Hospital readmission for DKA associated with increased mortality risk in type 1 diabetes
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Adults with type 1 diabetes who are hospitalized for diabetic ketoacidosis and readmitted within 30 days of discharge have an increased risk for inpatient mortality, according to a speaker at the ENDO annual meeting.
“About one-fifth of patients who had an episode of DKA with type 1 diabetes get readmitted back to the hospital within 30 days of discharge,” Hafeez Shaka, MD, an internal medicine resident at the John H. Stroger Jr. Hospital of Cook County, Chicago, said during a press conference. “This is a significantly high number.”
Shaka and colleagues reviewed data from the National Readmission Database of adults aged 18 years or older with type 1 diabetes who were admitted to a hospital for DKA from Jan. 1 to Nov. 30, 2017. Elective and traumatic admissions were not included in the analysis. Primary outcomes in the analysis were 30-day readmission rates, mortality, length of hospital stay and total hospital charges.
There were 91,625 cases of adults with type 1 diabetes who were hospitalized with DKA during the study period, with 91,401 being discharged. Of those who were discharged, 20.2% were readmitted to the hospital within 30 days, most principally readmitted for DKA.
Adults readmitted for DKA within 30 days of discharge had an increased risk for mortality compared with index admission (RR = 2.06; 95% CI, 1.74-2.43; P < .001). Readmitted adults also had an increased mean length of stay in the hospital of 1 day (95% CI, 0.9-1.2; P < .001) compared with the first admission and mean total hospitalization charges of $8,217 (95% CI, 6,940-9,492; P < .001).
In subgroup analysis, obesity (HR = 0.7; 95% CI, 0.62-0.79; P < .001) and hyperlipidemia (HR = 0.92; 95% CI, 0.87-0.98; P = .0007) were associated with a lower risk for DKA readmission.
“Obesity seemed to be protective in this case because obesity might be a surrogate marker of patients who had been traditionally more compliant with insulin, because as we know in patients with type 1 diabetes, they need insulin to store body fat,” Shaka said. “Most of these patients who are poorly controlled tend to be either underweight or within the normal limit. Patients who are being more compliant with their insulin, they are the patients that tend to be more overweight and have a lipid disorder.”
Hypertension, chronic kidney disease and anemia were independent predictors for DKA readmission. Women and those who were discharged against medical advice during their first hospitalization also had a higher risk for readmission.
“These factors should be identified early during the [initial] admission as a way of significantly preventing readmission, which is something most hospitals tend to work on and something that would also help reduce the morbidity and mortality in patients with type 1 diabetes,” Shaka said.
Perspective
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Osagie Ebekozien, MD, MPH, CPHQ
As a population health researcher, I commend the authors on working on such an important topic. The preliminary finding is timely as recent studies have demonstrated an increased risk of diabetic ketoacidosis among patients with type 1 diabetes and COVID-19.
I was surprised at the alarming DKA readmission rate in 2017, which was significantly higher than the previously reported 30-day DKA readmission rate of 12% identified by Hurtado and colleagues (Endocr Pract. 2019;doi:10.4158/EP-2018-0457) using the same database from 2010 to 2014. Clinicians and population health researchers must monitor this unfortunate trend closely.
One of the significant drivers not discussed in the study abstract is socioeconomic factors, which is a well-documented fact (Everett E, et al. J Clin Endocrinol Metab. 2019;doi:10.1210/jc.2018-02232). Socioeconomic factors play a critical role in DKA readmissions. It will be essential to analyze and discuss how health care affordability, food insecurity and, more broadly, systemic racism, among other factors, impact DKA readmission rates.
I encourage all patients with type 1 diabetes to increase their education and awareness of DKA, while health care providers should proactively address predictors of DKA admissions.
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Shaka H, et al. Rate and predictor of 30-day readmission in adults with type 1 diabetes hospitalized for diabetic ketoacidosis in the U.S.: A nationwide study. Presented at: ENDO annual meeting; March 20-23, 2021 (virtual meeting).
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