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Adrenal insufficiency increases ICU admission, prolongs hospital stay
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Hospitalized adults with primary or secondary adrenal insufficiency are more likely to be admitted to the ICU, be readmitted at 30 days or 1 year, and have a longer overall length of stay when compared with controls, according to findings from a propensity score-matched study published in the European Journal of Endocrinology.
“This population-based study investigating the health care burden of more than 5,000 hospitalized cases with adrenal insufficiency is one of the largest so far,” Alexander Kutz, MD, attending physician in the division of endocrinology, diabetes and metabolism at University Hospital Basel, Switzerland, told Endocrine Today. “We found that adrenal insufficiency still carries a clinically relevant health care burden, as mirrored by increased health care utilization, prolonged length of hospital stay and higher hospital readmission rates. Remarkably, we did not find an increased hospital mortality rate in our study.”
Kutz and colleagues analyzed data from adults with primary (n = 594) or secondary adrenal insufficiency (n = 4,880) hospitalized between 2011 and 2015, matched 1:1 with propensity-matched controls, using data from the Swiss Federal Statistical Office (mean age, 65 years). The primary outcome was 30-day all-cause, in-hospital mortality. Main secondary outcomes included ICU admission rate, length of hospital stay, 30-day and 1-year all-cause readmission rates.
Compared with matched controls, adults with primary or secondary adrenal insufficiency were no more likely to die while in hospital; however, patients with adrenal insufficiency were more likely to be admitted to the ICU, with ORs of 1.9 for those with primary adrenal insufficiency (95% CI, 1.27-2.72) and 1.5 for secondary adrenal insufficiency (95% CI, 1.35-1.75).
Researchers also found that patients with primary and secondary adrenal insufficiency stayed in hospital on average 1 (P = .037) and 3.3 (P < .001) additional days, respectively, when compared with controls. There were no between-group differences for 30-day or 1-year all-cause hospital readmission among patients with primary adrenal insufficiency vs. controls; however, those with secondary adrenal insufficiency had a higher 30-day readmission rate vs. controls (14.1% vs. 12.1%; P < .001) and higher 1-year readmission rate (50% vs. 40.7%; P < .001) vs. controls.
“Whether our findings are due to higher demand of health care resources as mirrored by prolonged hospital stay and increased readmission rates or due to higher vulnerability of patients with adrenal insufficiency remains debatable,” Kutz said. “However, increased efforts are warranted to tackle these shortcomings of patient-oriented outcomes in this fragile patient population, and thus, physician awareness of adrenal insufficiency in the hospital setting should be improved continuously.”
Kutz said it would be useful to replicate the findings using different and more sophisticated resources, including information about clinical appearance, disease severity and laboratory parameters to expedite appropriate and immediate therapeutic measures. – by Regina Schaffer
For more information:
Alexander Kutz, MD, can be reached at the Division of Endocrinology, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland; email: kutz.alexander@gmail.com.
Disclosures: The authors report no relevant financial disclosures.
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Ricardo Correa, MD, EsD, FACE, FACP, CMQ
Adrenal insufficiency increases morbidity and mortality in patients. There is evidence that in outpatient settings, patients have worse outcomes; however, there is not a large cohort analysis of inpatient settings. This study included the largest cohort to my knowledge that analyzed inpatient complications of individuals with primary or secondary adrenal insufficiency, using a Swiss national database. The study was powered for their primary outcome to evaluate inpatient mortality, but they were unable to find any difference between individuals with adrenal insufficiency and controls. When looking at secondary outcomes, they found that patients with adrenal insufficiency are more likely to be admitted to the ICU, but the length of stay in the ICU was more significant in secondary adrenal insufficiency vs. patients with primary adrenal insufficiency. The reason for this finding is unclear. Length of stay was increased for any inpatient with adrenal insufficiency vs. controls, and the readmission rate was higher only in secondary adrenal insufficiency.
This study has some limitations. There are fewer patients with primary adrenal insufficiency vs. secondary adrenal insufficiency. This is a national database, so there was no stratification according to different level of health care system, and the study design increased the risk for confounding factors, including underreporting of secondary diagnosis, as the authors noted. I agree with the conclusion of the authors that there is an increased burden of complications during hospital admission among patients with primary adrenal insufficiency or secondary adrenal insufficiency. This study has given us some data to raise awareness of the potential complications when patients have adrenal insufficiency. Research needs to be multicentric and assess other populations in other countries so we can better understand how these findings translate across the world.
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