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ElSayed NA, Aleppo G, Bannuru RR, Bruemmer D, Collins BS, Ekhlaspour L, Galindo RJ, Hilliard ME, Johnson EL, Khunti K, Lingvay I, Matfin G, McCoy RG, Perry ML, Pilla SJ, Polsky S, Prahalad P, Pratley RE, Segal AR, Seley JJ, Stanton RC, Gabbay RA. 16. Diabetes Care in the Hospital: Standards of Care in Diabetes-2024. Diabetes Care 2024; 47:S295-S306. [PMID: 38078585 PMCID: PMC10725815 DOI: 10.2337/dc24-s016] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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ElSayed NA, Aleppo G, Aroda VR, Bannuru RR, Brown FM, Bruemmer D, Collins BS, Hilliard ME, Isaacs D, Johnson EL, Kahan S, Khunti K, Leon J, Lyons SK, Perry ML, Prahalad P, Pratley RE, Seley JJ, Stanton RC, Gabbay RA, on behalf of the American Diabetes Association. 16. Diabetes Care in the Hospital: Standards of Care in Diabetes-2023. Diabetes Care 2023; 46:S267-S278. [PMID: 36507644 PMCID: PMC9810470 DOI: 10.2337/dc23-s016] [Citation(s) in RCA: 85] [Impact Index Per Article: 85.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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Crossen SS, Bruggeman BS, Haller MJ, Raymond JK. Challenges and Opportunities in Using Telehealth for Diabetes Care. Diabetes Spectr 2022; 35:33-42. [PMID: 35308158 PMCID: PMC8914589 DOI: 10.2337/dsi21-0018] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The ongoing coronavirus pandemic led to a rapid and dramatic increase in the use of telehealth for diabetes care. In the wake of this transition, we examine new opportunities and ongoing challenges for using telehealth within diabetes management, based on data and experiences from the pre-pandemic and pandemic time frames.
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Affiliation(s)
- Stephanie S. Crossen
- Division of Pediatric Endocrinology, University of California, Davis, Sacramento, CA
| | | | - Michael J. Haller
- Division of Pediatric Endocrinology, University of Florida, Gainesville, FL
| | - Jennifer K. Raymond
- Division of Pediatric Endocrinology, Children’s Hospital Los Angeles, Los Angeles, CA
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Abstract
The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc22-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc22-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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Saito K, Inoue T, Ariyasu H, Shimada T, Itoh H, Tanaka I, Terao C. The usefulness of subclassification of adult diabetes mellitus among inpatients in Japan. J Diabetes Investig 2021; 13:706-713. [PMID: 34743418 PMCID: PMC9017630 DOI: 10.1111/jdi.13707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 11/02/2021] [Accepted: 11/04/2021] [Indexed: 12/01/2022] Open
Abstract
Aims/Introduction We aimed to replicate a new diabetes subclassification based on objective clinical information at admission in a diabetes educational inpatient program. We also assessed the educational outcomes for each cluster. Methods We included diabetes patients who participated in the educational inpatient program during 2009–2020 and had sufficient clinical information for the cluster analysis. We applied a data‐driven clustering method proposed in a previous study and further evaluated the clinical characteristics of each cluster. We investigated the association between the clusters and changes in hemoglobin A1c level from the start of the education program. We also assessed the risk of re‐admission for the educational program. Results We divided a total of 651 patients into five clusters. Their clinical characteristics followed the same pattern as in previous studies. The intercluster ranking of the cluster center coordinates showed strong correlation coefficients with those of the previous studies (mean ρ = 0.88). Patients classified as severe insulin‐resistant diabetes (cluster 3) showed a more pronounced progression of renal dysfunction than patients classified as the other clusters. The patients classified as severe insulin‐deficient diabetes (cluster 2) had the highest rate of reduction in hemoglobin A1c level from the start of the program (P < 0.01) and a tendency toward a lower risk of re‐admission for the education program (hazard ratio 0.47, P = 0.09). Conclusion We successfully replicated the diabetes subclassification using objective clinical information at admission for the education program. In addition, we showed that severe insulin‐deficient diabetes patients tended to have better educational outcomes than patients classified as the other clusters.
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Affiliation(s)
- Kohei Saito
- Center for Diabetes, Endocrinology and MetabolismShizuoka General HospitalShizuokaJapan
- Department of Endocrinology, Metabolism and NephrologyKeio University School of MedicineTokyoJapan
- Clinical Research CenterShizuoka General HospitalShizuokaJapan
| | - Tatsuhide Inoue
- Center for Diabetes, Endocrinology and MetabolismShizuoka General HospitalShizuokaJapan
| | - Hiroyuki Ariyasu
- Center for Diabetes, Endocrinology and MetabolismShizuoka General HospitalShizuokaJapan
| | - Toshio Shimada
- Clinical Research CenterShizuoka General HospitalShizuokaJapan
| | - Hiroshi Itoh
- Department of Endocrinology, Metabolism and NephrologyKeio University School of MedicineTokyoJapan
| | - Issei Tanaka
- Center for Diabetes, Endocrinology and MetabolismShizuoka General HospitalShizuokaJapan
| | - Chikashi Terao
- Clinical Research CenterShizuoka General HospitalShizuokaJapan
- Department of Applied GeneticsSchool of Pharmaceutical SciencesUniversity of ShizuokaShizuokaJapan
- Laboratory for Statistical and Translational GeneticsRIKEN Center for Integrative Medical SciencesKanagawaJapan
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Bhalodkar A, Sonmez H, Lesser M, Leung T, Ziskovich K, Inlall D, Murray-Bachmann R, Krymskaya M, Poretsky L. The Effects of a Comprehensive Multidisciplinary Outpatient Diabetes Program on Hospital Readmission Rates in Patients with Diabetes: A Randomized Controlled Prospective Study. Endocr Pract 2021; 26:1331-1336. [PMID: 33471664 DOI: 10.4158/ep-2020-0261] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 07/07/2020] [Indexed: 01/04/2023]
Abstract
OBJECTIVE The diagnosis of diabetes mellitus is associated with an increased risk of hospital readmissions. The goal of this study was to determine whether there was a difference in the rates of 30-day and 365-day hospital readmissions between diabetic patients who, upon their discharge, received diabetes care in a standard primary care setting and those who received their care in a specialized multidisciplinary diabetes program. METHODS This was a randomized controlled prospective study. RESULTS One hundred and ninety two consecutive patients were recruited into the study, 95 (49%) into standard care (control group) and 97 (51%) into a multidisciplinary diabetes program (intervention group). The 30-day overall hospital readmission rates (including both emergency department and hospital readmissions) were 19% in the control group and 7% in the intervention group (P = .02). The 365-day overall hospital readmission rates were 38% in the control group and 14% in the intervention group (P = .0002). CONCLUSION Patients with diabetes who are assigned to a specialized multidisciplinary diabetes program upon their discharge exhibit significantly reduced hospital readmission rates at 30 days and 365 days after discharge.
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Affiliation(s)
- Arpita Bhalodkar
- Division of Endocrinology, Friedman Diabetes Institute, Department of Medicine, Lenox Hill Hospital, Northwell Health, New York, New York
| | - Halis Sonmez
- Division of Endocrinology, Friedman Diabetes Institute, Department of Medicine, Lenox Hill Hospital, Northwell Health, New York, New York
| | - Martin Lesser
- Biostatistics Unit - Feinstein Institutes for Medical Research, Northwell Health, Great Neck, New York
| | - Tungming Leung
- Biostatistics Unit - Feinstein Institutes for Medical Research, Northwell Health, Great Neck, New York
| | - Karina Ziskovich
- Division of Endocrinology, Friedman Diabetes Institute, Department of Medicine, Lenox Hill Hospital, Northwell Health, New York, New York
| | - Damian Inlall
- Division of Endocrinology, Friedman Diabetes Institute, Department of Medicine, Lenox Hill Hospital, Northwell Health, New York, New York
| | - Renee Murray-Bachmann
- Division of Endocrinology, Friedman Diabetes Institute, Department of Medicine, Lenox Hill Hospital, Northwell Health, New York, New York
| | - Marina Krymskaya
- Division of Endocrinology, Friedman Diabetes Institute, Department of Medicine, Lenox Hill Hospital, Northwell Health, New York, New York
| | - Leonid Poretsky
- Division of Endocrinology, Friedman Diabetes Institute, Department of Medicine, Lenox Hill Hospital, Northwell Health, New York, New York.
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Abstract
The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc21-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc21-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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Abstract
Diabetes management is well suited to use of telehealth, and recent improvements in both diabetes technology and telehealth policy make this an ideal time for diabetes providers to begin integrating telehealth into their practices. This article provides background information, specific recommendations for effective implementation, and a vision for the future landscape of telehealth within diabetes care to guide interested providers and practices on this topic. Note: This article was written prior to the COVID19 pandemic, and does not include information about recent telehealth policy changes that occurred during or as a result of this public health crisis.
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Affiliation(s)
- Stephanie Crossen
- Department of Pediatrics, University of California, Davis, Sacramento, California
- UC Davis Center for Health and Technology, Sacramento, California
- Address correspondence to: Stephanie Crossen, MD, MPH, Department of Pediatrics, University of California, Davis, 2516 Stockton Boulevard, Sacramento, CA 95817
| | - Jennifer Raymond
- Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Aaron Neinstein
- Department of Medicine, University of California, San Francisco, San Francisco, California
- UCSF Center for Digital Health Innovation, San Francisco, California
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Abstract
The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc20-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc20-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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Crossen SS, Marcin JP, Qi L, Sauers-Ford HS, Reggiardo AM, Chen ST, Tran VA, Glaser NS. Home Visits for Children and Adolescents with Uncontrolled Type 1 Diabetes. Diabetes Technol Ther 2020; 22:34-41. [PMID: 31448952 PMCID: PMC6945797 DOI: 10.1089/dia.2019.0214] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background: Home-based video visits were provided over one year as a supplement to in-person care for pediatric type 1 diabetes (T1D) patients with suboptimal glycemic control. We hypothesized that the intervention would be feasible and satisfactory for the target population and would significantly improve hemoglobin A1c (HbA1c) levels and completion of recommended quarterly diabetes clinic visits. Methods: This was a nonrandomized clinical trial. Fifty-seven patients aged 3-17 years with known T1D and HbA1c ≥8% (64 mmol/mol) were recruited to receive the intervention. The study population was 49% adolescent (13-17 years old) and 58% publicly insured patients. Video visits were scheduled every 4, 6, or 8 weeks depending on the HbA1c level. HbA1c levels as well as frequencies of clinic visits and of diabetes-related emergency department (ED) and hospital encounters were compared before and after the study. Results: Thirty participants completed 12 months of video visits. The study cohort demonstrated significant improvement in mean HbA1c in both intention-to-treat (N = 57) analysis (10.8% [95 mmol/mol] to 10.0% [86 mmol/mol], P = 0.01) and per-protocol (N = 30) analysis (10.8% [95 mmol/mol] to 9.6% [81 mmol/mol], P = 0.004). Completion of ≥4 annual diabetes clinic visits improved significantly from 21% at baseline to 83% during the study period for the entire cohort, P < 0.0001. The frequency of diabetes-related ED and hospital encounters did not change significantly. Conclusions: Home-based video visits are a feasible supplement to in-person care for children and adolescents with T1D and suboptimal glycemic control and can successfully improve HbA1c levels and adherence to recommended frequency of care in this high-risk clinical population.
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Affiliation(s)
- Stephanie S. Crossen
- Department of Pediatrics, University of California, Davis Health System, Sacramento, California
- Address correspondence to: Stephanie S. Crossen, MD, MPH, Department of Pediatrics, UC Davis Health, 2516 Stockton Boulevard, Sacramento, CA 95817
| | - James P. Marcin
- Department of Pediatrics, University of California, Davis Health System, Sacramento, California
| | - Lihong Qi
- Department of Public Health Sciences, University of California, Davis, Davis, California
| | - Hadley S. Sauers-Ford
- Department of Pediatrics, University of California, Davis Health System, Sacramento, California
| | - Allison M. Reggiardo
- Department of Pediatrics, University of California, Davis Health System, Sacramento, California
| | - Shelby T. Chen
- Department of Pediatrics, University of California, Davis Health System, Sacramento, California
| | - Victoria A. Tran
- Department of Pediatrics, University of California, Davis Health System, Sacramento, California
| | - Nicole S. Glaser
- Department of Pediatrics, University of California, Davis Health System, Sacramento, California
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Dungan K, Lyons S, Manu K, Kulkarni M, Ebrahim K, Grantier C, Harris C, Black D, Schuster D. An individualized inpatient diabetes education and hospital transition program for poorly controlled hospitalized patients with diabetes. Endocr Pract 2019; 20:1265-73. [PMID: 25100371 DOI: 10.4158/ep14061.or] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To evaluate predictors of outcomes associated with an inpatient diabetes education and discharge support program for hospitalized patients with poorly controlled diabetes (glycated hemoglobin [HbA1c]>9%). METHODS Patients participated in individualized diabetes education conducted by a certified diabetes educator (CDE) that included an exploration of barriers and goal setting during hospitalization with telephone follow-up and communication with primary providers at discharge. Predictors of HbA1c reduction, successful follow-up, and readmission were analyzed. RESULTS There were 82 subjects, and 48% were insulin naïve. Patients with type 2 diabetes (T2D, n = 58) had a significant decrease in HbA1c at follow-up (-2.8%, P<.0001), while those with type 1 diabetes (T1D, n = 19) did not (+0.02%, P = .96). However, after adjustment for other factors, only increasing age, higher baseline HbA1c, earlier education, and initiation of basal insulin were significant predictors of reduction in HbA1c. Higher area level income and empowerment and earlier education were significant predictors of outpatient follow-up within 30 days. While 28% were admitted for severe hyperglycemia, only 1 patient was readmitted with severe hyperglycemia. Successful phone contact was 77% and 57% with and without the support of non-CDE assistants respectively, but all outcomes were similar. CONCLUSION The study suggests that an individualized inpatient diabetes education and transition program is associated with a significant reduction in HbA1c that is dependent on baseline HbA1c, older age, initiation of insulin, and earlier enrollment. Additional interventions are needed to ensure better continuity of care.
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Affiliation(s)
- Kathleen Dungan
- Division of Endocrinology, The Ohio State University, Diabetes & Metabolism
| | - Sharon Lyons
- Division of Endocrinology, The Ohio State University, Diabetes & Metabolism
| | - Kavya Manu
- The Ohio State University College of Medicine
| | | | | | - Cara Grantier
- The Ohio State University College of Public Health, Columbus, Ohio
| | - Cara Harris
- Division of Endocrinology, The Ohio State University, Diabetes & Metabolism
| | - Dawn Black
- Division of Endocrinology, The Ohio State University, Diabetes & Metabolism
| | - Dara Schuster
- Division of Endocrinology, The Ohio State University, Diabetes & Metabolism
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Crossen S, Glaser N, Sauers-Ford H, Chen S, Tran V, Marcin J. Home-based video visits for pediatric patients with poorly controlled type 1 diabetes. J Telemed Telecare 2019; 26:349-355. [PMID: 30871408 DOI: 10.1177/1357633x19828173] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Management of type 1 diabetes (T1D) is labor-intensive, requiring multiple daily blood glucose measurements and insulin injections. Patients are seen quarterly by providers, but evidence suggests more frequent contact is beneficial. Current technology allows secure, remote sharing of diabetes data and video-conferencing between providers and patients in their home settings. METHODS Home-based video visits were provided for six months to pediatric T1D patients with poor glycemic control, indicated by a hemoglobin A1c (HbA1c) ≥8% at enrollment. Video visits were conducted every 4-8 weeks in addition to regularly scheduled clinic visits. Dates of clinic visits and HbA1c values were abstracted from the medical record at baseline and six months. Patients were surveyed at video visits regarding technical issues, and after six months a standardized survey was administered to assess satisfaction with video-based care. RESULTS A total of 57 patients enrolled and 36 completed six months of video visits. Patients completing six months averaged 4.0 video visits (SD 1.1). Their frequency of in-person care also increased from 3.2 clinic visits/year at baseline to 3.7 clinic visits/year during the study (P = 0.04). Mean HbA1c reduction among patients completing six months was 0.8% (95% CI 0.2-1.4%); 94% of these patients were "very satisfied" while 6% were "somewhat satisfied" with the experience. DISCUSSION This study demonstrates that home-based video visits are feasible and satisfactory for pediatric patients with poorly controlled T1D. Furthermore, use of video visits can improve frequency of subspecialty care and resulting glycemic control in this population.
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Affiliation(s)
- Stephanie Crossen
- Division of Pediatric Endocrinology and Diabetes, University of California, CA, USA
| | - Nicole Glaser
- Division of Pediatric Endocrinology and Diabetes, University of California, CA, USA
| | | | - Shelby Chen
- Center for Health and Technology, University of California, CA, USA
| | - Victoria Tran
- Division of Pediatric Endocrinology and Diabetes, University of California, CA, USA
| | - James Marcin
- Center for Health and Technology, University of California, CA, USA
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Abstract
The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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Abstract
This article was originally published with errors that were introduced during the editing process. The corrected version of this article appears below.
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Affiliation(s)
- Daniel J Rubin
- Section of Endocrinology, Diabetes, and Metabolism, School of Medicine, Temple University, 3322 N. Broad ST., Ste 205, Philadelphia, PA, 19140, USA.
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Abstract
The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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Golden SH, Maruthur N, Mathioudakis N, Spanakis E, Rubin D, Zilbermint M, Hill-Briggs F. The Case for Diabetes Population Health Improvement: Evidence-Based Programming for Population Outcomes in Diabetes. Curr Diab Rep 2017; 17:51. [PMID: 28567711 PMCID: PMC5553206 DOI: 10.1007/s11892-017-0875-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
PURPOSE OF REVIEW The goal of this review is to describe diabetes within a population health improvement framework and to review the evidence for a diabetes population health continuum of intervention approaches, including diabetes prevention and chronic and acute diabetes management, to improve clinical and economic outcomes. RECENT FINDINGS Recent studies have shown that compared to usual care, lifestyle interventions in prediabetes lower diabetes risk at the population-level and that group-based programs have low incremental medial cost effectiveness ratio for health systems. Effective outpatient interventions that improve diabetes control and process outcomes are multi-level, targeting the patient, provider, and healthcare system simultaneously and integrate community health workers as a liaison between the patient and community-based healthcare resources. A multi-faceted approach to diabetes management is also effective in the inpatient setting. Interventions shown to promote safe and effective glycemic control and use of evidence-based glucose management practices include provider reminder and clinical decision support systems, automated computer order entry, provider education, and organizational change. Future studies should examine the cost-effectiveness of multi-faceted outpatient and inpatient diabetes management programs to determine the best financial models for incorporating them into diabetes population health strategies.
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Affiliation(s)
- Sherita Hill Golden
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, 1830 E. Monument Street, Suite no. 333, Baltimore, MD, 21287, USA.
- Departments of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Nisa Maruthur
- Departments of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nestoras Mathioudakis
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, 1830 E. Monument Street, Suite no. 333, Baltimore, MD, 21287, USA
| | - Elias Spanakis
- Division of Endocrinology, Diabetes and Nutrition, Department of Medicine, University of Maryland Medical System, Baltimore, MD, USA
| | - Daniel Rubin
- Division of Endocrinology and Metabolism, Department of Medicine, Temple University School of Medicine, Philadelphia, PA, USA
| | - Mihail Zilbermint
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, 1830 E. Monument Street, Suite no. 333, Baltimore, MD, 21287, USA
- Johns Hopkins Community Physicians at Suburban Hospital, Bethesda, MD, USA
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Felicia Hill-Briggs
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, 1830 E. Monument Street, Suite no. 333, Baltimore, MD, 21287, USA
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Health, Behavior, and Society, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
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Crossen SS, Wilson DM, Saynina O, Sanders LM. Outpatient Care Preceding Hospitalization for Diabetic Ketoacidosis. Pediatrics 2016; 137:peds.2015-3497. [PMID: 27207491 PMCID: PMC4894257 DOI: 10.1542/peds.2015-3497] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/08/2016] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To identify patterns of outpatient care associated with diabetic ketoacidosis (DKA) among pediatric patients with type 1 diabetes (T1D). METHODS Retrospective cohort study using Medicaid claims data from 2009 to 2012 for children with T1D enrolled ≥365 consecutive days in California Children's Services, a Title V program for low-income children with chronic disease. Outcome was DKA hospitalization >30 days after enrollment. Outpatient visits to primary care, endocrinology, pharmacies, and emergency departments (EDs) were assessed during the 6 months before an index date: either date of first DKA hospitalization or end of enrollment for those without DKA. Univariate and multivariate analysis was used to evaluate independent associations between DKA and outpatient care at clinically meaningful intervals preceding the index date. RESULTS Among 5263 children with T1D, 16.7% experienced DKA during the study period. Patients with DKA were more likely to have had an ED visit (adjusted odds ratio [aOR] 3.99, 95% confidence interval [CI]: 2.60-6.13) or a nonpreventive primary care visit (aOR 1.35, 95% CI: 1.01-1.79) within 14 days before the index date, and less likely to have visited an endocrinologist (aOR 0.76, 95% CI: 0.65-0.89) within the preceding 120 days. Preventive visits and pharmacy claims were not associated with DKA. CONCLUSIONS For children with T1D, recent ED visits and long intervals without subspecialty care are important signals of impending DKA. Combined with other known risk factors, these health-use indicators could be used to inform clinical and case management interventions that aim to prevent DKA hospitalizations.
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Affiliation(s)
| | | | - Olga Saynina
- Center for Primary Care and Outcomes Research, and
| | - Lee M. Sanders
- Center for Primary Care and Outcomes Research, and,General Pediatrics, Stanford University School of Medicine, Stanford, California
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Simmons D, Hartnell S, Watts J, Ward C, Davenport K, Gunn E, Jenaway A. Effectiveness of a multidisciplinary team approach to the prevention of readmission for acute glycaemic events. Diabet Med 2015; 32:1361-7. [PMID: 25865087 DOI: 10.1111/dme.12779] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/08/2015] [Indexed: 11/30/2022]
Abstract
AIMS To describe the effect of a combined diabetes specialist/mental health team approach to prevent readmissions for acute glycaemic events among patients with diabetes. METHODS Consecutive patients with diabetes, readmitted to a single hospital for an acute glycaemic condition, were offered one or more diabetes (including assessment, education, medication, technology use and intensive support) and mental health (including assessment, training and therapies) interventions. The pilot service took place over 11 months, with the preceding 24 months and subsequent 8 months serving as control periods. RESULTS Of the 58 patients admitted, 50 had Type 1 diabetes and were from within the hospital catchment area, and were discharged home. Of these, 32 (64%) had a pre-existing mental health issue and 14 (28%) had a complex social situation. In all, 96% of patients were met as an inpatient by a team member, and 94% accepted at least one intervention. The mean ±sd number of admissions per patient/month dropped from 0.12 ± 0.10 to 0.05 ± 0.10 (P < 0.001) during the intervention, increasing, once the intervention ended, to 0.16 ± 0.36 (P = 0.002). The mean ± sd length of stay similarly decreased and increased (0.6 ± 0.9 to 0.2 ± 0.7 days; P < 0.001 to 0.006) to 0.6 ± 1.4 days (P = 0.003) per patient/month) across the three periods, as did the mean ±sd tariff paid per patient/month (₤258.0 ± 374.0 vs ₤92.1 ± 245.0 vs ₤287.3 ± 563.8; P < 0.001 and P = 0.018, respectively). The mean ± sd HbA1c level dropped from 99 ± 22 to 92 ± 24 mmol/mol (11.2 ± 4.2% vs 10.6 ± 4.3%; P = 0.014) but did not increase after the intervention [89 ± 26 mmol/mol (10.4 ± 4.5%)]. CONCLUSIONS The cost and long-term risks of hospitalization among patients with Type 1 diabetes and recurrent admissions can be reduced by a combined specialist diabetes/mental health team approach.
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Affiliation(s)
- D Simmons
- Institute of Metabolic Science, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - S Hartnell
- Institute of Metabolic Science, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - J Watts
- Institute of Metabolic Science, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - C Ward
- Institute of Metabolic Science, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - K Davenport
- Institute of Metabolic Science, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - E Gunn
- Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, UK
| | - A Jenaway
- Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, UK
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20
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Abstract
Hospital readmission is a high-priority health care quality measure and target for cost reduction. Despite broad interest in readmission, relatively little research has focused on patients with diabetes. The burden of diabetes among hospitalized patients, however, is substantial, growing, and costly, and readmissions contribute a significant portion of this burden. Reducing readmission rates of diabetic patients has the potential to greatly reduce health care costs while simultaneously improving care. Risk factors for readmission in this population include lower socioeconomic status, racial/ethnic minority, comorbidity burden, public insurance, emergent or urgent admission, and a history of recent prior hospitalization. Hospitalized patients with diabetes may be at higher risk of readmission than those without diabetes. Potential ways to reduce readmission risk are inpatient education, specialty care, better discharge instructions, coordination of care, and post-discharge support. More studies are needed to test the effect of these interventions on the readmission rates of patients with diabetes.
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Affiliation(s)
- Daniel J Rubin
- Section of Endocrinology, Diabetes, and Metabolism, School of Medicine, Temple University, 3322 N. Broad ST., Ste 205, Philadelphia, PA, 19140, USA.
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21
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Healy SJ, Black D, Harris C, Lorenz A, Dungan KM. Inpatient diabetes education is associated with less frequent hospital readmission among patients with poor glycemic control. Diabetes Care 2013; 36:2960-7. [PMID: 23835695 PMCID: PMC3781555 DOI: 10.2337/dc13-0108] [Citation(s) in RCA: 132] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To explore the relationship between inpatient diabetes education (IDE) and hospital readmissions in patients with poorly controlled diabetes. RESEARCH DESIGN AND METHODS Patients with a discharge diagnosis of diabetes (ICD-9 code 250.x) and HbA1c>9% who were hospitalized between 2008 and 2010 were retrospectively identified. All-cause first readmissions were determined within 30 days and 180 days after discharge. IDE was conducted by a certified diabetes educator or trainee. Relationships between IDE and hospital readmission were analyzed with stepwise backward logistic regression models. RESULTS In all, 2,265 patients were included in the 30-day analysis and 2,069 patients were included in the 180-day analysis. Patients who received IDE had a lower frequency of readmission within 30 days than did those who did not (11 vs. 16%; P=0.0001). This relationship persisted after adjustment for sociodemographic and illness-related factors (odds ratio 0.66 [95% CI 0.51-0.85]; P=0.001). Medicaid insurance and longer stay were also independent predictors in this model. IDE was also associated with reduced readmissions within 180 days, although the relationship was attenuated. In the final 180-day model, no IDE, African American race, Medicaid or Medicare insurance, longer stay, and lower HbA1c were independently associated with increased hospital readmission. Further analysis determined that higher HbA1c was associated with lower frequency of readmission only among patients who received a diabetes education consult. CONCLUSIONS Formal IDE was independently associated with a lower frequency of all-cause hospital readmission within 30 days; this relationship was attenuated by 180 days. Prospective studies are needed to confirm this association.
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22
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Abstract
Hospital readmission is an important contributor to total medical expenditures and is an emerging indicator of quality of care. Diabetes, similar to other chronic medical conditions, is associated with increased risk of hospital readmission. Risk factors include previous hospitalization, extremes in age, and socioeconomic barriers. Preliminary studies suggest that acute and/or chronic glycemic control may be of importance when diabetes is the primary diagnosis or when it is a comorbidity. Very limited evidence from prospective randomized controlled trials aimed at improving glycemic control is available. However, whether one concludes that inpatient or outpatient glycemic control is partly responsible for reduced hospitalizations, attention to glycemic control in the hospital may facilitate sustained glycemic control post-discharge. Limited prospective and retrospective evidence suggest that the involvement of a diabetes specialist team may improve readmission rates, but attention to more generalized comprehensive approaches may also be worthwhile. Prospective interventional studies targeting interventions for improving glycemic control are needed to determine whether glycemic control impacts readmission rates.
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Affiliation(s)
- Kathleen M Dungan
- Division of Endocrinology, Diabetes, and Metabolism, Ohio State University, Columbus, Ohio 43210, USA.
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23
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Liu CC, Chen KR, Chen HF, Huang SL, Chen CC, Lee MD, Ko MC, Li CY. Association of doctor specialty with diabetic patient risk of hospitalization due to diabetic ketoacidosis: a national population-based study in Taiwan. J Eval Clin Pract 2011; 17:150-5. [PMID: 20825533 DOI: 10.1111/j.1365-2753.2010.01414.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Diabetic ketoacidosis (DKA) is a life-threatening complication of diabetes mellitus, and its risks can be largely reduced by adequate and high-quality ambulatory diabetic care. The aim of this study is to assess the risk and frequency of developing DKA in relation to the specialty of doctors who provide diabetes cares. METHODS In searching for possible episodes of hospitalization due to DKA (ICD-9-CM: 250.1), we used a prospective cohort design in which 500,867 diabetic patients identified in the 1997 National Health Insurance (NHI) ambulatory care data set of Taiwan were linked to the 1997-2006 NHI inpatient claims data. The study subjects were categorized into four groups according to doctor specialty. A logistic regression model was used to assess the risk and frequency of DKA admission in relation to doctor's specialty. RESULTS Compared with the patients routinely cared by endocrinologists, those not consistently cared by endocrinologists had significantly increased odds ratios (ORs) of DKA admission, ranging between 1.51 and 2.12. Moreover, the adjusted OR of the higher DKA admission frequency (≥ 0.133 times/person-year) for the patients not regularly cared by endocrinologists was also significantly increased, between 4.45 and 6.93. CONCLUSIONS Doctor specialty significantly influenced the risk and frequency of DKA admission in diabetes patients in Taiwan. Local health care administrators and policy makers should therefore consider promoting the quality of diabetes care provided by non-endocrinologists.
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Affiliation(s)
- Chih-Ching Liu
- Department of Nursing, Zhong-Xing Branch of Taipei City Hospital, Taipei, Taiwan
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24
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Weber C, Kocher S, Neeser K, Joshi SR. Prevention of diabetic ketoacidosis and self-monitoring of ketone bodies: an overview. Curr Med Res Opin 2009; 25:1197-207. [PMID: 19327102 DOI: 10.1185/03007990902863105] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Diabetic ketoacidosis (DKA) is associated with significant morbidity and mortality. Self-monitoring of ketone bodies by diabetes patients can be done using blood or urine. We compared the two self-monitoring methods and summarized recent developments in the epidemiology and management of DKA. METHODS MEDLINE and EMBASE were searched for relevant publications addressing the epidemiology, management and prevention of DKA up to 2009. The current, relevant publications, along with the authors' clinical and professional experience, were used to synthesize this narrative review. FINDINGS Despite considerable advances in diabetes therapy, key epidemiological figures related to DKA remained nearly unchanged during the last decades at a global level. Prevention of DKA - especially in sick day management - relies on intensive self-monitoring of blood glucose and subsequent, appropriate therapy adjustments. Self-monitoring of ketone bodies during hyperglycemia can provide important, complementary information on the metabolic state. Both methods for self-monitoring of ketone bodies at home are clinically reliable and there is no published evidence favoring one method with respect to DKA prevention. CONCLUSIONS DKA is still a severe complication potentially arising during prolonged hyperglycemic episodes with possibly fatal consequences. Education of patients and their social environment to promote frequent testing - especially during sick days - and to lower their glucose levels, as well as to recognize the early symptoms of hyperglycemia and DKA is of paramount importance in preventing the development of severe DKA. Both methods for self-monitoring of ketone bodies are safe and clinically reliable.
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Affiliation(s)
- Christian Weber
- IMIB Institute for Medical Informatics and Biostatistics, Basel, Switzerland
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25
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Abstract
Ketosis-prone diabetes (KPD) is a widespread, emerging, heterogeneous syndrome characterized by patients who present with diabetic ketoacidosis or unprovoked ketosis but do not necessarily have the typical phenotype of autoimmune type 1 diabetes. Multiple, severe forms of beta-cell dysfunction appear to underlie the pathophysiology of KPD. Until recently, the syndrome has lacked an accurate, clinically relevant and etiologically useful classification scheme. We have utilized a large, longitudinally followed, heterogeneous, multiethnic cohort of KPD patients to identify four clinically and pathophysiologically distinct subgroups that are separable by the presence or absence of beta-cell autoimmunity and the presence or absence of beta-cell functional reserve. The resulting "Abeta" classification system of KPD has proven to be highly accurate and predictive of such clinically important outcomes as glycemic control and insulin dependence, as well as an aid to biochemical and molecular investigations into novel causes of beta-cell dysfunction. In this review, we describe the current state of knowledge in regard to the natural history, pathophysiology, and treatment of the subgroups of KPD, with an emphasis on recent advances in understanding their immunological and genetic bases.
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Affiliation(s)
- Ashok Balasubramanyam
- Translational Metabolism Unit, Division of Diabetes, Endocrinology and Metabolism, Baylor College of Medicine, Room 700B, One Baylor Plaza, and Endocrine Service, Ben Taub General Hospital, Houston, Texas 77030, USA.
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26
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Abstract
Diabetic ketoacidosis (DKA) is an acute potentially life-threatening complication of diabetes affecting more than 100,000 persons annually in the United States. Although major advances have improved diabetes care, DKA remains the leading cause of hospitalization, morbidity, and death in youth with type 1 diabetes (T1D). As the majority of patients presenting with DKA have established diabetes, it is important to address outpatient educational approaches directed at sick-day management and early identification and treatment of impending DKA. Teaching and reinforcement of sick-day rules involves improved self-care with consistent self-monitoring of blood glucose and ketones, and timely administration of supplemental insulin and fluids. DKA as an initial manifestation of T1D may be less amendable to prevention except with an increased awareness by the lay and medical communities of the symptoms of diabetes and surveillance in high-risk populations potentially identified by family history or genetic susceptibility. New technologies that can detect the blood ketone 3beta-hydroxybutyrate (3beta-OHB) instead of traditional urine ketones appears to provide opportunity for early identification and treatment of impending DKA leading to reduced need for hospitalization and potential cost-savings.
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Affiliation(s)
- Elise Bismuth
- Joslin Diabetes Center, Section on Genetics and Epidemiology, Pediatric, Adolescent, and Young Adult Section, Harvard Medical School, MA 02215, USA
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27
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Maldonado M, D'Amico S, Otiniano M, Balasubramanyam A, Rodriguez L, Cuevas E. Predictors of glycaemic control in indigent patients presenting with diabetic ketoacidosis. Diabetes Obes Metab 2005; 7:282-9. [PMID: 15811146 DOI: 10.1111/j.1463-1326.2004.00394.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
AIM To derive predictors of good glycaemic control in patients presenting with diabetic ketoacidosis (DKA) followed prospectively in a specialized clinic. METHODS One hundred and sixty-one adult patients were admitted during a 31-month period and followed for at least 12 months. After 1 year, the patients were classified into three groups: good control (GC) (HbA1c < or = 7%), intermediate control (IC) (HbA1c 7-9%) and poor control (PC) (HbA1c > 9%). Characteristics of patients in the three groups were compared both at baseline and during follow-up. RESULTS At 12 months, 36% of the patients were classified as GC, 27% as IC and 37% as PC. GC patients had higher fasting serum C-peptide levels 0.7 +/- 0.54 compared to 0.38 +/- 0.29 and 0.16 +/- 0.21 nmol/l, respectively, for the IC and PC patients (p < 0.0001). A higher proportion GC patient had a C-peptide level greater than 0.33 nmol/l than that for IC and PC patients (86, 61 and 19%, respectively; p < 0.0001). Exogenous insulin was safely discontinued in 50, 30 and 3% of patients, respectively, in the GC, IC and PC groups (p < 0.0001). Compliance with life-style interventions was higher in the GC than that in IC and PC patients (87, 41 and 5%, respectively; p < 0.0001). In the logistic regression analysis, predictors of good glycaemic control were having baseline fasting serum C-peptide value > or =0.33 mmol/l, OR: 3.01 (95% CI 1.07-8.55, p = 0.03) and compliance with life-style interventions OR 12.66 (95% CI 3.73-51.57, p = 0.0001). CONCLUSION Among adult patients with DKA, significant predictors of good glycaemic control are preserved beta-cell function and compliance with life-style modifications.
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Affiliation(s)
- M Maldonado
- Department of Medicine/Endocrinology, Baylor College of Medicine, One Baylor Plaza, Rm. N520, Houston, TX 77030, USA.
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28
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Maldonado MR, Chong ER, Oehl MA, Balasubramanyam A. Economic impact of diabetic ketoacidosis in a multiethnic indigent population: analysis of costs based on the precipitating cause. Diabetes Care 2003; 26:1265-9. [PMID: 12663608 DOI: 10.2337/diacare.26.4.1265] [Citation(s) in RCA: 94] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Diabetic ketoacidosis (DKA) is a common complication of diabetes. We analyzed the inpatient costs of treating DKA in a multiethnic, indigent population in Houston, Texas. RESEARCH DESIGN AND METHODS We measured the cost of resources utilized for all patients admitted to our hospital with DKA from 1 January to 31 December 1998. We also analyzed their medical records to determine the factors that precipitated the episode of DKA and then grouped them into three categories: acute illnesses, noncompliance with diabetes treatment, and new-onset diabetes. The data were analyzed by one-way ANOVA. The Tukey-Kramer procedure was used for post hoc multiple comparisons. RESULTS There were 167 admissions for DKA. The mean age was 40 +/- 13 years. The ethnic distribution was 49% African American, 32% Hispanic American, and 18% white. The total inhospital cost of treating DKA was $1,816,255. The mean cost per hospitalization was $10, 876 +/- 11,024. The frequency distribution by category of DKA-precipitating factor was 18% acute illness, 59% noncompliance, and 23% new onset. There were differences in mean cost of DKA associated with the three categories: $20,864 +/- 17,910 for acute illness, $11,863 +/- 8,701 for new onset, and $7,470 +/- 6,300 for noncompliance (P < 0.0001). The total cost for each category was $671,375 for acute illness, $694,082 for noncompliance, and $450,798 for new onset. CONCLUSIONS DKA is an expensive complication among indigent, multiethnic diabetic patients. Although the mean cost per admission was lowest for DKA precipitated by noncompliance, this causal category was responsible in sum for the greatest portion of the economic burden.
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Affiliation(s)
- Mario R Maldonado
- Division of Endocrinology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA.
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