Readmitted patients have two times the death rate during a second hospitalization with diabetic ketoacidosis, so providers should identify factors predisposing them to a second DKA episode, according to a study presented at ENDO 2021.
In “Rates and Predictors of 30-Day Readmission in Adults with Type 1 Diabetes Hospitalized for Diabetic Ketoacidosis in the US: A Nationwide Study,” which has since been published in Endocrinology in May, Hafeez Shaka, MD, an internal medicine resident at John H. Stroger Jr. Hospital of Cook County, in Chicago, Ill., and team used data from the National Readmissions Database (NRD) for 2017.
“Diabetic ketoacidosis is one of the emergencies in endocrinology,” Shaka says, “and is known to be associated with increased morbidity and mortality. Diabetes is a chronic condition, but diabetic ketoacidosis is one of those reasons a patient who is diabetic gets admitted.”
Diabetic ketoacidosis (DKA) is more common among patients with type 1 diabetes because insulin deficiency promoted lipolysis and ketogenesis. Because patients with type 2 diabetes have insulin, they are not as prone to developing acidosis when they have high blood glucose. The study involves patients who initially had an episode of DKA, were discharged from the inpatient setting, then returned to the hospital within the next 30 days. “We queried the NRD and other U.S. databases for hospitalizations involving people at least age 18 years between January 1 and November 30, 2017. We excluded patients who were electively admitted or admitted for traumatic reasons, and we assessed factors that might lead to readmission,” Shaka says.
Other outcomes assessed using the multivariate Cox regression model include mortality, length of stay, and hospitalization costs. Of 91,625 hospitalizations, 91,401 patients were discharged alive. Among those, 18,553 patients (20.2%) were readmitted within 30 days, most for DKA. Compared to the index (initial) admission, a 30-day readmission was associated with more than double the mortality rate. It was also significantly associated with longer hospital stays and much higher costs. Independent factors that conferred higher risk of readmission include female sex (40% higher) even after adjusting for age, self-discharge against medical advice (50% higher), hypertension, chronic kidney disease, and anemia.
Interestingly, the researchers found that obesity and hyperlipidemia exerted protective effects against subsequent DKA episodes and consequent readmission. “I do a lot of obesity-based research,” Shaka explains, “and recently the concept of the obesity paradox has emerged. This has been reported in patients with stroke and heart failure. Another concept is ‘metabolically healthy obesity.’ However, in patients with type 1 diabetes, obesity seems to indicate that they have been more compliant with insulin because they need insulin to be able to store body fat. This hypothesis remains to be tested.”
“Diabetes is a chronic condition, but diabetic ketoacidosis is one of those reasons a patient who is diabetic gets admitted.” – Hafeez Shaka, MD, John H. Stroger Jr. Hospital of Cook County, Chicago, Ill.
Shaka and team recommend that the risk factors for readmission should be identified quite early during the index admission as a way of significantly preventing readmission. “This is something most hospitals want to work on and something that would also help reduce the burden of morbidity and mortality in patients with type 1 diabetes,” concludes Shaka. Efforts should also be channeled toward proper discharge planning.
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