1. In children with type 1 diabetes mellitus (T1D), emergency department (ED) and outpatient acute care visits were found to be associated with an increased likelihood of diabetic ketoacidosis (DKA) in the 2 weeks following the visit.
2. Patients with DKA were less likely to have seen an endocrinologist within the past 120 days.
Evidence Rating Level: 2 (Good)
Study Rundown: DKA is a life-threatening complication of T1D. T1D patients often initially present to the emergency department in DKA. As DKA is a source of significant morbidity and mortality, in the current study, researchers sought to better understand how outpatient care can be optimized in the hopes of preventing DKA. Studies show that children with chronic illness who have an outpatient medical home and good follow-up care are less likely to be hospitalized. With this in mind, researchers assessed children with T1D. These children were enrolled in a 6-month study period and were assessed at the end of this period, or until they had their first DKA episode. Results showed that a minority of patients experienced DKA during the study, and it was found that those that did experience DKA were more likely to have an ED or non-preventative primary care visit within 14 days of the DKA presentation. In addition, they were also less likely to have been seen by an endocrinologist within the past 120 days. This study was limited by the integrity of administrative data and a potential lack of generalizability, as only those insured under Medicaid were included. These findings suggest that ED visits and outpatient primary care visits for patients with T1D may serve as an opportunity to assess DKA risk. Similarly, missed endocrinology appointments should raise concerns among providers and may serve as an indicator for the need for further patient education and encouragement for diligent follow-up. Further studies are needed to help elucidate whether diabetes is being discussed or addressed at the ED or acute care visits prior to the development of DKA.
In-Depth [retrospective cohort]: A total of 5263 children (defined as individuals under the age of 21 years) with T1D who were insured through Medicaid were enrolled during 2009-2012. Of those studied, 878 (16.7%) children were hospitalized for DKA during the research period. Demographics of children with DKA in this study are similar to previous studies that have associated DKA with age, gender, race/ethnicity, insurance status, and mental health comorbidities. ED visits within the previous 6 months were associated with increased odds of DKA (aOR 3.99, 95%CI: 2.60-6.13) and children with DKA were twice as likely to have visited an ED within the past 6 months as their counterparts who did not experience DKA (p < 0.001). Children who were diagnosed with DKA were also more likely to have had a non-primary care visit during the 14 days before the index date (aOR 1.35, 95%CI: 1.01–1.79). Analyses revealed that children with DKA were also less likely to have been seen by an endocrinologist within the past 120 days (aOR 0.76, 95%CI: 0.65–0.89).
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