Acute management and outcomes of patients with diabetes mellitus presenting to Canadian emergency departments with hypoglycemia

Modifiable factors to prevent severe hypoglycaemic and diabetic ketoacidosis presentations in people with type 1 diabetes

AIMS

In tackling rising diabetes-related emergencies, the need to understand and address emergency service usage by people with type 1 diabetes is vital. This review aimed to quantify current trends in presentations for type 1 diabetes-related emergencies and identify public health strategies that reduce the frequency of diabetes-related emergencies and improve glycaemic management.

METHODS

Medline (OVID), Cochrane and CINAHL were searched for studies published between 2000 and 2023, focusing on people with type 1 diabetes, severe hypoglycaemia and/or diabetic ketoacidosis, and ambulance and/or emergency department usage. There were 1313 papers identified, with 37 publications meeting review criteria.

RESULTS

The incidence of type 1 diabetes-related emergencies varied from 2.4 to 14.6% over one year for hypoglycaemic episodes, and between 0.07 and 11.8 events per 100 person-years for hyperglycaemic episodes. Notably, our findings revealed that ongoing diabetes education and the integration of diabetes technology, such as continuous glucose monitoring and insulin pump therapy, significantly reduced the incidence of these emergencies. However, socio-economic disparities posed barriers to accessing these technologies, subsequently shifting the cost to emergency healthcare and highlighting the need for governments to consider subsidising these technologies as part of preventative measures.

CONCLUSIONS

Improving access to continuous glucose monitoring and insulin pump therapy, in combination with ongoing diabetes education focusing on symptom recognition and early management, will reduce the incidence of diabetes-related emergencies. Concurrent research assessing emergency healthcare usage patterns during the implementation of such measures is essential to ensure these are cost-effective.

Latent Profile Analysis of Fear of Hypoglycemia in Middle-Aged and Elderly Hospitalized Patients with Type 2 Diabetes and Its Relationship with Sleep Quality

Introduction

Hypoglycemia is an acute complication that can appear in people with type 2 diabetes treated with drugs which are associated with a risk of hypoglycemia, and it may lead to individual's fear of hypoglycemia (FoH). FoH adversely affects diabetic self-management, psychological well-being, and quality of life, and it is associated with sleep quality. Nevertheless, this problem is often underestimated. The purpose of this study was to explore the heterogeneous characteristics of FoH in middle-aged and elderly hospitalized patients with type 2 diabetes and assess its relationship with the sleeping quality.

Patients and Methods

A cross-sectional study was performed on 263 middle-aged and elderly patients with type 2 diabetes hospitalized at the Zhejiang Veteran Hospital in Jiaxing, China, from May to August 2022, selected by a convenient sampling method. A questionnaire containing general information, fear of hypoglycemia scale-15 (FH-15) and the Pittsburgh sleep quality index (PSQI) was provided to the participants. Latent profile analysis was performed to examine the potential latent groups in the distribution of answers on the individual FoH items.

Results

The results identified three latent classes: Class 1 - Low FoH group (33%); Class 2 - No FoH group (61%); Class 3 - High FoH group (6%). The latent FoH class was the influencing factor of sleep quality, which was better in the No FoH group than in the Low FoH group, while the sleep quality of the Low FoH group was better than that in the High FoH group.

Conclusion

A heterogeneity was found in the FoH of middle-aged and elderly hospitalized patients with type 2 diabetes. Health-care providers should pay more attention to these patients with high FoH and develop intervention strategies to mitigate it and improve their sleep quality.

Quality improvement tools to manage emergency callbacks from patients with diabetes in a prehospital setting

Diabetes is rising at an alarming rate, as 1 in 10 adults worldwide now lives with the disease. In Qatar, a middle eastern Arab country, diabetes prevalence is equally concerning and is predicted to increase from 17% to 24% among individuals aged 45 and 54 years by 2050. While most healthcare strategies focus on preventative and improvement of in-hospital care of patients with diabetes, a notable paucity exists concerning diabetes in the prehospital setting should ideally be provided. This quality improvement study was conducted in a middle eastern ambulance service and aimed to reduce ambulance callbacks of patients with diabetes-related emergencies after refusing transport to the hospital at the first time. We used iterative four-stage problem-solving models. It focused on the education and training of both paramedics and patients. The study showed that while it was possible to reduce the rate of ambulance callbacks of patients with diabetes, this was short-lived and numbers increased again. The study demonstrated that improvements could be effective. Hence, changes that impacted policy, systems of care and ambulance protocols directed at managing and caring for patients with diabetes-related prehospital emergencies may be required to reify them.

How Outpatient Diabetes Education Programs Can Support Local Hospitals to Reduce Emergency Department Visits for Adults With Diabetes

OBJECTIVES

Our aim in this study was to assess the level of collaboration between a hospital-based outpatient diabetes education program (DEP) and emergency departments (EDs) for reducing number of ED revisits and hospital admissions by implementing intervention strategies to promote education services and streamlining referral and appointment intake processes.

METHODS

Patients (≥18 years of age) with an ED visit for hyper- or hypoglycemia were analyzed in 2 cohorts based on their intervention exposure. We conducted a single-cohort analysis of the exposed cohort (exposure to the intervention strategies) and compared 2-year outcomes with those of the unexposed cohort. Primary outcomes were hyper- or hypoglycemia-related ED revisit and hospitalization rates. Process outcomes included DEP referrals and DEP attendance.

RESULTS

There were no significant differences in ED revisits and hospital admissions between the exposed and unexposed cohorts. However, patients were more likely to be referred to a DEP by ED physicians (odds ratio [OR], 1.76; p=0.02) and to attend a DEP appointment (OR, 1.96; p<0.01) after intervention exposure. DEP attendees from both cohorts became less likely to revisit an ED (exposed: OR, 0.41; 95% confidence interval [CI], 0.23 to 0.71; unexposed: OR, 0.4; 95% CI, 0.15 to 1.15) at 12-month follow up; however, this reduction was sustained only among the exposed cohort (OR, 0.5; 95% CI, 0.31 to 0.81) and not the unexposed cohort (OR, 1.32; 95% CI, 0.60 to 2.91) at 24 months (p=0.04 when comparing the 2 cohorts).

CONCLUSIONS

Collaboration between outpatient DEPs with local EDs could effectively reduce diabetes-related ED revisits by increasing diabetes program utilization.

Patient and Prehospital Predictors of Hospital Admission for Patients With and Without Histories of Diabetes Treated by Paramedics for Hypoglycemia: A Health Record Review Study

OBJECTIVES

The objectives of this study were to describe the characteristics, management, and outcomes of patients treated by paramedics for hypoglycemia, and to determine the predictors of hospital admission for these patients within 72 hours of the initial hypoglycemia event.

METHODS

We performed a health record review of paramedic call reports and emergency department records over a 12-month period. We queried prehospital databases to identify cases, which included all patients ⩾18 years with prehospital glucose readings of <72 mg/dl (<4.0 mmol/L) and excluded terminally ill and cardiac arrest patients. We developed and piloted a standardized data collection tool and obtained consensus on all data definitions before initiation of data extraction by trained investigators. Data analyses included descriptive statistics univariate and logistic regression presented as adjusted odds ratios (aOR) with 95% confidence intervals (95%CI).

RESULTS

There were 791 patients with the following characteristics: mean age 56.2, male 52.3%, type 1 diabetes 11.6%, on insulin 43.3%, median initial glucose 54.0 mg/dl (3.0 mmol/L), from home 56.4%. They were treated by advanced care paramedics 80.1%, received intravenous D50 37.8%, intramuscular glucagon 17.8%, oral complex carbs/protein 25.7%, and accepted transport to hospital 70.2%. Among those transported, 134 (24.3%) were initially admitted and four more were admitted within 72 hours. One patient was admitted, discharged, and admitted again within 72 hours. Patients without documented histories of diabetes (aOR 2.35, CI 1.13-4.86), with cardiovascular disease (aOR 1.81, CI 1.10-3.00), on corticosteroids (aOR 4.63, CI 2.15-9.96), on oral hypoglycemic agent(s) (aOR 1.92, CI 1.02-3.62), or those given glucagon (aOR 1.77, CI 1.07-2.93) on scene were more likely to be admitted to hospital, whereas patients on insulin (aOR 0.49, CI 0.27-0.91), able to tolerate complex oral carbs/protein (aOR 0.22, CI 0.10-0.48), with final GCS scores of 15 (aOR 0.53, CI 0.34-0.83), or from public locations (aOR 0.40, CI 0.21-0.75) were less likely to be admitted.

CONCLUSIONS

There are several patient and prehospital management characteristics which, in combination, could be incorporated into a safe clinical decision tool for patients who present with hypoglycemia.

Hypoglycemia requiring paramedic assistance among adults in southwestern Ontario, Canada: a population-based retrospective cohort study

BACKGROUND

People with diabetes mellitus commonly experience hypoglycemia, but they may not necessarily present to hospital after severe hypoglycemia requiring paramedic assistance. We sought to describe the incidence and characteristics of calls for hypoglycemia requiring paramedic assistance among adults in southwestern Ontario, Canada, and to determine predictors of hospital transport.

METHODS

This population-based retrospective cohort study used data extracted from ambulance call reports (ACRs) of 8 paramedic services of the Southwest Ontario Regional Base Hospital Program from January 2008 to June 2014. We described calls in which treatment for hypoglycemia was administered, summarized the incidence of hypoglycemia calls and performed logistic regression to determine predictors of hospital transport.

RESULTS

Out of 470 467 ACRs during the study period, 9185 paramedic calls occurred in which hypoglycemia treatment was administered to an adult (mean age 60.2 yr, 56.8% male, 81.1% with documented diabetes). Refusal of hospital transport occurred in 2243 (24.4%) of calls. Documented diabetes diagnosis (adjusted odds ratio [OR] 0.82, 95% confidence interval [CI] 0.69-0.96), higher capillary blood glucose (adjusted OR 0.31, 95% CI 0.22-0.44) and overnight calls (adjusted OR 0.80, 95% CI 0.72-0.91) were associated with lower odds of hospital transport. Higher-acuity calls (adjusted OR 2.05, 95% CI 1.58-2.66) were associated with higher odds of transport. The estimated annual incidence rate of hypoglycemia requiring paramedic assistance was 108 per 10 000 people with diabetes per year.

INTERPRETATION

Hypoglycemia requiring paramedic assistance in southwestern Ontario is common, and close to 25% of calls do not result in hospital transport. Physicians managing diabetes care may be unaware of patients' hypoglycemia requiring paramedic care, suggesting a potential gap in follow-up care; we suggest that paramedics play an important role in identifying those at high recurrence risk and communicating with their care providers.

Hypoglycemic episodes in hospitalized people with diabetes in Portugal: the HIPOS-WARD study

BACKGROUND

We intended to estimate the proportion hypoglycemic/hyperglycemic emergency episodes in treated diabetes mellitus (DM) patients admitted to a hospital ward, and calculate the prevalence of risk factors for hypoglycemia and diabetic complications.

METHODS

In this cross-sectional, multicentered study, the observational data was collected by physicians from patient's hospitalization to discharge/death. Statistical tests were 2-tailed considering 5% significance level.

RESULTS

There were 646 ward admissions due to hyperglycemic emergencies and 176 hypoglycemic episodes with a ratio hypoglycemia/hyperglycemia 0.27 for all DM patients. In T2DM patients the ratio was 0.38. These were mainly female (55.1%), functionally dependent (61.4%) and retired/disabled (73.1%). Median age was 75 years and median duration of disease 11 years. Half the patients were on insulin-based therapy and 30.1% on secretagogue-based therapy. Approximately 57% of patients needed occasional/full assistance to manage the disease. The most frequent risk factor for hypoglycemia was polypharmacy (85.0%). Hypoglycemia in the 12 months before admission was higher in insulin-based therapy patients (66.1%; p = 0.001).

CONCLUSIONS

Hyperglycemic emergencies are the most frequent cause of hospitalization in Portugal, although severe hypoglycemic events represent a health and social problem in elderly/frail patients. There is still the need to optimize therapy in terms of the potential for hypoglycemia in this patient group and a review of anti-hyperglycemic agents to add on to insulin.

Conversations and Reactions Around Severe Hypoglycemia Study: Results of Hypoglycemia Experiences in Canadian Adults With Insulin-Treated Diabetes and Their Caregivers

OBJECTIVES

The Conversations and Reactions Around Severe Hypoglycemia cross-sectional study was conducted to better understand the severe hypoglycemia experiences in persons with diabetes (PWD) and their caregivers (CGs).

METHODS

Adults with type 1 or type 2 diabetes and CGs were recruited in 8 countries; Canadian cohort data are reported in this study. Insulin-treated PWD who reported a severe hypoglycemic event within the past 3 years and CGs who care for PWD ≥4 years old and who met the criteria were eligible for the study. Participants completed an online survey about their experience with severe hypoglycemia, its treatment and actions during and after severe hypoglycemia.

RESULTS

Of the 324 respondents, 139 (43%) reported discussions about severe hypoglycemia with a health-care provider (HCP) at every visit. During the most recent severe hypoglycemic event, the most common actions taken included ingestion of oral carbohydrates and calling emergency medical services; glucagon was rarely used. Despite many respondents (67%) feeling scared because of the most recent severe hypoglycemic event, only 55% (51% with type 1 and 61% with type 2) discussed this event with an HCP. The event affected the mood/emotional status, physical activities and sleep of PWD and CGs.

CONCLUSIONS

Severe hypoglycemia impacts the emotional and physical status of PWD and CGs. Despite this, many respondents did not report discussions about the most recent severe hypoglycemic event with HCPs. Furthermore, <50% of the respondents reported discussions about severe hypoglycemia with HCPs at every visit. Purposeful communication about severe hypoglycemia can help fulfil Diabetes Canada guideline recommendations to review experiences with hypoglycemia among PWD at every visit.

Characteristics, Prehospital Management, and Outcomes in Patients Assessed for Hypoglycemia: Repeat Access to Prehospital or Emergency Care

BACKGROUND

In Ontario, Canada, there currently are no prehospital treat-and-release protocols and the safety of this practice remains unclear. We sought to describe the characteristics, management, and outcomes of patients with hypoglycemia treated by paramedics, and to determine the predictors of repeat access to prehospital or emergency department (ED) care within 72 hours of initial paramedic assessment.

METHODS

We performed a health record review of paramedic call reports and ED records over a 12-month period. We queried prehospital databases to identify cases, which included all adult patients (≥ 18 years) with a prehospital glucose reading of <72mg/dl (4.0mmol/L) and excluded terminally ill and cardiac arrest patients. We developed and piloted a standardized data collection tool and obtained consensus on all data definitions before initiation of data extraction by trained investigators. Data analyses include descriptive statistics with standard deviations, Chi-square, t-tests, and logistic regression with adjusted odds ratios (AdjOR).

RESULTS

There were 791 patients with the following characteristics: mean age 56.2, male 52.3%, known diabetic 61.6%, on insulin 46.1%, mean initial glucose 50.0 dl/mg (2.8 mmol/L), from home 56.3%. They were treated by an Advanced Care Paramedic 80.1%, received IV D50W 38.0%, IM glucagon 18.3%, PO complex carbs 26.6%, and accepted transport to hospital 69.4%. Of those transported, 134/556 (24.3%) were admitted and 9 (1.6%) died in the ED. Overall, 43 patients (5.4%) had repeat access to prehospital/ED care, among those, 8 (18.6%) were related to hypoglycemia. Patients on insulin were less likely to have repeat access to prehospital/ED care (AdjOR 0.4; 95%CI 0.2-0.9). This was not impacted by initial (or refusal of) transport (AdjOR 1.1; 95%CI 0.5-2.4).

CONCLUSION

Although risk of repeat access to prehospital/ED care for patients with hypoglycemia exists, it was less common among patients taking insulin and was not predicted by an initial refusal of transport.

Geographical variation of diabetic emergencies attended by prehospital Emergency Medical Services is associated with measures of ethnicity and socioeconomic status

Geographical variation of diabetic emergencies attended by prehospital emergency medical services (EMS) and the relationship between area-level social and demographic factors and risk of a diabetic emergency were examined. All cases of hypoglycaemia and hyperglycaemia attended by Ambulance Victoria between 1/01/2009 and 31/12/2015 were tabulated by Local Government Area (LGA). Conditional autoregressive models were used to create smoothed maps of age and gender standardised incidence ratio (SIR) of prehospital EMS attendance for a diabetic emergency. Spatial regression models were used to examine the relationship between risk of a diabetic emergency and area-level factors. The areas with the greatest risk of prehospital EMS attendance for a diabetic emergency were disperse. Area-level factors associated with risk of a prehospital EMS-attended diabetic emergency were socioeconomic status (SIR 0.70 95% CrI [0.51, 0.96]), proportion of overseas-born residents (SIR 2.02 95% CrI [1.37, 2.91]) and motor vehicle access (SIR 1.47 95% CrI [1.08, 1.99]). Recognition of areas of increased risk of prehospital EMS-attended diabetic emergencies may be used to assist prehospital EMS resource planning to meet increased need. In addition, identification of associated factors can be used to target preventative interventions tailored to individual regions to reduce demand.

Altered Mental Status: Current Evidence-based Recommendations for Prehospital Care

Introduction

In the United States emergency medical services (EMS) protocols vary widely across jurisdictions. We sought to develop evidence-based recommendations for the prehospital evaluation and treatment of a patient with an acute change in mental status and to compare these recommendations against the current protocols used by the 33 EMS agencies in the State of California.

Methods

We performed a literature review of the current evidence in the prehospital treatment of a patient with altered mental status (AMS) and augmented this review with guidelines from various national and international societies to create our evidence-based recommendations. We then compared the AMS protocols of each of the 33 EMS agencies for consistency with these recommendations. The specific protocol components that we analyzed were patient assessment, point-of-care tests, supplemental oxygen, use of standardized scoring, evaluating for causes of AMS, blood glucose evaluation, toxicological treatment, and pediatric evaluation and management.

Results

Protocols across 33 EMS agencies in California varied widely. All protocols call for a blood glucose check, 21 (64%) suggest treating adults at <60mg/dL, and half allow for the use of dextrose 10%. All the protocols recommend naloxone for signs of opioid overdose, but only 13 (39%) give specific parameters. Half the agencies (52%) recommend considering other toxicological causes of AMS, often by using the mnemonic AEIOU TIPS. Eight (24%) recommend a 12-lead electrocardiogram; others simply suggest cardiac monitoring. Fourteen (42%) advise supplemental oxygen as needed; only seven (21%) give specific parameters. In terms of considering various etiologies of AMS, 25 (76%) give instructions to consider trauma, 20 (61%) to consider stroke, and 18 (55%) to consider seizure. Twenty-three (70%) of the agencies have separate pediatric AMS protocols; others include pediatric considerations within the adult protocol.

Conclusion

Protocols for patients with AMS vary widely across the State of California. The evidence-based recommendations that we present for the prehospital diagnosis and treatment of this condition may be useful for EMS medical directors tasked with creating and revising these protocols.

Association between Glycemic Control and Clinic Attendance in Emerging Adults with Type 1 Diabetes: A Tertiary Center Experience

AIMS

The transition of emerging adults with type 1 diabetes (T1D) from pediatric diabetes clinics to adult clinics between 18 and 21 years of age could result in decreased clinic attendance and thus worsen glycemic control. Our institutional policy offering surveillance till age 30 enabled us to evaluate clinic attendance without the confounding effect of transition. Our aim was to determine the association between glycemic control (HbA1c) and attendance rate.

METHODS

The medical records of 261 (54% males) young adult T1D patients (median age 22.9 years) were reviewed. Patients were stratified according to the attainment/nonattainment of glycemic targets (HbA1c ≤ 7% versus HbA1c > 7% (53 mmol/mol)). The attendance rate was calculated as the number of clinic visits/number of scheduled appointments.

RESULTS

Median annual number of scheduled visits was 3 (3, 4); attendance rate was 75% (53.6%, 100%). Seventy-four (28.4%) patients attained glycemic targets (median HbA1c 6.5% (48 mmol/mol) (6.3%, 6.8% (45.51 mmol/mol)); 187 (71.6%) patients had a median HbA1c of 7.8% (62 mmol/mol) (7.4%, 8.4% (57.68 mmol/mol)). The attainment of the treatment target was more prevalent in older patients (P = 0.006), in male patients (P = 0.007), and in patients with higher education (P = 0.017). Higher attendance rate (β (2.483), P < 0.001) and male gender (β (0.746), P = 0.015) were associated with better metabolic control.

CONCLUSIONS

In emerging adults with T1D during the ongoing stable phase of diabetes management, higher attendance rate, rather than absolute number of clinic visits, was associated with the attainment of glycemic targets.

Older people with Type 2 diabetes, including those with chronic kidney disease or dementia, are commonly overtreated with sulfonylurea or insulin therapies

AIM

To evaluate potential overtreatment with sulfonylurea and insulin therapies amongst older people with Type 2 diabetes, including those with chronic kidney disease or dementia.

METHODS

Using the ECLIPSE Live software tool, we developed a search to examine data on older people (age ≥ 70 years) with Type 2 diabetes, who were prescribed sulfonylurea or insulin therapies over the previous 90 days. Sixteen Norfolk general practices participated, representing a population of 24 661 older people, including 3862 (15.7%) with Type 2 diabetes. Of these, 1379 (35.7%) people were prescribed sulfonylurea or insulin therapies. Data extracted included age, sex, last recorded HbA_1c value, renal function and dementia codes.

RESULTS

The median age of the study cohort was 78 years. A total of 644 people (47.8%) had chronic kidney disease (estimated GFR < 60 mL/min/1.73m² ) and 60 people (4.35%) had dementia. The median (interquartile range) HbA_1c concentration for the entire cohort was 58 (51-69) mmol/mol [7.5 (6.8-8.5)%], with no difference in median HbA_1c between those with or without either chronic kidney disease or dementia. In total, 400 older people (29.9%) had an HbA_1c concentration < 53 mmol/mol (7%), of whom 162 (12.1%) had HbA_1c < 48 mmol/mol (6.5%). Stratified by prescription for sulfonylurea, insulin or combined insulin and sulfonylurea therapies, 282 (35.2%), 93 (24.2%) and 25 people (16.3%), respectively, had HbA_1c < 53 mmol/mol (7.0%). Treatment to an HbA_1c target of < 53 mmol/mol (7.0%) was as prevalent in those with chronic kidney disease or dementia as in those without.

CONCLUSION

In the present cohort of older people with Type 2 diabetes prescribed sulfonylurea or insulin therapies, overtreatment was common, even in the presence of comorbidities known to increase hypoglycaemia risk.

Presentations for hypoglycemia associated with diabetes mellitus to emergency departments in a Canadian province: A database and epidemiological analysis

AIMS

The prevalence of diabetes mellitus was reportedly 9% in 2014, making it one of the most common global chronic conditions. Hypoglycemia is an important complication of diabetes treatment. The objective of this study was to quantify and characterize hypoglycemia presentations associated with type 1 or 2 diabetes made to emergency departments (EDs) by adults in a Canadian province.

METHODS

A retrospective cohort study was conducted using reliable administrative data from Alberta for a five-year period (2010/11-2014/15). Records of interest were those with an ICD-10-CA diagnosis of diabetes-associated hypoglycemia (e.g., E10.63). A descriptive analysis was conducted.

RESULTS

Data extraction yielded 7835 presentations by 5884 patients. The majority (56.2%) of presentations were made by males, median patient age was 62, and 60.5% had type 2 diabetes. These episodes constituted 0.08% of presentations to Alberta EDs. The annual rate of presentations decreased by 11.8% during the five-year period. Most presentations (63.4%) involved transportation to ED via ambulance. Median length-of-stay was four hours. For 27.5% of presentations, an X-ray was obtained. Most hypoglycemic episodes (65.2%) were considered to be moderate, while 34.3% were considered to be severe.

CONCLUSIONS

Diabetes-associated hypoglycemia presentations to Alberta EDs are more commonly made by patients with type 2 diabetes, who are more likely to be transported via ambulance and also admitted. Each year, approximately one percent of Albertans with diabetes presented with a hypoglycemia episode; however, knowledge of the variation across regions can guide a strategy for improved care.

Sentinel visits in emergency department patients with diabetes mellitus as a warning sign for hyperglycemic emergencies

Objectives

Patients with poorly controlled diabetes mellitus may have a sentinel emergency department (ED) visit for a precipitating condition prior to presenting for a hyperglycemic emergency, such as diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS). This study’s objective was to describe the epidemiology and outcomes of patients with a sentinel ED visit prior to their hyperglycemic emergency visit.

Methods

This was a 1-year health records review of patients≥18 years old presenting to one of four tertiary care EDs with a discharge diagnosis of hyperglycemia, DKA, or HHS. Trained research personnel collected data on patient characteristics, management, disposition, and determined whether patients came to the ED within the 14 days prior to their hyperglycemia visit. Descriptive statistics were used to summarize the data.

Results

Of 833 visits for hyperglycemia, 142 (17.0%; 95% CI: 14.5% to 19.6%) had a sentinel ED presentation within the preceding 14 days. Mean (SD) age was 50.5 (19.0) years and 54.4% were male; 104 (73.2%) were discharged from this initial visit, and 98/104 (94.2%) were discharged either without their glucose checked or with an elevated blood glucose (>11.0 mmol/L). Of the sentinel visits, 93 (65.5%) were for hyperglycemia and 22 (15.5%) for infection. Upon returning to the ED, 61/142 (43.0%) were admitted for severe hyperglycemia, DKA, or HHS.

Conclusion

In this unique ED-based study, diabetic patients with a sentinel ED visit often returned and required subsequent admission for hyperglycemia. Clinicians should be vigilant in checking blood glucose and provide clear discharge instructions for follow-up and glucose management to prevent further hyperglycemic emergencies from occurring.

Current practice of hypoglycemia management in the ED

PURPOSE

To characterize hypoglycemia management and identify characteristics associated with refractory (need for additional treatment following initial management) and recurrent (adequate initial treatment followed by blood glucose [BG] ≤50 mg/dL) hypoglycemia.

METHODS

Retrospective review of adult emergency department (ED) patients who presented to a large academic medical center with hypoglycemia (BG ≤ 50 mg/dL) between January 2011 and July 2015. Data collection focused on BG measurements and treatment practices. Data are reported using descriptive statistics, Wilcoxon rank sum, and χ² analysis as appropriate.

RESULTS

Two hundred forty-four patients were included (mean age, 59 ± 18.7 years; weight, 85 ± 24.3 kg). Patients arriving via prehospital care (n = 124) were assessed faster in the ED (median, 25 minutes; interquartile range [IQR], 10-40 minutes) compared with ambulatory arrival (median, 43 minutes; IQR, 17-95 minutes; P = .0018). There were 174 patients with a BG ≤ 50 mg/dL in the ED. Of those, 108 (62.1%) were treated with intravascular bolus dextrose/intramuscular glucagon and 21 patients (12%) did not receive any treatment or food. The overall median time to treatment after identification of hypoglycemia was 12 minutes (IQR, 6-27.8 minutes); treatment was administered faster after bedside point-of-care testing assessment compared with when serum samples resulted (11 [IQR, 6-23.5] minutes vs 25 [IQR, 10.75-42.5] minutes, respectively; P = .015). The overall time to repeat BG was obtained 22 (IQR, 8-44) minutes after bolus treatment, but this interval increased with subsequent measurements. Refractory or recurrent hypoglycemia occurred in 30.3% of patients. Mean initial BG was lower in the subset of patients who developed refractory hypoglycemia compared with those who did not (35.1 ± 9.8 vs 37.6 ± 10.2 mg/dL, P = .079), although not statistically significant. Patients with recurrent hypoglycemia were also less likely to receive dextrose containing intravenous fluids compared with those without recurrent hypoglycemia (P = .028). Infection was the only associated characteristic with refractory or recurrent hypoglycemia (P = .021).

CONCLUSIONS

Overall, 12% of patients did not receive treatment for hypoglycemia in the ED with a BG ≤ 50 mg/dL. Time to treatment after identification was faster when identified by care testing vs serum sample result. Time to repeat BG in the ED was relatively quick, but did increase over time. About one-third of patients had refractory or recurrent hypoglycemia and infection was associated with this occurrence. Lack of dextrose containing intravenous fluid was associated with the incidence of recurrent hypoglycemia.

Preventing Unnecessary Costs of Drug-Induced Hypoglycemia in Older Adults with Type 2 Diabetes in the United States and Canada

BACKGROUND

The costs of drug-induced hypoglycemia are a critical but often neglected component of value-based arguments to reduce tight glycemic control in older adults with type 2 diabetes.

METHODS

An economic (decision-tree) analysis compared rates, costs, quality-adjusted life-years, and incremental costs per quality-adjusted life-year gained associated with mild, moderate and severe hypoglycemic events for 6 glucose-lowering medication classes in type 2 diabetic adults aged 65-79 versus those 80 years and older. The national U.S. (Center for Medicare Services) and Canadian public health payer perspectives were adopted.

FINDINGS

Incidence rates of drug-induced hypoglycemia were the highest for basal insulin and sulfonylureas: 8.64 and 4.32 events per person-year in 65-79 year olds, and 12.06 and 6.03 events per person-year for 80 years and older. In both the U.S. and Canada, metformin dominated sulfonylureas, basal insulin and glucagon-like peptide1 receptor agonists. Relative to sulfonylureas, thiazolidinediones had the lowest incremental cost-effectiveness ratios in the U.S. and dominated sulfonylureas in Canada for adults 80 years and older. Relative to sulfonylureas, dipeptidyl peptidase4 inhibitors were cost-effective for adults 80 years and older in both countries, and for 65-79 year olds in Canada. Annual costs of hypoglycemia for older adults attaining very tight glycemic control with the use of insulin or sulfonylureas were estimated at U.S.$509,214,473 in the U.S. and CAN$65,497,849 in Canada.

CONCLUSIONS

Optimizing drug therapy for older type 2 diabetic adults through the avoidance of drug-induced hypoglycemia will dramatically improve patient health while also generating millions of dollars by saving unnecessary medical costs.

Economic resources consumption structure in severe hypoglycemia episodes: a systematic review and meta-analysis

Diabetes mellitus (DM) is associated with severe hypoglycemia events (SHEs) that vary in severity and resource consumption. Here we perform a systematic review in Medline of studies evaluating SHE-related health resource use. Eligible studies investigated patients with DM and included ≥10 SHEs. We also assessed studies identified in another systematic review, and through references from the included studies. We identified 14 relevant studies and used data from 11 (encompassing 6075 patients). Study results were interpreted to fit our definitions, which sometimes required assumptions. SHE type structure was synthesized using Bayesian modeling. Estimating Type 1 & 2 DM separately revealed only small differences; therefore, we used joint results. Of the analyzed SHEs, 9.97% were hospital-treated, 22.3% medical professional-treated, and 67.73% family-treated. These meta-analysis results help in understanding the structure of resource consumption following SHE and can be used in economic studies.