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Feleke BE, Sacre J, Tomic D, Huynh Q, Shaw JE, Magliano DJ. Hospital admissions among people with diabetes: A systematic review. Diabet Med 2024; 41:e15236. [PMID: 37811704 DOI: 10.1111/dme.15236] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 08/25/2023] [Accepted: 10/02/2023] [Indexed: 10/10/2023]
Abstract
OBJECTIVE To describe the reasons for hospital admission among people with diabetes. METHODS We searched Emcare, Embase, Medline and Google Scholar databases for population-based studies describing the causes of hospitalisation among people with diabetes. We included articles published in English from 1980 to 2022. For each study, we determined the most frequent reasons for admission. Studies were assessed for quality using the Newcastle Ottawa quality assessment tool. RESULTS 6920 research articles were retrieved from the search of all sources. After screening the titles and abstracts of these, we reviewed the full text of 135 papers and finally included data from 42 studies. Admissions among the total diabetes were reported in 25 papers: 5 articles reported type 1 diabetes alone, 10 articles reported type 2 diabetes alone and the remaining 2 articles reported type 1 and type 2 diabetes separately. Among the 25 total and type 2 diabetes studies that reported the distribution of hospitalisations in broad categories, cardiovascular diseases (CVD) were the leading cause of admission in 19/25 (76%) of studies. Among the 19 studies that reported CVD admissions by subcategories, ischaemic or coronary heart disease was the leading subtype of CVD in 58% of studies. The other common causes of admissions were infections, renal disorders, endocrine, nutritional, metabolic and immunity disorders. In people with type 1 diabetes, acute diabetes complications were the leading cause of admission. CONCLUSION CVD are the leading cause of hospital admission for people with diabetes, with ischaemic or coronary heart disease as the predominant subtype.
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Affiliation(s)
- Berhanu Elfu Feleke
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Baker Heart and Diabetes Institute, Melbourne, Australia
| | - Julian Sacre
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Baker Heart and Diabetes Institute, Melbourne, Australia
| | - Dunya Tomic
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Baker Heart and Diabetes Institute, Melbourne, Australia
| | - Quan Huynh
- Baker Heart and Diabetes Institute, Melbourne, Australia
| | - Jonathan E Shaw
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Baker Heart and Diabetes Institute, Melbourne, Australia
| | - Dianna J Magliano
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Baker Heart and Diabetes Institute, Melbourne, Australia
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Saadeh NA, Hammouri HM, Zahran DJ. Diabetic Ketoacidosis in Northern Jordan: Seasonal Morbidity and Characteristics of Patients. Diabetes Metab Syndr Obes 2023; 16:3057-3064. [PMID: 37810572 PMCID: PMC10559898 DOI: 10.2147/dmso.s413405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 09/10/2023] [Indexed: 10/10/2023] Open
Abstract
Purpose This study aimed to characterize adult patients admitted with diabetic ketoacidosis (DKA) in northern Jordan. Methods The study examined medical records of patients diagnosed with DKA from January 2015 to April 2018. Variables analyzed included diabetes type, precipitating illness, admission month, hospital length of stay, and biochemical markers. Results Out of 232 admissions with DKA, 70% were diagnosed with type 2 diabetes, and 56% were females. 12% of admissions had a new diagnosis of diabetes, of which 51% had type 2 diabetes. Sepsis (48%), Non-adherence (26%), and diabetic foot infections (18%) were the most encountered precipitating factors for DKA in T1DM. As for T2DM, sepsis (52%), acute coronary syndrome (12%), and pancreatitis (8%) were the most precipitating factors for DKA. High urea levels, high creatinine levels, low phosphorous levels, low hemoglobin levels, and high platelet counts were associated with a longer hospital stay for type 1 diabetes. For type 2 diabetes, low pH on admission, old age, and high Hb A1c within 6 months of admission were factors associated with a prolonged hospital stay. The study found a significant peak of admissions for DKA in both type 1 and type 2 patients in the winter and spring months (Pearson P-value= 0.0013). Conclusion The results of the present study highlight the seasonal variation in the frequency of DKA hospitalizations. It also highlights sepsis as the most frequent precipitating factor of DKA in both type 1 and type 2 DM patients.
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Affiliation(s)
- Nesreen A Saadeh
- Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Hanan M Hammouri
- Department of Mathematics and Statistics, Jordan University of Science and Technology, Irbid, Jordan
| | - Deeb J Zahran
- St. James’s University Hospital, Infectious Diseases Department, Leeds, UK
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Tatovic D, Narendran P, Dayan CM. A perspective on treating type 1 diabetes mellitus before insulin is needed. Nat Rev Endocrinol 2023; 19:361-370. [PMID: 36914759 DOI: 10.1038/s41574-023-00816-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/17/2023] [Indexed: 03/16/2023]
Abstract
Type 1 diabetes mellitus (T1DM) is a progressive autoimmune disease that starts long before a clinical diagnosis is made. The American Diabetes Association recognizes three stages: stage 1 (normoglycaemic and positive for autoantibodies to β-cell antigens); stage 2 (asymptomatic with dysglycaemia); and stage 3, which is defined by glucose levels consistent with the definition of diabetes mellitus. This Perspective focuses on the management of the proportion of individuals with early stage 3 T1DM who do not immediately require insulin; a stage we propose should be termed stage 3a. To date, this period of non-insulin-dependent T1DM has been largely unrecognized. Importantly, it represents a window of opportunity for intervention, as remaining at this stage might delay the need for insulin by months or years. Extending the insulin-free period and/or avoiding unnecessary insulin therapy are important goals, as there is no risk of hypoglycaemia during this period and the adherence burden on patients of glycaemic monitoring and daily adjustments for diet and exercise is substantially reduced. Recognizing the pressing need for guidance on adequate management of children and adults with stage 3a T1DM, we present our perspective on the subject, which needs to be tested in formal and adequately powered clinical trials.
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Affiliation(s)
- Danijela Tatovic
- Diabetes Research Group, Division of Infection and Immunity, Cardiff University School of Medicine, Cardiff, UK
| | - Parth Narendran
- Institute of Immunology and Immunotherapy, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Colin M Dayan
- Diabetes Research Group, Division of Infection and Immunity, Cardiff University School of Medicine, Cardiff, UK.
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4
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Jeyam A, Gibb FW, McKnight JA, O'Reilly JE, Caparrotta TM, Höhn A, McGurnaghan SJ, Blackbourn LAK, Hatam S, Kennon B, McCrimmon RJ, Leese G, Philip S, Sattar N, McKeigue PM, Colhoun HM. Flash monitor initiation is associated with improvements in HbA 1c levels and DKA rates among people with type 1 diabetes in Scotland: a retrospective nationwide observational study. Diabetologia 2022; 65:159-172. [PMID: 34618177 PMCID: PMC8660764 DOI: 10.1007/s00125-021-05578-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 07/20/2021] [Indexed: 12/18/2022]
Abstract
AIMS/HYPOTHESIS We assessed the real-world effect of flash monitor (FM) usage on HbA1c levels and diabetic ketoacidosis (DKA) and severe hospitalised hypoglycaemia (SHH) rates among people with type 1 diabetes in Scotland and across sociodemographic strata within this population. METHODS This study was retrospective, observational and registry based. Using the national diabetes registry, 14,682 individuals using an FM at any point between 2014 and mid-2020 were identified. Within-person change from baseline in HbA1c following FM initiation was modelled using linear mixed models accounting for within-person pre-exposure trajectory. DKA and SHH events were captured through linkage to hospital admission and mortality data. The difference in DKA and SHH rates between FM-exposed and -unexposed person-time was assessed among users, using generalised linear mixed models with a Poisson likelihood. In a sensitivity analysis, we tested whether changes in these outcomes were seen in an age-, sex- and baseline HbA1c-matched sample of non-users over the same time period. RESULTS Prevalence of ever-FM use was 45.9% by mid-2020, with large variations by age and socioeconomic status: 64.3% among children aged <13 years vs 32.7% among those aged ≥65 years; and 54.4% vs 36.2% in the least-deprived vs most-deprived quintile. Overall, the median (IQR) within-person change in HbA1c in the year following FM initiation was -2.5 (-9.0, 2.5) mmol/mol (-0.2 [-0.8, 0.2]%). The change varied widely by pre-usage HbA1c: -15.5 (-31.0, -4.0) mmol/mol (-1.4 [-2.8, -0.4]%) in those with HbA1c > 84 mmol/mol [9.8%] and 1.0 (-2.0, 5.5) mmol/mol (0.1 [-0.2, 0.5]%) in those with HbA1c < 54 mmol/mol (7.1%); the corresponding estimated fold change (95% CI) was 0.77 (0.76, 0.78) and 1.08 (1.07, 1.09). Significant reductions in HbA1c were found in all age bands, sexes and socioeconomic strata, and regardless of prior/current pump use, completion of a diabetes education programme or early FM adoption. Variation between the strata of these factors beyond that driven by differing HbA1c at baseline was slight. No change in HbA1c in matched non-users was observed in the same time period (median [IQR] within-person change = 0.5 [-5.0, 5.5] mmol/mol [0.0 (-0.5, 0.5)%]). DKA rates decreased after FM initiation overall and in all strata apart from the adolescents. Estimated overall reduction in DKA event rates (rate ratio) was 0.59 [95% credible interval (CrI) 0.53, 0.64]) after FM vs before FM initiation, accounting for pre-exposure trend. Finally, among those at higher risk for SHH, estimated reduction in event rates was rate ratio 0.25 (95%CrI 0.20, 0.32) after FM vs before FM initiation. CONCLUSIONS/INTERPRETATION FM initiation is associated with clinically important reductions in HbA1c and striking reduction in DKA rate. Increasing uptake among the socioeconomically disadvantaged offers considerable potential for tightening the current socioeconomic disparities in glycaemia-related outcomes.
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Affiliation(s)
- Anita Jeyam
- MRC Institute of Genetics and Cancer (formally known as Institute of Genetic and Molecular Medicine), University of Edinburgh, Edinburgh, UK.
| | - Fraser W Gibb
- Edinburgh Centre for Endocrinology & Diabetes, Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | - Joseph E O'Reilly
- MRC Institute of Genetics and Cancer (formally known as Institute of Genetic and Molecular Medicine), University of Edinburgh, Edinburgh, UK
| | - Thomas M Caparrotta
- MRC Institute of Genetics and Cancer (formally known as Institute of Genetic and Molecular Medicine), University of Edinburgh, Edinburgh, UK
| | - Andreas Höhn
- MRC Institute of Genetics and Cancer (formally known as Institute of Genetic and Molecular Medicine), University of Edinburgh, Edinburgh, UK
| | - Stuart J McGurnaghan
- MRC Institute of Genetics and Cancer (formally known as Institute of Genetic and Molecular Medicine), University of Edinburgh, Edinburgh, UK
| | - Luke A K Blackbourn
- MRC Institute of Genetics and Cancer (formally known as Institute of Genetic and Molecular Medicine), University of Edinburgh, Edinburgh, UK
| | - Sara Hatam
- MRC Institute of Genetics and Cancer (formally known as Institute of Genetic and Molecular Medicine), University of Edinburgh, Edinburgh, UK
| | - Brian Kennon
- Queen Elizabeth University Hospital, Glasgow, UK
| | - Rory J McCrimmon
- Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | | | - Sam Philip
- Grampian Diabetes Research Unit, Diabetes Centre, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Naveed Sattar
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Paul M McKeigue
- Usher Institute of Population Health Sciences and Informatics, Centre for Population Health Sciences, School of Molecular, Genetic and Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Helen M Colhoun
- MRC Institute of Genetics and Cancer (formally known as Institute of Genetic and Molecular Medicine), University of Edinburgh, Edinburgh, UK
- Public Health, NHS Fife, Kirkcaldy, UK
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Bak JCG, Mul D, Serné EH, de Valk HW, Sas TCJ, Geelhoed-Duijvestijn PH, Kramer MHH, Nieuwdorp M, Verheugt CL. DPARD: rationale, design and initial results from the Dutch national diabetes registry. BMC Endocr Disord 2021; 21:122. [PMID: 34134677 PMCID: PMC8207714 DOI: 10.1186/s12902-021-00782-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 05/18/2021] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Treatment of diabetes mellitus has majorly improved over the past century, however, the disease burden is high and its prevalence still expanding. Further insight in the diabetes population is imperative to improve the quality of diabetes care by enhancement of knowledge-based diabetes management strategies. To this end, in 2017 a Dutch nationwide consortium of diabetologists, paediatric endocrinologists, and diabetes patients has founded a national outpatient diabetes care registry named Dutch Pediatric and Adult Registry of Diabetes (DPARD). We aim to describe the implementation of DPARD and to provide an overview of the characteristics of patients included during the first 2 years. METHODS For the DPARD cohort with long-term follow-up of observational nature, hospital data are gathered directly from electronic health records and securely transferred and stored. DPARD provides weekly updated clinical information on the diabetes population care on a hospital-level benchmarked against the national average. RESULTS Between November 2017 and January 2020, 20,857 patients were included from 8 (11%) Dutch hospitals with a level of care distribution representative of all diabetic outpatients in the Netherlands. Among patients with known diabetes type, 41% had type 1 diabetes, 51% type 2 diabetes, and 8% had diabetes due to other causes. Characteristics of the total patient population were similar to patients with unknown diabetes classification. HbA1c levels decreased over the years, while BMI levels showed an increase over time. CONCLUSIONS The national DPARD registry aims to facilitate investigation of prevalence and long-term outcomes of Dutch outpatients with diabetes mellitus and their treatment, thus allowing for quality improvement of diabetes care as well as allowing for comparison of diabetes care on an international level.
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MESH Headings
- Adolescent
- Adult
- Aged
- Aged, 80 and over
- Biomarkers/blood
- Blood Glucose/analysis
- Child
- Child, Preschool
- Diabetes Mellitus, Type 1/epidemiology
- Diabetes Mellitus, Type 1/metabolism
- Diabetes Mellitus, Type 1/pathology
- Diabetes Mellitus, Type 1/prevention & control
- Diabetes Mellitus, Type 2/epidemiology
- Diabetes Mellitus, Type 2/metabolism
- Diabetes Mellitus, Type 2/pathology
- Diabetes Mellitus, Type 2/prevention & control
- Female
- Follow-Up Studies
- Humans
- Hypoglycemic Agents/therapeutic use
- Male
- Middle Aged
- Netherlands/epidemiology
- Prognosis
- Registries/statistics & numerical data
- Young Adult
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Affiliation(s)
- Jessica C G Bak
- Department of Vascular Medicine, Amsterdam University Medical Centres, location AMC, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands
- Dutch Institute for Clinical Auditing, Leiden, The Netherlands
| | - Dick Mul
- Diabeter, Centre for paediatric and adult diabetes care and research, Rotterdam, The Netherlands
| | - Erik H Serné
- Department of Vascular Medicine, Amsterdam University Medical Centres, location AMC, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands
| | - Harold W de Valk
- Department of Internal Medicine, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Theo C J Sas
- Diabeter, Centre for paediatric and adult diabetes care and research, Rotterdam, The Netherlands
- Department of Pediatric Endocrinology, Erasmus Medical Centre, Rotterdam, The Netherlands
| | | | - Mark H H Kramer
- Department of Vascular Medicine, Amsterdam University Medical Centres, location AMC, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands
| | - Max Nieuwdorp
- Department of Vascular Medicine, Amsterdam University Medical Centres, location AMC, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands
| | - Carianne L Verheugt
- Department of Vascular Medicine, Amsterdam University Medical Centres, location AMC, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands.
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Bak JCG, Serné EH, Kramer MHH, Nieuwdorp M, Verheugt CL. National diabetes registries: do they make a difference? Acta Diabetol 2021; 58:267-278. [PMID: 32770407 PMCID: PMC7907019 DOI: 10.1007/s00592-020-01576-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 07/07/2020] [Indexed: 12/16/2022]
Abstract
AIMS The global epidemic of diabetes mellitus continues to expand, including its large impact on national health care. Measuring diabetes outcomes and their causes of variation highlights areas for improvement in care and efficiency gains; large registries carry this potential. By means of a systematic review, we aimed to give an overview of national registries worldwide by quantifying their data and assessing their influence on diabetes care. METHODS The literature on MEDLINE up to March 31, 2020, was searched, using keywords diabetes mellitus, national, registry, registration, and/or database. National disease-specific registries from corresponding articles were included. Database characteristics and clinical variables were obtained. All registries were compared to the ICHOM standard set of outcomes. RESULTS We identified 12 national clinical diabetes registries, comprising a total of 7,181,356 diabetic patients worldwide. Nearly all registries recorded weight, HbA1c, lipid profile, and insulin treatment; the recording of other variables varied to a great extent. Overall, registries corresponded fairly well with the ICHOM set. Most registries proved to monitor and improve the quality of diabetes care using guidelines as a benchmark. The effects on national healthcare policy were more variable and often less clear. CONCLUSIONS National diabetes registries confer clear insights into diagnostics, complications, and treatment. The extent to which registries influenced national healthcare policy was less clear. A globally implemented standard outcome set has the potential to improve concordance between national registries, enhance the comparison and exchange of diabetes outcomes, and allocate resources and interventions where most needed.
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Affiliation(s)
- Jessica C G Bak
- Department of Vascular Medicine, Amsterdam UMC, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Erik H Serné
- Department of Vascular Medicine, Amsterdam UMC, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Mark H H Kramer
- Department of Vascular Medicine, Amsterdam UMC, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Max Nieuwdorp
- Department of Vascular Medicine, Amsterdam UMC, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Carianne L Verheugt
- Department of Vascular Medicine, Amsterdam UMC, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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Moulson H, Sanders S, Coppin S, Meyrick J. What psychosocial interventions work to reduce hospital admissions in people with diabetes and elevated HbA 1c : a systematic review of the evidence. Diabet Med 2020; 37:1280-1290. [PMID: 32443172 DOI: 10.1111/dme.14332] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/18/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Diabetes is a chronic condition that can lead to devastating complications if not managed effectively. Individuals with elevated HbA1c are at higher risk of developing complications resulting in diabetes-related hospital admissions, an additional pressure and expense for healthcare systems. AIM To systematically review evidence of the effectiveness of psychosocial interventions among individuals with elevated HbA1c , as indicated by hospital admissions. METHODS Electronic databases (MEDLINE, PsychINFO, CINAHL, AMED, Embase and Scopus) were used to identify studies systematically. Studies were screened against eligibility criteria and included if they evaluated the effectiveness of a psychosocial intervention on diabetes-related hospital admissions in individuals with elevated HbA1c . Risk of bias was assessed using the Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies, and a narrative synthesis was conducted. RESULTS Of 15 362 studies, five were included in the review. Psychosocial interventions were found to significantly reduce diabetes-related hospital admissions in four of these studies and interventions involving psychotherapy in particular were found to reduce admissions. The methodological quality of studies ranged from weak to moderate, due to lack of blinding, weak study design and issues with withdrawals and drop-outs. CONCLUSIONS Psychosocial interventions may reduce diabetes-related hospital admissions in individuals with elevated HbA1c ; however, due to variability in methodological rigour, the conclusion remains tentative. Further research targeting this group, particularly within the adult population, is recommended. (PROSPERO registration number: CRD42019133456).
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Affiliation(s)
- H Moulson
- Department of Psychology, University of West England, Bristol, UK
| | - S Sanders
- Department of Psychology, University of West England, Bristol, UK
| | - S Coppin
- Department of Psychology, University of West England, Bristol, UK
| | - J Meyrick
- Department of Psychology, University of West England, Bristol, UK
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Yamanouchi L, Leong WB, Lloyd J, Smith A, Davies P, Basu A. Using survival modelling as a composite measure of outcome to demonstrate insulin pump therapy effectiveness in type 1 diabetes. PRACTICAL DIABETES 2020. [DOI: 10.1002/pdi.2264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
| | - Wen Bun Leong
- Sandwell and West Birmingham Hospitals NHS TrustBirmingham UK
| | - Joanne Lloyd
- Sandwell and West Birmingham Hospitals NHS TrustBirmingham UK
| | - Angela Smith
- Sandwell and West Birmingham Hospitals NHS TrustBirmingham UK
| | - Peter Davies
- Sandwell and West Birmingham Hospitals NHS TrustBirmingham UK
| | - Ansu Basu
- Sandwell and West Birmingham Hospitals NHS TrustBirmingham UK
- University of BirminghamEdgbaston Birmingham UK
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Russel-Szymczyk M, Valov V, Savova A, Manova M. Cost-effectiveness of insulin degludec versus insulin glargine U100 in adults with type 1 and type 2 diabetes mellitus in Bulgaria. BMC Endocr Disord 2019; 19:132. [PMID: 31796048 PMCID: PMC6891960 DOI: 10.1186/s12902-019-0460-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 11/22/2019] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND This analysis evaluates the cost-effectiveness of insulin degludec (degludec) versus biosimilar insulin glargine U100 (glargine U100) in patients with type 1 (T1DM) and type 2 diabetes mellitus (T2DM) in Bulgaria. METHODS A simple, short-term model was used to compare the treatment costs and outcomes associated with hypoglycaemic events with degludec versus glargine U100 in patients with T1DM and T2DM from the perspective of the Bulgarian National Health Insurance Fund. Cost-effectiveness was analysed over a 1-year time horizon using data from clinical trials. The incremental cost-effectiveness ratio (ICER) was the main outcome measure. RESULTS In Bulgaria, degludec was highly cost-effective versus glargine U100 in people with T1DM and T2DM. The ICERs were estimated to be 4493.68 BGN/quality-adjusted life year (QALY) in T1DM, 399.11 BGN/QALY in T2DM on basal oral therapy (T2DMBOT) and 7365.22 BGN/QALY in T2DM on basal bolus therapy (T2DMB/B), which are below the cost-effectiveness threshold of 39,619 BGN in Bulgaria. Degludec was associated with higher insulin costs in all three patient groups; however, savings from a reduction in hypoglycaemic events with degludec versus glargine U100 partially offset these costs. Sensitivity analysis demonstrated that the results were robust and largely insensitive to variations in input parameters. At a willingness-to-pay threshold of 39,619 BGN/QALY, the probability of degludec being cost-effective versus glargine U100 was 60.0% in T1DM, 99.4% in T2DMBOT and 91.3% in T2DMB/B. CONCLUSION Degludec is a cost-effective alternative to biosimilar glargine U100 for patients with T1DM and T2DM in Bulgaria. Degludec could be of particular benefit to those patients suffering recurrent hypoglycaemia and those who require additional flexibility in the dosing of insulin.
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Affiliation(s)
| | | | | | - Manoela Manova
- Faculty of Pharmacy, Medical University Sofia, Sofia, Bulgaria
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10
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Wolf RA, Haw JS, Paul S, Spezia Faulkner M, Cha E, Findley MK, Khan F, Markley Webster S, Alexopoulos AS, Mehta K, Alfa DA, Ali MK. Hospital admissions for hyperglycemic emergencies in young adults at an inner-city hospital. Diabetes Res Clin Pract 2019; 157:107869. [PMID: 31560962 PMCID: PMC6914263 DOI: 10.1016/j.diabres.2019.107869] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 08/18/2019] [Accepted: 09/23/2019] [Indexed: 12/16/2022]
Abstract
AIMS There is limited information characterizing young adults (18-35 years) (YA) with diabetes, especially those admitted for hyperglycemic emergencies. The study aims were to examine associations of patient-level characteristics with hyperglycemic emergency hospitalization and to identify variations based on diabetes type and glycemic control. METHODS We conducted retrospective analysis of 273 YA admitted to an inner-city hospital with diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic nonketotic syndrome (HHS). T-tests, Chi-Square tests, and ANOVA identified differences in demographics, diabetes history, clinical indicators, complications/comorbidities, and hospital admission stratified separately by diabetes type (1 vs 2) and admission HbA1c < 9% (75 mmol/mol), ≥9% to 12% (108 mmol/mol), ≥12%). RESULTS Mean admission HbA1c was 12.4% (112 mmol/ml). HbA1c was ≥9.0% for 90.5%. The main DKA/HHS trigger was medication nonadherence (57.9%), with 35.6% presenting with new-onset type 2 diabetes. Only 3.7% utilized outpatient diabetes clinics, 38.8% were re-hospitalized within the year, and 69% lacked insurance. Diabetes complications (44.7%) and psychiatric co-morbidities (35.5%) were common. Significantly more YA with type 1 diabetes had insurance, whereas YA with type 2 diabetes had higher admission HbA1c. YA with HbA1c ≥12% were more likely to be Black and lack insurance. CONCLUSIONS YA hospitalized for DKA/HHS in an inner-city hospital tended to have severely uncontrolled diabetes. Many already had comorbidities and diabetes complications, high use of acute care services and low use of diabetes specialty services. YA characteristics varied by diabetes type and HbA1c. Overall, a substantial percentage lacked insurance, potentially impacting healthcare utilization patterns and medication adherence, and leading to DKA/HHS admissions.
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Affiliation(s)
- Rachel A Wolf
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, United States.
| | - J Sonya Haw
- School of Medicine, Emory University, Atlanta, GA, United States
| | - Sudeshna Paul
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, United States
| | - Melissa Spezia Faulkner
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, United States; School of Nursing, Georgia State University, Atlanta, GA, United States
| | - EunSeok Cha
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, United States; Chungnam National University, College of Nursing, Daejeon, South Korea
| | - M K Findley
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, United States
| | - Farah Khan
- School of Medicine, Emory University, Atlanta, GA, United States; Division of Metabolism, Endocrinology and Nutrition, University of Washington, Seattle, WA, United States
| | | | | | - Komal Mehta
- School of Medicine, Emory University, Atlanta, GA, United States
| | - David A Alfa
- School of Medicine, Emory University, Atlanta, GA, United States
| | - Mohammed K Ali
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, United States; Rollins School of Public Health, Emory University, Atlanta, GA, United States
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Brandstaetter E, Bartal C, Sagy I, Jotkowitz A, Barski L. Recurrent diabetic ketoacidosis. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2019; 63:531-535. [PMID: 31365631 PMCID: PMC10522260 DOI: 10.20945/2359-3997000000158] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 03/17/2019] [Indexed: 11/23/2022]
Abstract
OBJECTIVE The purpose of this study is to examine risk factors for recurrence of diabetic ketoacidosis and determine interventions to prevent future admissions. MATERIALS AND METHODS Review article. RESULTS Recurrent diabetic ketoacidosis is a serious and not uncommon health problem. Diabetic ketoacidosis is associated with severe morbidity and mortality and hospital admissions due to this problem constitute a serious economic burden on the healthcare system. Younger age at diabetic ketoacidosis onset, poor baseline glycemic control and elevated HbA1C, patient comorbidities, depression, alcohol or substance abuse, particularly active cocaine use, have been associated with recurrent diabetic ketoacidosis. In addition, socioeconomic factors (such as ethnic minority status, use of public health insurance and underinsurance), psychosocial, economic, and behavioral factors (including financial constraint, stretching a limited insulin supply, and homelessness) have been all reported to be associated with readmission among diabetic ketoacidosis patients. CONCLUSIONS Identifying high-risk patients during the first diabetic ketoacidosis admission and performing relevant interventions (repeated instructions of insulin use, social help and involvement of family members in medical treatment, collaboration with the patient's primary care physician in order to establish a close and frequent follow up program) may help prevent future admissions. Further studies need to take place to determine whether early interventions with those factors prevent future admissions.
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Affiliation(s)
- Evgenia Brandstaetter
- Department of Internal Medicine FSoroka University Medical CenterBeer-ShevaIsraelDepartment of Internal Medicine F, Soroka University Medical Center, Beer-Sheva, Israel
| | - Carmi Bartal
- Department of Internal Medicine ESoroka University Medical CenterBeer-ShevaIsraelDepartment of Internal Medicine E, Soroka University Medical Center, Beer-Sheva, Israel
| | - Iftach Sagy
- Department of Internal Medicine FSoroka University Medical CenterBeer-ShevaIsraelDepartment of Internal Medicine F, Soroka University Medical Center, Beer-Sheva, Israel
- Clinical Research CenterSoroka University Medical CenterBeer ShevaIsraelClinical Research Center, Soroka University Medical Center, Beer Sheva, Israel
| | - Alan Jotkowitz
- Department of Internal Medicine FSoroka University Medical CenterBeer-ShevaIsraelDepartment of Internal Medicine F, Soroka University Medical Center, Beer-Sheva, Israel
| | - Leonid Barski
- Department of Internal Medicine FSoroka University Medical CenterBeer-ShevaIsraelDepartment of Internal Medicine F, Soroka University Medical Center, Beer-Sheva, Israel
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12
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Doubova SV, Ferreira-Hermosillo A, Pérez-Cuevas R, Barsoe C, Gryzbowski-Gainza E, Valencia JE. Socio-demographic and clinical characteristics of type 1 diabetes patients associated with emergency room visits and hospitalizations in Mexico. BMC Health Serv Res 2018; 18:602. [PMID: 30075779 PMCID: PMC6091092 DOI: 10.1186/s12913-018-3412-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Accepted: 07/23/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND To describe the demographic and clinical characteristics of Type 1 diabetes (T1D) patients affiliated with the Mexican Institute of Social Security (IMSS) and ascertain the socio-demographic and clinical risk factors associated with emergency room (ER) visits and diabetes-related hospitalizations. METHODS We conducted secondary data analysis of a cross-sectional study. The study included T1D patients 18 years of age and older who in 2016 attended follow-up visits at the endocrinology department of two IMSS tertiary care hospitals in Mexico City. The study variables included demographics, acute and chronic complications, and healthcare services utilization. Multiple Poisson and negative binomial regressions served to determine the association between the study covariates and the dependent variables: ER visits and diabetes-related hospitalizations. RESULTS The study included 192 patients, of which 29.2% were men; average age was 32.3 years, with only 13.6% controlled (glycosylated hemoglobin (HbA1C) < 7%); the mean HbA1C was 9.2, and 64.6% presented chronic complications. During 2016, 39.0% visited ER services, and 33.9% were hospitalized. The common risk factors for ER visits and hospitalization were older age at the beginning of diabetes, severe acute complications, chronic microvascular and macrovascular complications, and other comorbidities. Female sex, high school education, depression, and repeated visits to the endocrinologist were associated with ER visits, whereas active smoking and the interaction between diabetes duration > 10 years and HbA1c > 9.0% were additional risk factors for hospitalization. CONCLUSION The poor clinical conditions of T1D patients contribute to explain the escalating demand for health services for diabetes patients at the IMSS. The identification of risk factors enables focalizing interventions to improve the health outcomes of T1D patients and reduce the proportion of ER visits and hospital admissions.
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Affiliation(s)
- Svetlana V. Doubova
- Epidemiology and Health Services Research Unit, CMN Siglo XXI, Mexican Institute of Social Security, Av. Cuauhtemoc 330, Col. Doctores, 06720 Mexico City, Mexico
| | - Aldo Ferreira-Hermosillo
- Unidad de Investigación en Endocrinología Experimental, Hospital de Especialidades del CMN siglo XXI, Mexico City, Mexico
| | - Ricardo Pérez-Cuevas
- Center for Health Systems Research, National Institute of Public Health, Universidad No. 655 Colonia Santa María Ahuacatitlán, 62100 Cuernavaca, Mexico
| | - Casper Barsoe
- Diabetes Health Economics & Reimbursement, Medtronic, Devonshire St 18000, Northridge, CA 91325-1219 USA
| | | | - Juan E. Valencia
- Diabetes Health Economics & Reimbursement, Medtronic, NW 41st Street 9850, Miami, FL 33178 USA
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13
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Abstract
This article was originally published with errors that were introduced during the editing process. The corrected version of this article appears below.
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Affiliation(s)
- Daniel J Rubin
- Section of Endocrinology, Diabetes, and Metabolism, School of Medicine, Temple University, 3322 N. Broad ST., Ste 205, Philadelphia, PA, 19140, USA.
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14
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Zhu B, Bu L, Zhang M, Gusdon AM, Zheng L, Rampersad S, Li J, Qu S. HbA 1c as a Screening tool for Ketosis in Patients with Type 2 Diabetes Mellitus. Sci Rep 2016; 6:39687. [PMID: 28009017 PMCID: PMC5180185 DOI: 10.1038/srep39687] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 11/25/2016] [Indexed: 12/21/2022] Open
Abstract
Ketosis in patients with type 2 diabetes mellitus (T2DM) is overlooked due to atypical symptoms. The objective of this study is to evaluate the value of hemoglobin A1c (HbA1c) as a screening tool for ketosis in T2DM patients. This retrospective study consisted of 253 T2DM patients with ketosis at Shanghai 10th People’s Hospital during a period from January 1, 2011 to June 30, 2015. A control group consisted of 221 T2DM patients without ketosis randomly selected from inpatients during the same period. Receiver operating characteristic curve (ROC) analysis was used to examine the sensitivity and specificity of HbA1c as an indicator for ketosis. Higher HbA1c levels were correlated with ketosis. In patients with newly diagnosed T2DM, the area under the curve (AUC) was 0.832, with 95% confidence interval (CI) 0.754–0.911. The optimal threshold was 10.1% (87 mmol/mol). In patients with previously diagnosed T2DM, the AUC was 0.811 (95% CI: 0.767–0.856), with an optimal threshold of 8.6% (70 mmol/mol). HbA1c is a potential screening tool for ketosis in patients with T2DM. Ketosis is much more likely with HbA1c values at ≥10.1% in patients with newly diagnosed T2DM and HbA1c values at ≥8.6% in patients with previously diagnosed T2DM.
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Affiliation(s)
- Bing Zhu
- Department of Endocrinology and Metabolism, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Le Bu
- Department of Endocrinology and Metabolism, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Manna Zhang
- Department of Endocrinology and Metabolism, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Aaron M Gusdon
- Department of Neurology and Neuroscience, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, United States of America
| | - Liang Zheng
- Heart, Lung and Blood Vessel Center, Tongji University, Shanghai, China
| | - Sharvan Rampersad
- Department of Endocrinology and Metabolism, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Jue Li
- Heart, Lung and Blood Vessel Center, Tongji University, Shanghai, China
| | - Shen Qu
- Department of Endocrinology and Metabolism, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China.,Department of Endocrinology, School of Medicine, Nanjing Medical University, Nanjing, China
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15
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Bradford AL, Crider CC, Xu X, Naqvi SH. Predictors of Recurrent Hospital Admission for Patients Presenting With Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar State. J Clin Med Res 2016; 9:35-39. [PMID: 27924173 PMCID: PMC5127213 DOI: 10.14740/jocmr2792w] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2016] [Indexed: 11/11/2022] Open
Abstract
Background Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are two serious, preventable complications of diabetes mellitus. Analysis of variables associated with recurrent DKA and HHS admission has the potential to improve patient outcomes by identifying possible areas for intervention. The aim of this study was to evaluate potential predictors of recurrent DKA or HHS admission. Methods This was a retrospective case-control study of 367 patients presenting during a 5-year period with DKA or HHS at a US tertiary academic medical center. Six potential readmission risk factors identified via literature review were coded as “1” if present and “0” if absent. Readmission odds ratios (ORs) for each risk factor and for the combined score of significant risk factors were calculated by logistic regression. Results Readmission odds were significantly increased for patients with age < 35, history of depression or substance/alcohol abuse, and self-pay/publicly funded insurance. HbA1C > 10.6% on admission and ethnic minority status did not significantly increase readmission odds, with inadequate study power for these variables. A total “ABCD” score, based on Age (< 35 years), Behavioral health (depression), insurance Coverage (self-pay/publicly funded insurance), and Drug/alcohol abuse, also had a significant effect on readmission odds. Conclusions Consideration of individual risk factors and the use of a scoring system based on objective predictors of recurrent DKA and HHS admission could be of value in helping identify patients with high readmission risk, allowing interventions to be targeted most effectively to reduce readmission rates, associated morbidity, and mortality.
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Affiliation(s)
- Annabel L Bradford
- Department of Psychiatry, Maine Medical Center, 22 Bramhall St., Portland, ME 04102, USA
| | - Courtney Champagne Crider
- Department of Dermatology, Saint Louis University, 1755 South Grand Boulevard, St. Louis, MO 63104, USA
| | - Xizheng Xu
- University of Missouri School of Medicine, One Hospital Drive, Columbia, MO 65212, USA
| | - Syed Hasan Naqvi
- University of Missouri School of Medicine, One Hospital Drive, Columbia, MO 65212, USA
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16
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Kneck Å, Eriksson LE, Lundman B, Fagerberg I. Encumbered by vulnerability and temporality - the meanings of trigger situations when learning to live with diabetes. J Clin Nurs 2016; 25:2874-83. [PMID: 27478056 DOI: 10.1111/jocn.13339] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/01/2016] [Indexed: 11/29/2022]
Abstract
AIMS AND OBJECTIVES The aim of the study was to illuminate the meanings of trigger situations experienced in everyday life when learning to live with diabetes. BACKGROUND Adults become active learners when faced with situations they do not know how to manage, triggering a need to understand something in a different way than before. Knowing more about experiential learning for persons living with diabetes is important for understanding how learning can be supported by health care. DESIGN A life-world approach with a phenomenological hermeneutical method, inspired by the philosophy of Paul Ricoeur. METHODS This method was used for interpreting transcriptions of interviews and consists of three stages: naïve understanding, structural analysis and a comprehensive understanding. Participants (n = 13), with either type I or type II diabetes, were interviewed on three different occasions over a three-year period after being diagnosed with diabetes. RESULTS When learning to live with diabetes, the meanings of trigger situations were described as 'the unpredictable body heightens insecurity with awareness of one's own dependability', 'losing control in unsustainable situations' and 'encumbered by vulnerability and temporality in earlier familiar situations'. CONCLUSION The meanings of trigger situations were to lose the smooth, unreflected way of managing an everyday life situation, interlaced with feelings of lost control of how to live with new insights of being vulnerable. Trigger situations meant an opportunity for learning, as well as being demanding, unplanned and with limited freedom of choice. Trigger situations presented life and body as unpredictable. RELEVANCE TO CLINICAL PRACTICE If healthcare professionals can identify the worries and questions raised in trigger situations, knowledge gaps can be identified and reflected on to stimulate learning.
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Affiliation(s)
- Åsa Kneck
- Department of Health Care Sciences, Ersta Sköndal University College, Stockholm, Sweden. .,Division of Nursing, Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Stockholm, Sweden.
| | - Lars E Eriksson
- Division of Nursing, Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Stockholm, Sweden.,Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden.,School of Health Sciences, City University, London, UK
| | - Berit Lundman
- Department of Nursing, Umeå University, Umeå, Sweden
| | - Ingegerd Fagerberg
- Department of Health Care Sciences, Ersta Sköndal University College, Stockholm, Sweden.,Division of Nursing, Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Stockholm, Sweden
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17
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Butalia S, Johnson JA, Ghali WA, Southern DA, Rabi DM. Temporal variation of diabetic ketoacidosis and hypoglycemia in adults with type 1 diabetes: A nationwide cohort study. J Diabetes 2016; 8:552-8. [PMID: 26301804 DOI: 10.1111/1753-0407.12336] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Revised: 05/16/2015] [Accepted: 08/19/2015] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Seasonality in health outcomes has long been recognized for conditions such as colds and flus. The aim of the present study was to determine whether hospitalizations for acute complications of type 1 diabetes (T1D) vary by month and season. METHODS An observational study was performed of national administrative health data. Hospitalizations for acute complications in adults (aged ≥18 years) with T1D were identified using ICD-10 (Canadian revision) codes between 2004 and 2010. Monthly and seasonal counts per year were determined for the study period. For each acute complication, the ratio of the number of observed hospitalizations/expected number of hospitalizations was calculated for each month and season per year, adjusting for varied lengths of month, season, and year. RESULTS In all, there were 21 568 hospitalizations for diabetic ketoacidosis (DKA) and 5349 hospitalizations for hypoglycemia during the study period. December had higher than expected hospitalizations for DKA and March had higher than expected hospitalizations for hypoglycemia. There did not appear to be variation for either DKA or hypoglycemia hospitalizations by season. CONCLUSIONS The results of the present study suggest temporal variation in hospitalizations for DKA and hypoglycemia, and therefore signal important times of patient vulnerability. Potential mechanisms underlying this pattern warrant further examination. Prevention strategies and resources for patients with T1D may need to be increased at specific times during the year.
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Affiliation(s)
| | | | - William A Ghali
- Cardiac Sciences, Faculty of Medicine, University of Calgary, Calgary
| | | | - Doreen M Rabi
- Cardiac Sciences, Faculty of Medicine, University of Calgary, Calgary
- Department of Public Health Sciences, University of Alberta, Edmonton, Canada
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18
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Steventon A, Ariti C, Fisher E, Bardsley M. Effect of telehealth on hospital utilisation and mortality in routine clinical practice: a matched control cohort study in an early adopter site. BMJ Open 2016; 6:e009221. [PMID: 26842270 PMCID: PMC4746461 DOI: 10.1136/bmjopen-2015-009221] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
OBJECTIVES To assess the effects of a home-based telehealth intervention on the use of secondary healthcare and mortality. DESIGN Observational study of a mainstream telehealth service, using person-level administrative data. Time to event analysis (Cox regression) was performed comparing telehealth patients with controls who were matched using a machine-learning algorithm. SETTING A predominantly rural region of England (North Yorkshire). PARTICIPANTS 716 telehealth patients were recruited from community, general practice and specialist acute care, between June 2010 and March 2013. Patients had chronic obstructive pulmonary disease, congestive heart failure or diabetes, and a history of associated inpatient admission. Patients were matched 1:1 to control patients, also selected from North Yorkshire, with respect to demographics, diagnoses of health conditions, previous hospital use and predictive risk score. INTERVENTIONS Telehealth involved the remote exchange of medical data between patients and healthcare professionals as part of the ongoing management of the patient's health condition. Monitoring centre staff alerted healthcare professionals if the telemonitored data exceeded preset thresholds. Control patients received usual care, without telehealth. PRIMARY AND SECONDARY OUTCOME MEASURES Time to the first emergency (unplanned) hospital admission or death. Secondary metrics included time to death and time to first admission, outpatient attendance and emergency department visit. RESULTS Matched controls and telehealth patients were similar at baseline. Following enrolment, telehealth patients were more likely than matched controls to experience emergency admission or death (adjusted HR 1.34, 95% CI 1.16 to 1.56, p<0.001). They were also more likely to have outpatient attendances (adjusted HR=1.25, 1.11 to 1.40, p<0.001), but mortality rates were similar between groups. Sensitivity analyses showed that we were unlikely to have missed reductions in the likelihood of an emergency admission or death because of unobserved baseline differences between patient groups. CONCLUSIONS Telehealth was not associated with a reduction in secondary care utilisation.
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Affiliation(s)
| | - Cono Ariti
- Data Analytics, The Health Foundation, London, UK
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19
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Steventon A, Grieve R, Bardsley M. An Approach to Assess Generalizability in Comparative Effectiveness Research: A Case Study of the Whole Systems Demonstrator Cluster Randomized Trial Comparing Telehealth with Usual Care for Patients with Chronic Health Conditions. Med Decis Making 2015; 35:1023-36. [PMID: 25986472 PMCID: PMC4592957 DOI: 10.1177/0272989x15585131] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Accepted: 02/25/2015] [Indexed: 01/25/2023]
Abstract
BACKGROUND Policy makers require estimates of comparative effectiveness that apply to the population of interest, but there has been little research on quantitative approaches to assess and extend the generalizability of randomized controlled trial (RCT)-based evaluations. We illustrate an approach using observational data. METHODS Our example is the Whole Systems Demonstrator (WSD) trial, in which 3230 adults with chronic conditions were assigned to receive telehealth or usual care. First, we used novel placebo tests to assess whether outcomes were similar between the RCT control group and a matched subset of nonparticipants who received usual care. We matched on 65 baseline variables obtained from the electronic medical record. Second, we conducted sensitivity analysis to consider whether the estimates of treatment effectiveness were robust to alternative assumptions about whether "usual care" is defined by the RCT control group or nonparticipants. Thus, we provided alternative estimates of comparative effectiveness by contrasting the outcomes of the RCT telehealth group and matched nonparticipants. RESULTS For some endpoints, such as the number of outpatient attendances, the placebo tests passed, and the effectiveness estimates were robust to the choice of comparison group. However, for other endpoints, such as emergency admissions, the placebo tests failed and the estimates of treatment effect differed markedly according to whether telehealth patients were compared with RCT controls or matched nonparticipants. CONCLUSIONS The proposed placebo tests indicate those cases when estimates from RCTs do not generalize to routine clinical practice and motivate complementary estimates of comparative effectiveness that use observational data. Future RCTs are recommended to incorporate these placebo tests and the accompanying sensitivity analyses to enhance their relevance to policy making.
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Affiliation(s)
- Adam Steventon
- Adam Steventon, Health Foundation, 90 Long Acre, London WC2E 9RA; e-mail:
| | - Richard Grieve
- Health Foundation, London, UK (AS)
- London School of Hygiene and Tropical Medicine, Keppel Street, London (AS, RG)
- Nuffield Trust, London (MB)
| | - Martin Bardsley
- Health Foundation, London, UK (AS)
- London School of Hygiene and Tropical Medicine, Keppel Street, London (AS, RG)
- Nuffield Trust, London (MB)
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20
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Miranda LG, Pedrosa HC, Falleiros RKMM, Oliveira RDM, Tolentino M, Casulari LA. Evaluation of diabetic patients after three month use of continuous subcutaneous insulin infusion, dispensed by a protocolled form at outpatient reference clinic of Taguatinga Regional Hospital. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2015; 59:23-8. [PMID: 25926110 DOI: 10.1590/2359-3997000000005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Accepted: 11/24/2014] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To evaluate the data of continuous subcutaneous insulin infusion protocol (CSII) for diabetics waived by the Health State Secretariat of Distrito Federal (HSSDF) and therapeutic responses three months after the transfer of multiple daily injections regimen for CSII. SUBJECTS AND METHODS Eighty patients (49 female) took part in this experimental study, mean age and disease duration were 27.9 years and 13 years, respectively; 96% patients had type 1 diabetes mellitus. RESULTS The entire sample (ECO) and 3 subgroups (group 1 - A1c decrease, group 2 - A1c stable, and group 3 - A1c increase), stratified according to a ≥ 0.5% change in A1c, were analyzed. Group 1 involved 64% of the patients. The ECO showed a significant A1c decrease: MDI 8.1 ± 1.4% vs. CSII 7.3 ± 0.9%, p < 0.0001 (0.8% difference pro CSII therapy). Group 1 demonstrated an A1c decrease from 8.7% to 7.3% (1.4% difference). Group 2 mean A1c was 7.1%. Rate of hypoglycemia (< 50 mg/dL) decreased 61% in the ECO and 79% in Group 2. CONCLUSION This study reinforces the safety and efficacy of CSII with a robust A1c reduction and hypoglycemia. The pioneer care HSSDF ambulatory attests to be achievable the free dispensing by Unified Health System (UHS) following a protocol, and this approach results in less wastage to the patient and represents a rational policy of therapy with CSII for UHS.
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Affiliation(s)
| | | | | | | | - Monica Tolentino
- Research Centre, Taguatinga Regional Hospital, Brasília, DF, Brazil
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21
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Abstract
Hospital readmission is a high-priority health care quality measure and target for cost reduction. Despite broad interest in readmission, relatively little research has focused on patients with diabetes. The burden of diabetes among hospitalized patients, however, is substantial, growing, and costly, and readmissions contribute a significant portion of this burden. Reducing readmission rates of diabetic patients has the potential to greatly reduce health care costs while simultaneously improving care. Risk factors for readmission in this population include lower socioeconomic status, racial/ethnic minority, comorbidity burden, public insurance, emergent or urgent admission, and a history of recent prior hospitalization. Hospitalized patients with diabetes may be at higher risk of readmission than those without diabetes. Potential ways to reduce readmission risk are inpatient education, specialty care, better discharge instructions, coordination of care, and post-discharge support. More studies are needed to test the effect of these interventions on the readmission rates of patients with diabetes.
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Affiliation(s)
- Daniel J Rubin
- Section of Endocrinology, Diabetes, and Metabolism, School of Medicine, Temple University, 3322 N. Broad ST., Ste 205, Philadelphia, PA, 19140, USA.
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22
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van Dijk PR, Logtenberg SJJ, Gans ROB, Bilo HJG, Kleefstra N. Intraperitoneal insulin infusion: treatment option for type 1 diabetes resulting in beneficial endocrine effects beyond glycaemia. Clin Endocrinol (Oxf) 2014; 81:488-97. [PMID: 25041605 DOI: 10.1111/cen.12546] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Revised: 05/11/2014] [Accepted: 07/03/2014] [Indexed: 11/28/2022]
Abstract
Continuous intraperitoneal insulin infusion (CIPII) is a treatment option for patients with type 1 diabetes mellitus who fail to reach adequate glycaemic control despite intensive subcutaneous (SC) insulin therapy. CIPII has clear advantages over SC insulin administration in terms of pharmacokinetic and pharmacodynamic properties and has been shown to improve glycaemic regulation. Due to the delivery of insulin predominantly in the portal vein, as opposed to systemically, CIPII offers a unique research model to investigate the effects of insulin on endocrine and metabolic parameters in vivo. The aim of the present article is to provide an overview of the literature with respect to the effects of CIPII on glucose management, quality of life, complications and costs, with additional focus on metabolic and endocrine aspects. Finally, future use and research objectives are discussed.
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23
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Steventon A, Bardsley M, Doll H, Tuckey E, Newman SP. Effect of telehealth on glycaemic control: analysis of patients with type 2 diabetes in the Whole Systems Demonstrator cluster randomised trial. BMC Health Serv Res 2014; 14:334. [PMID: 25100190 PMCID: PMC4128403 DOI: 10.1186/1472-6963-14-334] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Accepted: 07/23/2014] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND The Whole Systems Demonstrator was a large, pragmatic, cluster randomised trial that compared telehealth with usual care among 3,230 patients with long-term conditions in three areas of England. Telehealth involved the regular transmission of physiological information such as blood glucose to health professionals working remotely. We examined whether telehealth led to changes in glycosylated haemoglobin (HbA1c) among the subset of patients with type 2 diabetes. METHODS The general practice electronic medical record was used as the source of information on HbA1c. Effects on HbA1c were assessed using a repeated measures model that included all HbA1c readings recorded during the 12-month trial period, and adjusted for differences in HbA1c readings recorded before recruitment. Secondary analysis averaged multiple HbA1c readings recorded for each individual during the trial period. RESULTS 513 of the 3,230 participants were identified as having type 2 diabetes and thus were included in the study. Telehealth was associated with lower HbA1c than usual care during the trial period (difference 0.21% or 2.3 mmol/mol, 95% CI, 0.04% to 0.38%, p = 0.013). Among the 457 patients in the secondary analysis, mean HbA1c showed little change for controls following recruitment, but fell for intervention patients from 8.38% to 8.15% (68 to 66 mmol/mol). A higher proportion of intervention patients than controls had HbA1c below the 7.5% (58 mmol/mol) threshold that was targeted by general practices (30.4% vs. 38.0%). This difference, however, did not quite reach statistical significance (adjusted odds ratio 1.63, 95% CI, 0.99 to 2.68, p = 0.053). CONCLUSIONS Telehealth modestly improved glycaemic control in patients with type 2 diabetes over 12 months. The scale of the improvements is consistent with previous meta-analyses, but was relatively modest and seems unlikely to produce significant patient benefit. TRIAL REGISTRATION NUMBER International Standard Randomized Controlled Trial Number Register ISRCTN43002091.
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24
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Kneck Å, Fagerberg I, Eriksson LE, Lundman B. Living with diabetes - development of learning patterns over a 3-year period. Int J Qual Stud Health Well-being 2014; 9:24375. [PMID: 25030359 PMCID: PMC4101455 DOI: 10.3402/qhw.v9.24375] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/24/2014] [Indexed: 11/14/2022] Open
Abstract
Background Learning involves acquiring new knowledge and skills, and changing our ways of thinking, acting, and feeling. Learning in relation to living with diabetes is a lifelong process where there is limited knowledge of how it is experienced and established over time. It was considered important to explore how learning was developed over time for persons living with diabetes. Aim The aim of the study was to identify patterns in learning when living with diabetes, from recently being diagnosed, and over a 3-year period. Materials and methods A longitudinal qualitative descriptive design was used. Thirteen participants, with both type I and type II diabetes, were interviewed at three different occasions during a 3-year period. Qualitative content analysis was used in different steps in order to distinguish patterns. Findings Five main patterns of learning were identified. Two of the patterns (I and II) were characterized by gradually becoming comfortable living with diabetes, whereas for one pattern (IV) living with diabetes became gradually more difficult. For pattern V living with diabetes was making only a limited impact on life, whereas for Pattern III there was a constant management of obstacles related to illness. The different patterns in the present study showed common and different ways of learning and using different learning strategies at different timespans. Conclusion The present study showed that duration of illness is not of importance for how far a person has come in his own learning process. A person-centered care is needed to meet the different and changing needs of persons living with diabetes in relation to learning to live with a lifelong illness.
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Affiliation(s)
- Åsa Kneck
- Department of Health Care Sciences, Ersta Sköndal University College, Stockholm, Sweden; Division of Nursing, Department of Neurolobiology, Care Sciences and Society, Karolinska Institutet, Solna, Sweden;
| | - Ingegerd Fagerberg
- Department of Health Care Sciences, Ersta Sköndal University College, Stockholm, Sweden; Division of Nursing, Department of Neurolobiology, Care Sciences and Society, Karolinska Institutet, Solna, Sweden
| | - Lars E Eriksson
- Division of Nursing, Department of Neurolobiology, Care Sciences and Society, Karolinska Institutet, Solna, Sweden; Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden; School of Health Sciences, City University London, London, United Kingdom
| | - Berit Lundman
- Department of Nursing, Umeå Universitet, Umeå, Sweden
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Butalia S, Patel AB, Johnson JA, Ghali WA, Rabi DM. Association between diabetic ketoacidosis hospitalizations and driving distance to outpatient diabetes centres in adults with type 1 diabetes mellitus. Can J Diabetes 2014; 38:451-5. [PMID: 24821389 DOI: 10.1016/j.jcjd.2013.12.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2013] [Revised: 12/16/2013] [Accepted: 12/17/2013] [Indexed: 12/27/2022]
Abstract
OBJECTIVE The purpose of this study was to assess the relationship between diabetic ketoacidosis (DKA) hospitalization and driving distance from home to outpatient diabetes care in adults with type 1 diabetes mellitus. METHODS We identified adults with type 1 diabetes using clinical and administrative databases living in Calgary, Alberta. The International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, codes were used to identify DKA hospitalizations, and geographic information systems were used to obtain road distance. Multivariate logistic regression was used to assess the association between driving distance (exposure) to diabetes care sites and the outcome of DKA hospitalization. RESULTS We identified 1467 patients (151 patients with DKA) with type 1 diabetes. Patients with DKA hospitalizations were younger (35.6 vs. 41.0 years), had shorter duration of diabetes (13.6 vs. 18.7 years) and higher glycated hemoglobin (9.2% vs. 8.4%). Driving distance from home to diabetes centre 1 (adjusted odds ratio 1.02 per 1 km; 95% confidence interval, 0.96 to 1.07), diabetes centre 2 (adjusted odds ratio 1.01; 95% confidence interval, 0.99 to 1.04) or closest general practitioner (adjusted odds ratio 0.9; 95% confidence interval, 0.63 to 1.25) was not associated with DKA hospitalization. Driving distance was also not associated with glycemic control. CONCLUSIONS Within a large urban city, driving distance to diabetes centres does not appear to be protective of DKA hospitalization. However, this work does not preclude the role of local travel distance and diabetes outcomes. More research is required to explore the role of other individual, neighbourhood and community factors that influence DKA hospitalization.
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Affiliation(s)
- Sonia Butalia
- Department of Medicine, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada.
| | - Alka B Patel
- Department of Community Health Sciences, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jeffrey A Johnson
- Department of Public Health Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - William A Ghali
- Department of Medicine, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Doreen M Rabi
- Department of Medicine, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Public Health Sciences, University of Alberta, Edmonton, Alberta, Canada; Department of Cardiac Sciences, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada
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Steventon A, Tunkel S, Blunt I, Bardsley M. Effect of telephone health coaching (Birmingham OwnHealth) on hospital use and associated costs: cohort study with matched controls. BMJ 2013; 347:f4585. [PMID: 23920348 PMCID: PMC3805495 DOI: 10.1136/bmj.f4585] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/09/2013] [Indexed: 12/04/2022]
Abstract
OBJECTIVES To test the effect of a telephone health coaching service (Birmingham OwnHealth) on hospital use and associated costs. DESIGN Analysis of person level administrative data. Difference-in-difference analysis was done relative to matched controls. SETTING Community based intervention operating in a large English city with industry. PARTICIPANTS 2698 patients recruited from local general practices before 2009 with heart failure, coronary heart disease, diabetes, or chronic obstructive pulmonary disease; and a history of inpatient or outpatient hospital use. These individuals were matched on a 1:1 basis to control patients from similar areas of England with respect to demographics, diagnoses of health conditions, previous hospital use, and a predictive risk score. INTERVENTION Telephone health coaching involved a personalised care plan and a series of outbound calls usually scheduled monthly. Median length of time enrolled on the service was 25.5 months. Control participants received usual healthcare in their areas, which did not include telephone health coaching. MAIN OUTCOME MEASURES Number of emergency hospital admissions per head over 12 months after enrolment. Secondary metrics calculated over 12 months were: hospital bed days, elective hospital admissions, outpatient attendances, and secondary care costs. RESULTS In relation to diagnoses of health conditions and other baseline variables, matched controls and intervention patients were similar before the date of enrolment. After this point, emergency admissions increased more quickly among intervention participants than matched controls (difference 0.05 admissions per head, 95% confidence interval 0.00 to 0.09, P=0.046). Outpatient attendances also increased more quickly in the intervention group (difference 0.37 attendances per head, 0.16 to 0.58, P<0.001), as did secondary care costs (difference £175 per head, £22 to £328, P=0.025). Checks showed that we were unlikely to have missed reductions in emergency admissions because of unobserved differences between intervention and matched control groups. CONCLUSIONS The Birmingham OwnHealth telephone health coaching intervention did not lead to the expected reductions in hospital admissions or secondary care costs over 12 months, and could have led to increases.
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Butalia S, Johnson JA, Ghali WA, Rabi DM. Clinical and socio-demographic factors associated with diabetic ketoacidosis hospitalization in adults with Type 1 diabetes. Diabet Med 2013; 30:567-73. [PMID: 23323955 DOI: 10.1111/dme.12127] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Revised: 10/26/2012] [Accepted: 01/10/2013] [Indexed: 01/28/2023]
Abstract
AIM To identify the clinical and socio-demographic factors associated with hospitalization for diabetic ketoacidosis in adults with Type 1 diabetes. METHODS We combined clinical and administrative health data from a large urban diabetes clinic to perform a data linkage study. We identified adults (aged ≥ 18 years old) with Type 1 diabetes and linked to hospital discharge abstracts to assess for diabetic ketoacidosis hospitalization. The study period was between 1 January 2004 and 31 December 2009, with all individuals living in the same geographic area. Multivariate logistic regression was used to identify potential predictors of diabetic ketoacidosis hospitalization. RESULTS We identified 255 individuals with a diabetic ketoacidosis hospitalization and 1739 without a diabetic ketoacidosis hospitalization. Mean (standard deviation) age was 40.0 (15.8) years, 51.7% were men and mean duration of diabetes was 17.8 (12.9) years. Diabetic ketoacidosis hospitalization was associated with shorter duration of diabetes (odds ratio 0.96 per year; 95% confidence interval 0.95-0.98), gastroparesis (odds ratio 4.13; 95% confidence interval 1.82-9.35), psychiatric diagnosis (odds ratio 1.98; 95% confidence interval 1.22-3.19), and higher HbA1c (odds ratio 1.25 per 1% increase; 95% confidence interval 1.16-1.35). CONCLUSIONS This study identifies specific clinical factors associated with diabetic ketoacidosis hospitalization in adults with Type 1 diabetes. This information can help to inform the detection of high-risk patients, for whom special attention and interventions may be warranted to prevent diabetic ketoacidosis.
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Affiliation(s)
- S Butalia
- Department of Medicine, Faculty of Medicine, University of Calgary, Calgary, AB, Canada.
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Hoey H, Mlinac A, Tran CT, Schlaeger C. 5(th) Annual Symposium on Self-Monitoring of Blood Glucose (SMBG) applications and beyond, May 3-5, 2012, Dublin, Ireland. Diabetes Technol Ther 2012; 14:1155-73. [PMID: 23216339 PMCID: PMC3696943 DOI: 10.1089/dia.2012.0230] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Govan L, Maietti E, Torsney B, Wu O, Briggs A, Colhoun HM, Fischbacher CM, Leese GP, McKnight JA, Morris AD, Sattar N, Wild SH, Lindsay RS. The effect of deprivation and HbA1c on admission to hospital for diabetic ketoacidosis in type 1 diabetes. Diabetologia 2012; 55:2356-60. [PMID: 22733482 PMCID: PMC4209851 DOI: 10.1007/s00125-012-2601-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2012] [Accepted: 05/08/2012] [Indexed: 12/18/2022]
Abstract
AIMS/HYPOTHESIS Diabetic ketoacidosis is a potentially life-threatening complication of diabetes and has a strong relationship with HbA(1c). We examined how socioeconomic group affects the likelihood of admission to hospital for diabetic ketoacidosis. METHODS The Scottish Care Information - Diabetes Collaboration (SCI-DC), a dynamic national register of all cases of diagnosed diabetes in Scotland, was linked to national data on hospital admissions. We identified 24,750 people with type 1 diabetes between January 2005 and December 2007. We assessed the relationship between HbA(1c) and quintiles of deprivation with hospital admissions for diabetic ketoacidosis in people with type 1 diabetes adjusting for patient characteristics. RESULTS We identified 23,479 people with type 1 diabetes who had complete recording of covariates. Deprivation had a substantial effect on odds of admission to hospital for diabetic ketoacidosis (OR 4.51, 95% CI 3.73, 5.46 in the most deprived quintile compared with the least deprived). This effect persisted after the inclusion of HbA(1c) and other risk factors (OR 2.81, 95% CI 2.32, 3.39). Men had a reduced risk of admission to hospital for diabetic ketoacidosis (OR 0.71, 95% CI 0.63, 0.79) and those with a history of smoking had increased odds of admission to hospital for diabetic ketoacidosis by a factor of 1.55 (95% CI 1.36, 1.78). CONCLUSIONS/INTERPRETATION Women, smokers, those with high HbA(1c) and those living in more deprived areas have an increased risk of admission to hospital for diabetic ketoacidosis. The effect of deprivation was present even after inclusion of other risk factors. This work highlights that those in poorer areas of the community with high HbA(1c) represent a group who might be usefully supported to try to reduce hospital admissions.
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Affiliation(s)
- L Govan
- Health Economics and Health Technology Assessment, Institute of Health and Wellbeing, University of Glasgow, 1 Lilybank Gardens, Glasgow G12 8RZ, UK.
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Affiliation(s)
- John C Pickup
- Diabetes Research Group, Division of Diabetes and Nutritional Sciences, King's College London School of Medicine and Guy's Hospital, London, United Kingdom.
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