Outpatient Care Preceding Hospitalization for Diabetic Ketoacidosis

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.

FIGURE 1

Consolidated Standards of Reporting Trials (CONSORT) diagram depicting selection of the study population.

FIGURE 2

Cumulative percentages of patients with and without DKA hospitalization experiencing an ED visit during the previous 180 days. Visits within 1 day of the index date were excluded to avoid capturing encounters that led directly to hospitalization.