transmission within health care facilities. Introduction of physical distancing, a heightened focus on hand hygiene and workplace cleanliness, and widespread moves to telehealth provision have been observed (1,2). However, little is known about the impact of the pandemic on provision of diabetes care in countries like Australia with universal health care coverage.

Because of mandated changes in clinical environments, we were unable to administer the scheduled Australian National Diabetes Audit (ANDA), a national annual benchmarking audit of diabetes center performance. In lieu of ANDA, we developed and administered the ANDA–COVID-19 service survey in consultation with the National Association of Diabetes Centres. The survey examined seven areas of service delivery: preparedness and ability to adapt to a crisis such as COVID-19; changes made to the health service space; challenges in delivery; changes in access to services from other health professionals and shortages of medications; and the impact on staffing as a result of COVID-19, workload in key clinical areas, and different modes of health care delivery. A health professional from each participating site was invited to complete the survey. Monash Health Human and Research Ethics Committee approved the study as an amendment to ANDA (LNR/17/MonH/123, amendment number AM/35106/MonH-2020-212691). The same survey was administered three times between May and November 2020; this letter reports results from the data collection completed in May 2020, when Australia was experiencing its first wave of COVID-19 infections. In addition, we also present temporal comparisons for centers that provided complete follow-up data at 3 and 6 months using the McNemar test.

Seventy-one diabetes centers across Australia responded (response rate 47% [71 of 152]). These were a mix of primary and secondary care centers (n = 41) and tertiary care centers (n = 30), with 31 centers from metropolitan areas and 40 from regional/rural areas. Metropolitan centers were mainly tertiary care centers (68%), while regional/rural centers were predominantly primary and secondary care centers (78%). No differences were observed for location (metro/regional) (P = 0.07) or service type (primary and secondary/tertiary) (P = 0.186) between responders and nonresponders by χ2 test.

Despite the rapid nature of changes required to mitigate COVID-19 risks, only 32% of respondents reported that their diabetes center was unprepared to deal with the COVID-19–related service changes. Similarly, only 34% of diabetes centers found it difficult to adapt to the required changes. However, 45% reported staffing shortages because of self-isolation or quarantine requirements, and 97% reported staffing concerns about exposure to COVID-19. A total of 73% of centers reported that staff had experienced stress as a result of staffing changes, and 86% reported that staff experienced stress because of work practice changes. For these centers, factors that contributed to these difficulties can be inferred from their responses to subsequent questions (Table 1). These findings suggest that adaption to telehealth and access to other clinical services have impacted staff stress along with staff shortages and additional workplace requirements as a result of COVID-19. Our findings mirror work in other clinical areas that describe heightened psychological distress among clinical staff during the COVID-19 pandemic (3).

The main change to diabetes care reported was widespread uptake of telehealth, with a majority of centers (97%) reporting some degree of difficulty with telehealth setup. This may reflect logistical difficulties across Australia at this time, such as funding difficulties, technological challenges, lack of telehealth training, and limited logistical support to move entire health care workforces to virtual delivery (4). Centers reporting an increase in telehealth appointments commonly saw increases for general diabetes care (84%), diabetes education (80%), and gestational diabetes mellitus (69%).

Changes in hospital and emergency presentations were also seen: 42% of centers reported decreases in inpatient admissions, while 20%, 17%, and 16% reported decreases in presentations for diabetic ketoacidosis, hypoglycemic emergencies, and hyperosmolar hyperglycemic state, respectively. In an analysis of a subset of centers with data for all three survey periods, there were significant increases in inpatient admissions from baseline to 3 months (P = 0.001) and baseline to 6 months (P = 0.007) and for presentations for diabetic ketoacidosis from baseline to 3 months (P = 0.03). While global trends are toward decreased presentations during the pandemic (5), these findings suggest that decreases in presentations were not maintained for the entire 6-month period. This raises concerns about possible undertreatment of serious diabetic complications in the first wave of COVID-19.

This work shows that most Australian diabetes centers were able to respond and adapt to unforeseen changes in service delivery early in the COVID-19 pandemic, despite staff shortages, concern regarding exposure to COVID-19, decreases in emergency presentations, and difficulties with telehealth setup.

This article is part of a special article collection available at https://care.diabetesjournals.org/collection/diabetes-and-COVID19.

Acknowledgments. The authors gratefully acknowledge the input of all participating Australian diabetes centers.

Funding. M.Q. is funded by an Australian Government Research Training Program Domestic Stipend Scholarship.

The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Duality of Interest. S.Z. reports payment to her institution (Monash University) from Eli Lilly Australia Ltd., Boehringer Ingelheim, MSD Australia, AstraZeneca, Novo Nordisk, Sanofi, and Servier for work outside the submitted work. No other potential conflicts of interest relevant to this article were reported.

Author Contributions. M.Q. drafted the manuscript, conducted the analyses, and provided input into data interpretation. A.E. was the senior biostatistician for the project and oversaw the analyses. N.S. managed the process of producing snapshot reports at each time point and provided critical clinical insight. N.W. facilitated the data collection through diabetes centers registered with the National Association of Diabetes Centres and provided critical clinical insight. S.Z. was the primary investigator responsible for conceptualization and management of the study as well as for providing intellectual insight. All authors collaborated to design the survey sent to health care professionals. S.Z. is the guarantor of this work and, as such, had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

1.
Fisher
JR
,
Tran
TD
,
Hammarberg
K
, et al
.
Mental health of people in Australia in the first month of COVID-19 restrictions: a national survey
.
Med J Aust
2020
;
213
:
458
464
2.
Taylor
CB
,
Fitzsimmons-Craft
EE
,
Graham
AK
.
Digital technology can revolutionize mental health services delivery: the COVID-19 crisis as a catalyst for change
.
Int J Eat Disord
2020
;
53
:
1155
1157
3.
Lu
W
,
Wang
H
,
Lin
Y
,
Li
L
.
Psychological status of medical workforce during the COVID-19 pandemic: a cross-sectional study
.
Psychiatry Res
2020
;
288
:
112936
4.
Smith
AC
,
Thomas
E
,
Snoswell
CL
, et al
.
Telehealth for global emergencies: implications for coronavirus disease 2019 (COVID-19)
.
J Telemed Telecare
2020
;
26
:
309
313
5.
Bonora
BM
,
Morieri
ML
,
Avogaro
A
,
Fadini
GP
.
The toll of lockdown against COVID-19 on diabetes outpatient care: analysis from an outbreak area in Northeast Italy
.
Diabetes Care
2020
;
44
:
e18
e21
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