Diabetic Ketoacidosis Admissions Research Articles

The Incidence of Diabetic Ketoacidosis During "Emerging Adulthood" in the USA and Canada: a Population-Based Study.

As children with diabetes transition to adulthood, they may be especially vulnerable to diabetic ketoacidosis (DKA). Cross-national comparisons may inform efforts to avoid this complication. To compare DKA hospitalization rates in the USA and Manitoba, Canada, during the vulnerable years known as "emerging adulthood." Cross-sectional study using inpatient administrative databases in the USA (years 1998-2014) and Manitoba, Canada (years 2003-2013). Individuals aged 12-30years hospitalized with DKA, identified using ICD-9 (USA) or ICD-10 codes (Manitoba). DKA hospitalization rates per 10,000 population by age (with a focus on those aged 15-17 vs. 19-21). Admissions were characterized by gender, socioeconomic status, year of hospitalization, and mortality during hospitalization. The DKA rate was slightly higher in the USA among those aged 15-17: 4.8 hospitalizations/10,000 population vs. 3.7/10,000 in Manitoba. Among those aged 19-21, the DKA hospitalization rate rose 90% in the USA to 9.2/10,000, vs. 23% in Manitoba, to 4.5/10,000. In both the USA and Manitoba, rates were higher among those from poorer areas, and among adolescent girls compared with adolescent boys. DKA admissions rose gradually during the period under study in the USA, but not in Manitoba. In years of "emerging adulthood," the Canadian healthcare system appears to perform better than that of the USA in preventing hospitalizations for DKA. Although many factors likely contribute to this difference, universal and seamless coverage over the lifespan in Canada may contribute.

SAT-138 Predictors and Health Care Expenditures Associated with Recurrent Diabetic Ketoacidosis Admissions in Adults with Type 1 Diabetes

Introduction: Diabetic ketoacidosis (DKA) is a serious complication in patients with type 1 diabetes (T1D). Recurrent DKA admissions have been associated with increased mortality and substantial healthcare costs. In contrast to pediatrics, significantly less attention has been devoted to exploring and addressing recurrent DKA admissions in adults with T1D. We aimed to characterize the adult population of T1D admitted with DKA in Maryland, identify predictors of recurrent DKA admissions, and quantify their associated healthcare costs. Methods: We conducted a cross-sectional study using the Maryland Health Services Cost Review Commission's database, which collects data from all acute care hospitals in the state. We defined DKA using ICD diagnostic codes for ketoacidosis and hyperosmolality in T1D. We selected adult patients (age 20 or above) with T1D who lived in or bordering Maryland and had at least one admission with a primary diagnosis of DKA between January 1, 2012 and December 31, 2017. The predictors analyzed in this study represent patient characteristics from the first DKA admission. The primary outcome was readmission for DKA in the study period. The summation of admission charges was used to calculate DKA healthcare expenditures. Results: There were 6,147 DKA admissions by 3,368 T1D adults admitted in Maryland in the study period. Readmissions occurred in 915 (27%) patients, with 1-3 and >4 readmissions occurring in 700 (76%) and 487 (24%) of these patients, respectively. Overall, the patients admitted with DKA were predominately non-Hispanic (96%) white (45%) or black (45%) men (53%) between the ages 20-39 years old (48%) from areas of low to moderate socioeconomic status (SES). The majority of patients were insured by private (37%) and Medicaid (27%) insurance. The strongest predictors for DKA readmissions were female sex (OR 1.3; 95%CI 1.1-1.6), residing in an area of low SES (OR 1.5; 95% 1.1-2.0), being insured by Medicare (OR 1.7; 95%CI 1.3-2.2), Medicaid (OR 1.5 95%CI 1.2-1.8) or Self-pay/charity (OR 1.5; 95%CI 1.1-1.9), and discharge against medical advice (OR 1.6; 95%CI 1.2-2.3). Older and non-white patients had a reduced odds of readmission. The expenditure of all adult DKA admissions totaled 5.4 billion dollars. While patients who had DKA readmissions consisted of only 27% of those admitted with DKA, their total costs were 59% of these DKA charges at 3.2 billion dollars. Conclusion: There is a high prevalence of recurrent DKA admissions in adults with T1D. Younger patients, women, having non-private insurance and those living in areas of low SES have the highest odds for readmission. Although these patients are a minority, they account for a majority of DKA health expenditures. Further studies are needed to understand drivers of these admissions in order to intervene in this population at high risk for poor outcomes. Supported by a NIH T32 Grant T32 and Saudek Fellowship Award.

MON-LB003 Risk Factors For 30-day Readmission After Diabetic Ketoacidosis Using Nationwide Readmissions Database

Introduction: Nearly 1 in 10 individuals in the United States have Diabetes Mellitus [1]. One potential preventable complication is Diabetic Ketoacidosis (DKA). Better understanding of the risk factors for readmissions of DKA will allow the development and implementation of specific patient-centered interventions to decrease future readmissions. We sought out to determine the 30-day all-cause readmission rate for adults (age > 18) admitted with DKA and the associated predictors of readmissions. Methods: We utilized Agency of Healthcare Research and Quality’s (AHRQ) Health Care Utilization Project’s (HCUP) 2014 Nationwide Readmission Database which includes 14.9 Million discharges across 22 states accounting for 51.2% of the total U.S. population and 49.3% of all U.S. hospitalizations to identify admissions with a DKA related ICD-9 diagnosis (250.10, 250.11, 250.12, and 250.13) associated with both Type 1 and Type 2 Diabetes Mellitus. Applicable admissions were all adults (age > 18)with an index hospitalization between January 1 and November 30, 2014. Patients who died during index admission and those with missing covariates were excluded. All-cause readmission including DKA within 30-days of DKA were analyzed. Statistical analysis was completed with Stata 15 (StataCorp, College Station, TX) with p-values < 0.05 considered statistically significant. A univariate and multivariate analysis of data collected was completed using both odds ratio and chi square test for significance. Predictors for readmission were determined using a multivariate logistic regression model following sequential step-wise elimination of covariates including demographics, comorbidities, hospital characteristics, length of stay (LOS) for index admission, and the modified Elixhauser Comorbidity Index. Results: A total of 66,896 patients met criteria for DKA related index admission. Of which, there was 12,954 (19.36%) all-cause readmissions within 30-days including 7,167 were again for DKA accounting for 55.32% of all readmissions. Multivariate analysis showed that the predictors of 30-day readmission were younger age, (with adults age <35 the highest risk), female, disposition at discharge to short term hospital or home health or against medical advice), from a zip code with the lowest income quartile, Medicare as payer, lengthier LOS, presence of comorbidities, absence of obesity, and presence of renal failure. Conclusion: Almost 1 in 5 (19.36%) patients discharged after a DKA admission were readmitted within 30 days. Physician awareness and development of targeted interventions for individuals with risk factors and high-risk for readmissions may help decrease future morbidity and mortality.

SUN-136 Know Your Patients: Our Experience with DKA in the Suburbs

Background: A variety of precipitating factors and clinical presentations have been identified for Diabetic Ketoacidosis (DKA). Most of the available data is from inner city hospitals which cater to a specific demographic much different from suburban medical centers. This study was performed at a suburban community hospital to analyze disease and demographic characteristics of patients admitted with DKA. Methods: Data was retrospectively collected from electronic medical record review for patients admitted with DKA between January 1, 2017 and January 1, 2018. Data included demographics, medical history, hemoglobin A1C, ancillary laboratory tests and length of hospital stay. Patients who left against medical advice were excluded. For patients with multiple DKA admissions, only the first admission was analyzed. Per hospital policy, all DKA patients were admitted to the medical intensive care unit. Results: 55 hospitalizations met the inclusion criteria involving 50 patients. 5 out of 55 patients had readmissions for DKA. The mean age was 47(range 17-85) years. 52% (n=26) of the population were males. The patient population comprised of 52% (n=26) African Americans, 48 % (n=24) Caucasians and 2%(n=1) other ethnic groups. The most common presenting symptom was nausea/vomiting reported by 48% (n=24) of the study subjects. Lethargy/fatigue, abdominal pain was the second and third most common reported symptom by 30% (n=15) and 26% (n=13) subjects respectively. Other presenting symptoms were polyuria 20%(n=10), polydipsia 18%(n=9), confusion 18%(n=9), weakness 12%(n=6), headache 4%(n=2) and blurring of vision 2%(n=1). The above reported symptoms were not mutually exclusive. The most common precipitant for DKA was medication noncompliance 44%(n=22) which was comparable in African American (11/26) and Caucasian (11/24) subgroups. This was followed by infectious etiologies in 36%(n=18) of the cases. DKA was the first presentation of undiagnosed DM in 10%(n=5) of the subjects. Steroid use was implicated in 4%(n=2) patients. Insulin pump failure was implicated in one subject. No definite cause was identified in 4%(n=2) of the patients. Mean hemoglobin A1C was 12.5% (range 8.2-12.5). The mean acute physiology and chronic health evaluation score (APACHE II) at admission was 15 (range 3-28). There was no mortality in the study population. The average length of hospital stay was found to be 3.7 days. Conclusions: (1) Suburban patients with DKA have subtle differences in characteristics as compared to inner city residents and more studies are required to explore these characteristics. (2) Elevated hemoglobin A1C reflects the need for better long-term glycemic control even in patients reporting good compliance. (3) Medication noncompliance rates appear to be independent of ethnicity. (4) Despite high APACHE scores, DKA remains a low mortality condition.

Association of socioeconomic status and DKA readmission in adults with type 1 diabetes: analysis of the US National Readmission Database

ObjectiveTo identify patient and hospital predictors of recurrent diabetic ketoacidosis (DKA) admissions in adults in the USA with type 1 diabetes, focusing on socioeconomic indicators.Research design and methodsThis cross-sectional study...

Causes and Predictors for 30-DAY Re-Admissions in Adult Patients with Diabetic Ketoacidosis in the United States: a Nationwide Analysis, 2010–2014

We aimed to determine the causes and predictors for 30-day re-admission following a hospitalization for diabetic ketoacidosis (DKA) in the United States. This retrospective cohort study analyzed data from the National Re-admission Database. We included adult patients with a primary discharge diagnosis of DKA, from 2010 to 2014. Our primary objective was to determine the frequency and causes for 30-day re-admission after an index hospitalization for DKA. We also performed multivariate regression analyses using covariates from the index admission to identify predictors for 30-day re-admissions. Among 479,590 admissions for DKA, 58,961 (12.3%) were re-admitted within 30 days. Recurrent DKA represented 40.8% of all-cause re-admissions. In multivariate analysis, end-stage renal disease (odds ratio [OR], 2.13; 95% confidence interval [CI], 2.00 to 2.27; P<.001), Charlson Comorbidity Index ≥3 (OR, 2.49; 95% CI, 2.42 to 2.58; P<.001), discharge against medical advice (OR, 1.97; 95% CI, 1.86 to 2.09; P<.001), and drug use (OR, 1.78; 95% CI, 1.71 to 1.86; P<.001) were the most significant predictors for 30-day re-admission. About 50% of patients were re-admitted within 2 weeks after discharge. In the U.S., about one in every eight patients with DKA is re-admitted within 30 days, with 40.8% representing recurrent DKA episodes. Patients with end-stage renal disease, high comorbidity burden, drug use, and/or leaving against medical advice represented the highest risk group for re-admissions. Future studies with interventions focusing on high-risk population are critically needed. AKI = acute kidney injury; BMI = body mass index; CCI = Charlson Comorbidity Index; CI = confidence interval; DKA = diabetic ketoacidosis; DM1 = type 1 diabetes mellitus; DM2 = type 2 diabetes mellitus; ESRD = end-stage renal disease; ICD-9-CM = International Classification of Diseases, Ninth Edition, Clinical Modification; IQR = interquartile range; LOS = length of stay; NRD = National Re-admission Database; OR = odds ratio.

The incidence of diabetic ketoacidosis during Ramadan fasting: A 10-year single-centre retrospective study

ContextThere has been an increased interest in the potential metabolic derangements and acute complications of diabetes related to the Muslims’ fasting during the month of Ramadan. ObjectivesWe compared the incidence of admissions due to diabetic ketoacidosis (DKA) during Ramadan with the admissions during other months. MethodsThis is a retrospective electronic database and chart review study that included all Muslims who were admitted with DKA to Sheikh Khalifa Medical City in Abu Dhabi, United Arab Emirates. We explored the relationship of admissions to Ramadan over ten years (2005–2014). ResultsThere were 432 episodes of DKA involving 283 patients. Of these, 370 episodes (85.6%) involved 231 patients (81.6%) with type 1 diabetes. The number of admission episodes was not different during Ramadan from the average calendar month [3.6 ± 2.6 (Range 0–15) episodes/month versus 3.3 ± 2.1 (Range 1–7) episodes/month respectively, P = 0.77]. No recurrences of admissions were observed during Ramadan. There was a non-significant numerical tendency for more episodes in March and September (4.6 episodes for both) and fewer episodes in July (2.6 episodes) than other months; P values were 0.06; 0.13, and 0.32 respectively. This seasonality was not related to the month of Ramadan. ConclusionsThe present study confirmed that DKA admissions during Ramadan were not significantly higher than the average monthly admissions over ten years. Seasonality trends were not related to Ramadan.

Increase in chloride from baseline is independently associated with mortality in critically ill children.

To determine if there is an association between mortality and admission chloride levels and/or increases in the chloride level in critically ill children. We performed a retrospective cohort study of all patients admitted to the paediatric intensive care unit (PICU) from January 2014 to December 2015. Patients were excluded for the following reasons: (1) age < 90days or > 18years, (2) admission to the cardiac intensive care unit, (3) no laboratory values upon admission to the PICU, (4) history of end-stage renal disease, (5) a disorder of chloride transport, and (6) admission for diabetic ketoacidosis. The patients were stratified on the basis of admission chloride levels (hypochloraemia, < 96mEq/L; normochloraemia, 96-109mEq/L; and hyperchloraemia, ≥ 110mEq/L) and dichotomised on the basis of an increase in chloride in the first day (< 5mEq/L, ≥ 5mEq/L). Our primary outcome was in-hospital mortality. A total of 1935 patients [55% female, median age 6.3years IQR (1.9-13.4)] were included. The overall mortality was 4% (n = 71) and day 2 AKI occurred in 17% (n = 333. Hypochloraemia, hyperchloraemia, and an increase in serum chloride ≥ 5mEq/L occurred in 2%, 21%, and 12%, respectively. After adjusting for confounders, increase in chloride ≥ 5mEq/L was associated with a 2.3 (95% CI 1.03-5.21) greater odds of mortality. An increase in serum chloride level in the first day of admission is common and an independent risk factor for mortality in critically ill children. Further studies are warranted to identify how chloride disturbances contribute to mortality risk in critically ill children.

Diabetic Ketoacidosis (DKA) at Diabetes Diagnosis in Children (0-18 years) in Ontario, Canada: A Population-Based Retrospective Cohort Study of Health Administrative Data

IntroductionDiabetic ketoacidosis (DKA), a life-threatening complication of diabetes, is the leading cause of mortality and disability in children. The high cost of care for DKA and negative consequences of DKA on child’s health are known; however, the pediatric DKA trends in Ontario were not studied in the last fifteen years.&#x0D; Objectives and ApproachTo examine time trends of the prevalence of pediatric DKA at diabetes diagnosis and socio-demographic characteristics associated with the DKA risk (child’s sex; age; geographic region; rural residence; material deprivation and ethnic concentration) in Ontario, Canada. Person-level de-identified data from the provincial registry for all Ontario children (0-18 years) newly diagnosed with diabetes (type 1 and 2) in 2004-2012 was linked with records in the national discharge abstract database (CIHI DAD) at the Institute for Clinical and Evaluative Sciences (ICES). SAS software (v.9.3) was used for Poisson and logistic regressions.&#x0D; ResultsOf 10,617 children diagnosed with diabetes, 15.5% were diagnosed during a hospital admission for DKA. Prevalence of DKA at diagnosis did not change over the nine-year period (ptrend =0.99). There were statistically significant within-province regional differences in DKA prevalence at diabetes diagnosis, with the highest prevalence in South-Western Ontario (17.2%). Younger children (0-6 years and 7-12 years) were at higher DKA risk than 13-18 years old children (adjusted odds ratio (OR) 2.5 95% CI 2.2-2.8 and 2.1 95% CI 1.9-2.4). DKA at diabetes diagnosis was associated with material deprivation in young children (0-6 years)(OR 1.9 95% CI 1.4-2.5 for “most deprived” versus “least deprived”). In the older group (13-18 years), boys were at higher DKA risk than girls (OR 1.4 95% CI 1.1-1.7).&#x0D; Conclusion/ImplicationsPrevalence of pediatric DKA at diabetes diagnosis in Ontario is among the lowest in the world; however, higher DKA prevalence among children residing in some geographic regions or most deprived neighbourhoods of the province despite the universal access to government-funded health care warrants further research.

Identifying all persons in Wales with type 1 diabetes mellitus using routinely collected linked data

IntroductionType 1 diabetes mellitus (T1DM) is an autoimmune condition characterised by hyperglycaemia, caused by the destruction of insulin producing β-cells in the pancreas. Previous epidemiological population level studies of T1DM and its complications have typically used recorded T1DM diagnoses to determine diabetes status and define cohorts.&#x0D; Objectives and ApproachThe objective was to identify all persons with T1DM in Wales from Primary (~70\% population coverage) and Secondary Care (100% coverage) data held in the Secure Anonymised Information Linkage (SAIL) databank. People with a coded T1DM diagnosis (using Read codes in Primary Care data and International Classification of Disease (ICD10) codes in Secondary Care data), plus either insulin prescribed shortly after diagnosis or a hospital admission for diabetic ketoacidosis were identified as having T1DM. A sub-group of this SAIL e-cohort were validated using a register of persons diagnosed with T1DM in Wales under 15 years old (Brecon cohort).&#x0D; Results18,285 people had a T1DM diagnosis and 10,539 had more T1DM than type 2 diabetes mellitus (T2DM) diagnoses. 6,375 persons were identified with T1DM in Primary Care data using our criteria, with a median diagnosis age of 19.2 years (interquartile range 11.0, 35.5). 47.5\% were diagnosed under 18 years of age. 39.6% of people with a T1DM diagnosis did not have T1DM using our criteria. False positive and negative rates of 4.8% and 4.5% respectively were achieved by comparing persons in the SAIL e-cohort against the Brecon cohort. Clinician estimated false positive and negative rates were 1.4% and 3.9% respectively. The prevalence of T1DM in Wales in 2016 was 0.37% or 11,049 people.&#x0D; Conclusion/ImplicationsOur criteria for identifying people with T1DM was more reliable than using diagnosis codes alone, allowing for a more accurate, efficient and reproducible means of identifying individuals with T1DM for researchers utilising the SAIL databank, and other national health repositories.

Insulin infusion responses in diabetic ketoacidosis alone and with a mixed hypochloremic alkalosis

AimsAlthough diabetic ketoacidosis (DKA) commonly presents as a pure diabetic ketoacidosis (PDKA), up to 30% of cases may be associated with a mixed hypochloremic metabolic alkalosis (HMA). It is unknown whether there is a difference in treatment outcomes between these two entities. We evaluated an insulin infusion protocol (IIP), previously validated for hyperglycemia management in ICU's, for the management of PDKA and HMA. Materials and methodsA retrospective case series/cohort study of 41 DKA admissions was further characterized as having PDKA or HMA. HMA was defined in those having an elevated delta-delta gradient (ΔAG-ΔHCO3) ≥ 5 mmol/L and base excess chloride (BECl) > 2.7 mmol/L. The main outcome measures were times to recovery of glucose levels to ≤250 mg/dL and of anion gap to ≤12 mmol/L. ResultsThe initial serum glucose was 553 ± 265 mg/dL, serum bicarbonate of 8.8 ± 5.1 mmol/L, and venous pH 7.13 ± 0.2). Recovery of glucose occurred in 5 h: 25 min (±3 h:39min), and for anion gap in 11 h:25 min (±6 h:56min). HMA compared with PDKA had a delayed recovery of serum glucose (7 h: 23min ± 3 h: 35min vs. 4 h: 31min ± 3:h:21min, p = 0.017), which was due to the higher initial level of glucose (p = 0.02) rather than level of BECl (p = 0.17). There was no difference in time to anion gap closure between the PDKA and HMA. ConclusionsCorrection of hyperglycemia and acidosis in PDKA as well as in HMA was managed through the IIP. The simultaneous fluid and electrolyte management corrected the hypochloremic alkalosis.

Increasing Hospitalizations for DKA: A Need for Prevention Programs.

Diabetic ketoacidosis (DKA) is a diabetes emergency associated with high morbidity in patients with diabetes (1). In patients with type 1 diabetes, DKA can occur at new onset of diabetes but can also recur due to lack of insulin use and precipitating causes such as infection. DKA is a hallmark of type 1 diabetes; however, DKA is increasingly recognized in patients with type 2 diabetes (2). In contrast to patients with type 1 diabetes who require life-long insulin therapy, most patients with type 2 diabetes who present with DKA can recover insulin secretion and maintain glycemic control with oral antidiabetes medications (3). While inpatient mortality rates for DKA are generally very low, <1% in the U.K. (4) and in the U.S. (5), DKA is the leading cause of mortality among children and young adults with type 1 diabetes, accounting for ∼50% of all deaths in this population (1). In addition, rates vary substantially based on health care setting; a recent analysis conducted in India reported that up to 30% of hospitalized DKA cases result in inpatient death (6). The article by Zhong et al. (7) in this issue of Diabetes Care examines temporal trends of DKA according to the diagnosis of type 1 and type 2 diabetes between the years 1998 and 2013 in the U.K. This report used the Clinical Practice Research Datalink and the Hospital Episode Statistics databases. Overall, the authors found that hospitalizations for DKA increased in the U.K. for patients with both type 1 and type 2 diabetes. Most cases of DKA were associated with type 1 diabetes, but one in five cases of DKA were associated with a patient history of type 2 diabetes. For patients with type 1 diabetes, DKA admissions increased from 1998 to 2007 and then the rate stabilized from 2007 …

HbA1c values and hospital admissions in children and adolescents receiving continuous subcutaneous insulin infusion therapy.

To assess HbA1c values and hospitalization rates before, during and after continuous subcutaneous insulin infusion (CSII) therapy. Demographic and hospitalization data were extracted from 161 individuals with Type 1 diabetes who received continuous subcutaneous insulin infusion (CSII) therapy between 2002 and 2013 at the Leeds Children and Young People's Diabetes Service for those aged < 20 years. The median (range) age at CSII start was 11.9 (1.1-17.6) years. The median (range) follow-up time was 2.3 (0-8.1) years. Random intercept models were used to compare HbA1c values before and during CSII initiation (and after CSII for those who discontinued it). Hospitalization rates were calculated for diabetic ketoacidosis and severe hypoglycaemia. The mean HbA1c concentration decreased by 7 mmol/mol [95% CI 6-8; 0.6% (95% CI 0.5-0.7%)]. For the discontinued group (n=30), mean HbA1c decreased by 5 mmol/mol [95% CI 2-8; 0.4% (95% CI 0.2-0.7%)]. HbA1c returned to pre-CSII start levels at the end of this therapy. Diabetic ketoacidosis admissions increased threefold during CSII compared with before CSII start [2.2 per 100 person-years (95% CI 1.3 to 3.6) vs 7.4 per 100 person-years (95% CI 5.1 to 10.8)] and was highest during the first year of CSII. No difference in severe hypoglycaemia incidence rate was found during CSII compared with the pre-CSII period. Despite significant reductions in HbA1c levels for individuals treated with CSII, improvements are needed to reduce diabetic ketoacidosis hospitalizations for those new to the therapy.

Health Care Utilization and Burden of Diabetic Ketoacidosis in the U.S. Over the Past Decade: A Nationwide Analysis.

Diabetes is one of the most common chronic diseases and a leading cause of morbidity and mortality in the U.S. Although our ability to treat diabetes and its associated complications has significantly improved, presentation with uncontrolled diabetes leading to ketoacidosis remains a significant problem. We aimed to determine the incidence and costs of hospital admissions associated with diabetic ketoacidosis (DKA). We reviewed the National Inpatient Sample database for all hospitalizations in which DKA (ICD-9 codes 250.10, 250.11, 250.12, and 250.13) was the principal discharge diagnosis during 2003-2014 and calculated the population incidence by using U.S. census data. Patients with ICD-9 codes for diabetic coma were excluded because the codes do not distinguish between hypoglycemic and DKA-related coma. We then analyzed changes in temporal trends of incidence, length of stay, costs, and in-hospital mortality by using the Cochrane-Armitage test. There were 1,760,101 primary admissions for DKA during the study period. In-hospital mortality for the cohort was 0.4% (n = 7,031). The total number of hospital discharges with the principal diagnosis of DKA increased from 118,808 in 2003 to 188,965 in 2014 (P < 0.0001). The length of stay significantly decreased from an average of 3.64 days in 2003 to 3.24 days in 2014 (P < 0.01). During this period, the mean hospital charges increased significantly from $18,987 (after adjusting for inflation) per admission in 2003 to $26,566 per admission in 2014. The resulting aggregate charges (i.e., national bill) for diabetes with ketoacidosis increased dramatically from $2.2 billion (after adjusting for inflation) in 2003 to $ 5.1 billion in 2014 (P < 0.001). However, there was a significant reduction in mortality from 611 (0.51%) in 2003 to 620 (0.3%) in 2014 (P < 0.01). Our analysis shows that the population incidence for DKA hospitalizations in the U.S. continues to increase, but the mortality from this condition has significantly decreased, indicating advances in early diagnosis and better inpatient care. Despite decreases in the length of stay, the costs of hospitalizations have increased significantly, indicating opportunities for value-based care intervention in this vulnerable population.

Validation of data from electronic data warehouse in diabetic ketoacidosis: Caution is needed

AimsThis study validated enterprise data warehouse (EDW) data for a cohort of hospitalized patients with a primary diagnosis of diabetic ketoacidosis (DKA). Methods247 patients with 319 admissions for DKA (ICD-9 code 250.12, 250.13, or 250.xx with biochemical criteria for DKA) were admitted to Northwestern Memorial Hospital from 1/1/2010 to 9/1/2013. Validation was performed by electronic medical record (EMR) review of 10% of admissions (N = 32). Classification of diabetes type (Type 1 vs. Type 2) and DKA clinical status were compared between the EMR review and EDW data. ResultsKey findings included incorrect classification of diabetes type in 5 of 32 (16%) admissions and indeterminable classification in 5 admissions. DKA was not present, based on the review, in 11 of 32 (34%) admissions. DKA was not present, based on biochemical criteria, in 15 of 32 (47%) admissions. ConclusionsThis study found that EDW data have substantial errors. Some discrepancies can be addressed by refining the EDW query code, while others, related to diabetes classification and DKA diagnosis, cannot be corrected without improving clinical coding accuracy, consistency of medical record documentation, or EMR design. These results support the need for comprehensive validation of data for complex clinical populations obtained through data repositories such as the EDW.

Access to a youth-specific service for young adults with type 1 diabetes mellitus is associated with decreased hospital length of stay for diabetic ketoacidosis.

Management of type 1 diabetes mellitus in youth with diabetes (YWD) is complex, and glycaemic control often deteriorates during this challenging period. We hypothesise that attendance at a youth-specific diabetes clinic reduces hospital admission rates and length of stay (LOS) for diabetic ketoacidosis (DKA). To assess the impact of a youth-specific diabetes service for YWD on DKA admissions in two adjacent local health districts. A retrospective cohort analysis of admissions for DKA in YWD aged 15-25 years, presenting to four hospitals in Western Sydney in 2011 was performed. Number of admissions, LOS and DKA severity were assessed. Cost was analysed as a function of LOS. Groups were divided by attendance at a youth-specific diabetes service and no record of attendance. There were 55 DKA admissions from 39 patients (median age 20.0 years); the majority of admissions (82%) was YWD not supported by a youth-specific diabetes service. Median LOS was significantly longer in the unsupported group (3.0 vs 1.5 days, P = 0.028). Median pH at presentation in the unsupported group was significantly lower, 7.11 versus 7.23 (P = 0.05). The admission rate was four times greater for those not supported by youth-specific diabetes services, 5.5% compared with 1.6% (P = 0.001). The estimated cost saved by youth-specific services was over $250,000 pa. Lack of access to supported care for YWD during transition from paediatric to adult care has an adverse impact on subsequent DKA admission rates and LOS.

Health outcomes for youth with type 1 diabetes at 18 months and 30 months post transition from pediatric to adult care

AimsTo identify (a) determinants of glycated haemoglobin (HbA1c) at 18 and 30 months following transition in young people with Type 1 diabetes mellitus (T1DM) to a youth-specific diabetes service; and to (b) evaluate the impact of the service on acute admissions with diabetic ketoacidosis (DKA) over a 14-year period. MethodsAn audit of records of youth with T1DM referred from paediatric services to the multidisciplinary transition service at Westmead Hospital, from 2001 to 2012, and followed-up to 2014. ResultsData from 439 adolescents and young adults (Median age: 18) were analysed. The recommended standard of glycaemic control, HbA1c < 7.5% (58 mmol/mol), was achieved by 23% at baseline, 22% at 18-months, and 20% at 30-month. After adjusting for lag time (>3 months) and diabetes duration (>7 years), glycaemic control at first visit predicted subsequent glycaemic control at 18-month and 30-month follow-up. From 2001 to 2014, only 8.6% were lost to follow-up; admissions and readmissions for DKA reduced from 72% (32/47) to 4% (14/340) (p < 0.001). Furthermore, mean length of stay (LOS) significantly decreased from 6.56 to 2.36 days (p < 0.001). ConclusionsContinuing engagement with the multidisciplinary transition service prevented deterioration in HbA1c following transition. Age-appropriate education and regular follow-up prevents DKA admissions and significantly reduced admission LOS.

Trends in Hospital Admission for Diabetic Ketoacidosis in Adults With Type 1 and Type 2 Diabetes in England, 1998-2013: A Retrospective Cohort Study.

This study determined trends in hospital admission for diabetic ketoacidosis (DKA) in adults with type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM) from 1998 to 2013 in England. The study population included 23,246 adults with T1DM and 241,441 adults with T2DM from the Clinical Practice Research Datalink (CPRD) and Hospital Episode Statistics (HES). All hospital admissions for DKA as the primary diagnosis from 1998 to 2013 were identified. Trends in hospital admission for DKA in incidence, length of hospital stay, 30-day all-cause readmission rate, and 30-day and 1-year all-cause mortality rates were determined using joinpoint regression, negative binomial regression, and logistic regression models. For T1DM, the incidence of hospital admission for DKA increased between 1998 and 2007 and remained static until 2013. The incidence in 2013 was higher than that in 1998 (incidence rate ratio 1.53 [95% CI 1.09-2.16]). For T2DM, the incidence increased 4.24% (2.82-5.69) annually between 1998 and 2013. The length of hospital stay decreased over time for both diabetes types (P ≤ 0.0004). Adults with T1DM were more likely to be discharged within 2 days compared with adults with T2DM (odds ratio [OR] 1.28 [1.07-1.53]). The 30-day readmission rate was higher in T1DM than in T2DM (OR 1.61 [1.04-2.50]) but remained unchanged for both diabetes types over time. Trends in 30-day and 1-year all-cause mortality rates were also stable, with no difference by diabetes type. In the previous two decades in England, hospitalization for DKA increased in adults with T1DM and in those with T2DM, and associated health care performance did not improve except decreased length of hospital stay.

Clinical profile of children with diabetic ketoacidosis in fifteen years of management in a Critical Care Unit.

Diabetic ketoacidosis (DKA) is the main cause of morbidity and mortality in children with type 1 diabetes mellitus (T1DM) due to clinical and biochemical alterations associated, cerebral edema as one of the most critical because of the high mortality rates and long-term neurological se quelae. To analyze the clinical characteristics and complications of patients with DKA ad mitted to a pediatric intensive care unit. Retrospective study of DKA patients treated at the Hospital Clínico, Pontificia Universidad Católica de Chile (UPCPUC) between 2000 and 2015. Demographic characteristics, clinical manifestations, biochemical alterations, treatment, complications, and prognosis were assessed. Patients with T1DM onset were compared with those patients already diagnosed with diabetes, analyzing variables according to distribution. 46 DKA events were identified, 67% of them were the first episode of DKA. 66% of patients already diagnosed with diabetes were admitted due to poor adherence to treatment. The main symptoms described were: 63% polydipsia, 56% polyuria, 48% vomiting, 39% weight loss and 35% abdominal pain, and mean blood sugar levels of 522 mg/dL, pH 7.17, and plasma osmolality of 305 mOsm/L. 89% of patients received insulin infusion, and 37% presented hypokalemia. No episodes of cerebral edema or deaths were registered. Most of the DKA admissions were due to T1DM onset. In the group of patients already diagnosed with diabetes, the poor adherence to treatment was the main cause of decompensation. There were no serious complications or deaths associated with DKA management during the studied period. Early diagnosis and proper and standardized treatment contributed to reducing morbidity and mortality in children with DKA.

Antibody-Mediated Extreme Insulin Resistance: A Report of Three Cases

BackgroundType 2 diabetes mellitus is characterized by relative insulin deficiency and insulin resistance. Features suggesting severe insulin resistance include acanthosis nigricans, hyperandrogenism, weight loss, and recurrent hospital admissions for diabetic ketoacidosis. In rare circumstances, hyperglycemia persists despite administration of massive doses of insulin. In these cases, it is important to consider autoimmune etiologies for insulin resistance, such as type B insulin resistance and insulin antibody-mediated extreme insulin resistance, which carry high morbidity and mortality if untreated. Encouragingly, immunomodulatory regimens have recently been published that induce remission at high rates. Methods/ResultsWe describe 3 cases of extreme insulin resistance mediated by anti-insulin receptor autoantibodies or insulin autoantibodies. All cases were effectively treated with an immunomodulatory regimen. ConclusionAlthough cases of extreme insulin resistance are rare, it is important to be aware of autoimmune causes, recognize suggestive signs and symptoms, and pursue appropriate diagnostic evaluation. Prompt treatment with immunomodulators is key to restoring euglycemia in patients with autoimmune etiologies of insulin resistance.