Longitudinal shifts in diabetes care delivery during the COVID-19 pandemic: implications for post-pandemic models of chronic disease management

Abstract

Abstract Background The COVID-19 pandemic profoundly disrupted chronic disease management, including diabetes care. While early studies described short-term changes in access to care and laboratory monitoring, the long-term evolution of diabetes care delivery remains poorly understood. This study evaluates four-year longitudinal shifts in healthcare utilization, telemedicine adoption, preventive screening, pharmacologic treatment, and metabolic outcomes before and during the pandemic. Methods We conducted a retrospective cohort study of adults with diabetes or prediabetes receiving care at a single health system from March 2018 to February 2022. Outcomes included primary care engagement, telemedicine use, adherence to ophthalmology and podiatry screening, medication prescribing patterns, HbA1c, BMI, urinary albumin–creatinine ratio (uACR), and mortality. A COVID-19–positive subgroup was analyzed separately. A sensitivity analysis was conducted restricting the cohort to patients with confirmed diabetes mellitus only (HbA1c ≥ 6.5%, n = 2,729). Results Among 2,804 included patients (40.6% Black, 28.0% Hispanic, 19.3% White, 12.1% other), primary care and telemedicine visits increased significantly during the pandemic, while specialist screening for retinopathy and foot care declined substantially. Glycemic control remained stable (6.9% vs. 7.0%, p = 0.343), accompanied by higher prescribing of SGLT2 inhibitors, GLP-1 receptor agonists, and insulin regimens. In the COVID-19–positive subgroup ( n = 180), healthcare utilization doubled, but no significant deterioration in HbA1c, BMI, or uACR was observed. A sensitivity analysis restricted to patients with confirmed diabetes mellitus yielded consistent findings. Conclusions Diabetes care underwent a sustained transformation during the pandemic, characterized by expanded telemedicine use, increased primary care engagement, and marked medication intensification amid persistent screening gaps. Stable glycemic outcomes despite reduced in-person assessments suggest that virtual care and therapeutic adjustment compensated for service disruptions. Post-pandemic care models should integrate permanent telemedicine infrastructure, address persistent gaps in utilization of preventive screening, and develop hybrid systems capable of maintaining continuity during future public health crises. From a policy standpoint, preserving telemedicine reimbursement parity will be essential to sustaining advances in hybrid care.