Recurrent hospitalizations for severe hypoglycemia and hyperglycemia among U.S. adults with diabetes
Introduction
Patients with diabetes who experience severe hypoglycemia or hyperglycemia incur potentially preventable morbidity,1,2 mortality,3 high costs,4., 5., 6., 7. and impaired quality of life,4,7,8 particularly when the events are so severe as to require hospitalization. Despite being potentially preventable with optimal ambulatory care, rates of hospitalization for hypoglycemia9., 10., 11. and hyperglycemia9,10 remain high. In a recent study of hospitalizations and readmissions among patients with diabetes, admissions for severe dysglycemia accounted for 2.6% of all hospitalizations and 2.5% of all 30-day readmissions.9 Such hospitalizations may reflect underlying deficiencies in patient care and diabetes management, particularly if patients need to be readmitted for hypoglycemia or hyperglycemia shortly after hospitalization for a similar event.
Preventing hospitalizations and readmissions is key to improving care quality and lowering costs of care. To promote high quality care for people with diabetes, the Centers for Medicare & Medicaid Services (CMS) uses rates of 30-day all-cause unplanned readmissions among all patients12 and of all-cause unplanned admissions among patients with diabetes13 for public reporting and payment adjustment. Identifying patients at highest risk for readmission specifically for severe hypoglycemic or hyperglycemic events is an important first step toward their prevention.
Prior studies identified several risk factors for hypoglycemia including prior hypoglycemia,14,15 intensive glucose-lowering therapy,16,17 insulin and sulfonylurea use,11,15., 16., 17., 18., 19. older age,11,15,19., 20., 21. multimorbidity,11,16 and cognitive impairment.22 Severe hyperglycemia is more common among younger patients21 and patients with depression or substance use.24,45 Elevated hemoglobin A1c (HbA1c) 11,23,24 and socioeconomic disadvantage 23,25., 26., 27., 28., 29. are associated with both hypoglycemia and hyperglycemia. However, there is little information about recurrent hospitalizations for severe dysglycemia among adults with diabetes. Because patients may be experiencing both types of events, concurrently examining severe hypoglycemia and hyperglycemia would present a more complete and holistic representation of diabetes care, and potentially identify clinically meaningful trends and risk factors. To address this knowledge gap, we examine hospital readmissions for severe hypoglycemia and hyperglycemia that occur within 30 days of hospital discharge for another hypoglycemic or hyperglycemic event in a national cohort of adults with established diabetes.
Section snippets
Study design and data source
We conducted a retrospective analysis of patients with medical and pharmacy claims data from OptumLabs Data Warehouse (OLDW), an administrative database of >100 million privately insured and Medicare Advantage enrollees throughout the U.S. (Appendix A.1)30,31 This national dataset encompasses a wide range of ages and racial/ethnic groups. All study data were accessed after the data were de-identified, consistent with Health Insurance Portability and Accountability Act expert de-identification
Study population and 30-day readmissions
Between January 1, 2009 and December 31, 2014, 11,161 patients experienced 13,291 index hospitalizations, including 6419 index hospitalizations for hypoglycemia among 5911 patients and 6872 index hospitalizations for hyperglycemia among 5250 patients. Overall, 1338 patients (12%) had more than one index hospitalization during the 5-year study period. Baseline patient characteristics at the time of index admission are shown in Table 1. Patients hospitalized for hypoglycemia were significantly
Discussion
Severe hypoglycemia and hyperglycemia, particularly when requiring hospitalization, are common, harmful, yet potentially avoidable with optimal diabetes care. Patients experiencing severe hypoglycemia or hyperglycemia are at risk for recurrent events, particularly if risk factors for these events are not identified and addressed. In this study, we examined 6419 hospitalizations for the primary diagnosis of severe hypoglycemia and 6872 for severe hyperglycemia (ketoacidosis and hyperglycemic
Conclusions
Hospitalizations for severe hypoglycemia and hyperglycemia continue to be common and 10% result in 30-day readmission. Patients hospitalized for severe hyperglycemia are likely to be readmitted for recurrent hyperglycemia, while patients hospitalized for hypoglycemia are generally readmitted for unrelated causes. Importantly, these data represent only a fraction of severe hypoglycemic and hyperglycemic events experienced by patients with diabetes, as most episodes do not result in
Acknowledgments
Author contributions: Dr. McCoy had full access to all the data in the study and serves as the guarantors for this work, taking responsibility for the integrity of the data and the accuracy of the data analysis. Study conception and design: McCoy, Shah. Acquisition of data: Herrin, Shah. Interpretation of data: McCoy, Herrin, Shah. Drafting of the manuscript: McCoy. Critical revision of the manuscript for important intellectual content: McCoy, Lipska, Herrin, Shah. Statistical analysis: Herrin.
Declarations of interest
None.
References (47)
- et al.
The burden of hypoglycemia on healthcare utilization, costs, and quality of life among type 2 diabetes mellitus patients
J Diabetes Complications
(2012) - et al.
Costs associated with emergency care and hospitalization for severe hypoglycemia
Nutr Metab Cardiovasc Dis
(2016) - et al.
Recurrent diabetic ketoacidosis in two community teaching hospitals
Endocr Pract
(2013) - et al.
A new method of classifying prognostic comorbidity in longitudinal studies: development and validation
J Chronic Dis
(1987) - et al.
Hypoglycemia and risk of cardiovascular disease and all-cause mortality in insulin-treated people with type 1 and type 2 diabetes: a cohort study
Diabetes Care
(2015) - et al.
Severe hypoglycaemia and cardiovascular disease: systematic review and meta-analysis with bias analysis
BMJ
(2013) - et al.
Risk of death following admission to a UK hospital with diabetic ketoacidosis
Diabetologia
(2016) - et al.
Economic impact of severe and non-severe hypoglycemia in patients with type 1 and type 2 diabetes in the United States
J Med Econ
(2015) - et al.
Medical resource use, disturbance of daily life and burden of hypoglycemia in insulin-treated patients with diabetes: results from a European online survey
Expert Rev Pharmacoecon Outcomes Res
(2013) - et al.
Self-report of hypoglycemia and health-related quality of life in patients with type 1 and type 2 diabetes
Endocr Pract
(2013)