Recurrent hospitalizations for severe hypoglycemia and hyperglycemia among U.S. adults with diabetes

https://doi.org/10.1016/j.jdiacomp.2018.04.007Get rights and content

Abstract

Aims

Examine 30-day readmissions for recurrent hypoglycemia and hyperglycemia in a national cohort of adults with diabetes.

Methods

Retrospective analysis of data from OptumLabs Data Warehouse for all adults with diabetes hospitalized January 1, 2009 to December 31, 2014 with a principal diagnosis of hypoglycemia or hyperglycemia. We examined the rates and risk factors of 30-day readmissions for hypoglycemia and hyperglycemia.

Results

After 6419 index hypoglycemia hospitalizations, 1.2% were readmitted for recurrent hypoglycemia, 0.2% for hyperglycemia, and 8.6% for other causes. Multimorbidity was the strongest predictor of recurrent hypoglycemia. After 6872 index hyperglycemia hospitalizations, 4.0% were readmitted for recurrent hyperglycemia, 0.4% for hypoglycemia, and 5.4% for other causes. Recurrent hyperglycemia was less likely in older patients (OR 0.6, 95% CI 0.5–0.9 for 45–64 vs. <45 years) and with the addition of a new glucose-lowering medication at index discharge (OR 0.40; 95% CI 0.2–0.7). New hypoglycemia readmissions were most likely among patients ≥75 years (OR 13.3, 95% CI 2.4–73.4, vs. <45 years).

Conclusions

Patients hospitalized for hyperglycemia are often readmitted for recurrent hyperglycemia, while patients hospitalized for hypoglycemia are generally readmitted for unrelated causes. Early recognition of high risk patients may identify opportunities to improve post-discharge management and reduce these events.

Introduction

Patients with diabetes who experience severe hypoglycemia or hyperglycemia incur potentially preventable morbidity,1,2 mortality,3 high costs,4., 5., 6., 7. and impaired quality of life,4,7,8 particularly when the events are so severe as to require hospitalization. Despite being potentially preventable with optimal ambulatory care, rates of hospitalization for hypoglycemia9., 10., 11. and hyperglycemia9,10 remain high. In a recent study of hospitalizations and readmissions among patients with diabetes, admissions for severe dysglycemia accounted for 2.6% of all hospitalizations and 2.5% of all 30-day readmissions.9 Such hospitalizations may reflect underlying deficiencies in patient care and diabetes management, particularly if patients need to be readmitted for hypoglycemia or hyperglycemia shortly after hospitalization for a similar event.

Preventing hospitalizations and readmissions is key to improving care quality and lowering costs of care. To promote high quality care for people with diabetes, the Centers for Medicare & Medicaid Services (CMS) uses rates of 30-day all-cause unplanned readmissions among all patients12 and of all-cause unplanned admissions among patients with diabetes13 for public reporting and payment adjustment. Identifying patients at highest risk for readmission specifically for severe hypoglycemic or hyperglycemic events is an important first step toward their prevention.

Prior studies identified several risk factors for hypoglycemia including prior hypoglycemia,14,15 intensive glucose-lowering therapy,16,17 insulin and sulfonylurea use,11,15., 16., 17., 18., 19. older age,11,15,19., 20., 21. multimorbidity,11,16 and cognitive impairment.22 Severe hyperglycemia is more common among younger patients21 and patients with depression or substance use.24,45 Elevated hemoglobin A1c (HbA1c) 11,23,24 and socioeconomic disadvantage 23,25., 26., 27., 28., 29. are associated with both hypoglycemia and hyperglycemia. However, there is little information about recurrent hospitalizations for severe dysglycemia among adults with diabetes. Because patients may be experiencing both types of events, concurrently examining severe hypoglycemia and hyperglycemia would present a more complete and holistic representation of diabetes care, and potentially identify clinically meaningful trends and risk factors. To address this knowledge gap, we examine hospital readmissions for severe hypoglycemia and hyperglycemia that occur within 30 days of hospital discharge for another hypoglycemic or hyperglycemic event in a national cohort of adults with established diabetes.

Section snippets

Study design and data source

We conducted a retrospective analysis of patients with medical and pharmacy claims data from OptumLabs Data Warehouse (OLDW), an administrative database of >100 million privately insured and Medicare Advantage enrollees throughout the U.S. (Appendix A.1)30,31 This national dataset encompasses a wide range of ages and racial/ethnic groups. All study data were accessed after the data were de-identified, consistent with Health Insurance Portability and Accountability Act expert de-identification

Study population and 30-day readmissions

Between January 1, 2009 and December 31, 2014, 11,161 patients experienced 13,291 index hospitalizations, including 6419 index hospitalizations for hypoglycemia among 5911 patients and 6872 index hospitalizations for hyperglycemia among 5250 patients. Overall, 1338 patients (12%) had more than one index hospitalization during the 5-year study period. Baseline patient characteristics at the time of index admission are shown in Table 1. Patients hospitalized for hypoglycemia were significantly

Discussion

Severe hypoglycemia and hyperglycemia, particularly when requiring hospitalization, are common, harmful, yet potentially avoidable with optimal diabetes care. Patients experiencing severe hypoglycemia or hyperglycemia are at risk for recurrent events, particularly if risk factors for these events are not identified and addressed. In this study, we examined 6419 hospitalizations for the primary diagnosis of severe hypoglycemia and 6872 for severe hyperglycemia (ketoacidosis and hyperglycemic

Conclusions

Hospitalizations for severe hypoglycemia and hyperglycemia continue to be common and 10% result in 30-day readmission. Patients hospitalized for severe hyperglycemia are likely to be readmitted for recurrent hyperglycemia, while patients hospitalized for hypoglycemia are generally readmitted for unrelated causes. Importantly, these data represent only a fraction of severe hypoglycemic and hyperglycemic events experienced by patients with diabetes, as most episodes do not result in

Acknowledgments

Author contributions: Dr. McCoy had full access to all the data in the study and serves as the guarantors for this work, taking responsibility for the integrity of the data and the accuracy of the data analysis. Study conception and design: McCoy, Shah. Acquisition of data: Herrin, Shah. Interpretation of data: McCoy, Herrin, Shah. Drafting of the manuscript: McCoy. Critical revision of the manuscript for important intellectual content: McCoy, Lipska, Herrin, Shah. Statistical analysis: Herrin.

Declarations of interest

None.

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