Diabetic Ketoacidosis Readmissions Common in Children

Miriam E. Tucker

July 25, 2013

Approximately 1 in 5 hospital admissions for diabetic ketoacidosis at US children's hospitals is readmission within 1 year, a new retrospective study has found.

But diabetic ketoacidosis readmission rates varied widely nationwide, as did hospital resource use and length of stay, Joel S. Tieder, MD, assistant professor of pediatrics, Division of Hospital Medicine, Seattle Children's Hospital, Washington, and colleagues report online July 22 in Pediatrics.

"The main message is that nationally the US healthcare system is failing to deliver adequate healthcare to all children with diabetes. This failure has substantial consequences in terms of cost and patient outcomes," Dr. Tieder told Medscape Medical News.

"Hospitals and healthcare providers should be aware that children with diabetes are at risk for diabetic ketoacidosis and that this is preventable," he added. "They should develop processes to improve self-management for these patients at both an organizational and a provider level."

Wide Variation in Diabetic Ketoacidosis Readmission

Diabetic ketoacidosis is a short-term complication of type 1 diabetes that results in acidosis and dehydration. It is the most common reason for hospitalization and mortality in children with type 1 diabetes. Despite this, differences in hospital-based resource utilization and readmission rates across major US children's hospitals remain unknown, Dr. Tieder and colleagues explain.

So they retrospectively analyzed 24,890 diabetic ketoacidosis admissions from 38 of 43 children's hospitals that participate in the Pediatric Health Information System, all of which are affiliated with the Children's Hospital Association.

The hospitals had a median of 113 diabetic ketoacidosis admissions per year from 2004 to 2009, with a range of 21 to 305. They had an average of 9 endocrinologists on staff, and two thirds of the hospitals employed endocrinology fellows (median, 4). Neither  these factors nor bed number were associated with outcomes, the authors note.

Of the total 24,890 admissions for children aged 2 to 18 years (mean age, 11.6 years), 2.8% were 30-day readmissions and 20.3% were readmissions within 1 year. However, the range was wide, from 0% to 7.1% at 30 days and from 6.5% to 41.1% at 1 year. Even after adjustment for patient variables, the variation in readmission rates at both time points remained statistically significant (P < .001).

Analyzing all patients as if they were the same regardless of hospital factors, the authors found the overall total mean standardized cost per patient encounter was $7162. Of that, more than half (54.4%) was attributed to bed utilization, including daily room and nursing costs. Other major contributors were laboratory testing (19.3%), clinical therapies (15.0%), and pharmacy (8.2%).

The average standardized per-patient cost per hospital was $7142, ranging from $4125 to $11,916 across hospitals, and this degree of variation was greater than what would be expected at random (P < .001), the authors say.

The average length of stay (LOS) for all encounters was 2.4 days, with 79.2% of the costs attributed to non–intensive care unit (ICU) bed days. But by hospital, LOS varied from 1.5 to 3.7 days, with ICU stay varying from 0.7 to 2.7 days. Adjustment for patient-level factors somewhat reduced the variation in LOS, but the general rankings of high vs low hospitals remained unchanged.

Work Ongoing to Identify Readmission Factors

Dr. Tieder told Medscape Medical News that this study couldn't identify factors predicting cost and readmission rates but that the best practices would most likely be at the community, organizational, or provider level. However, he said, "Data like these can help doctors, nurses, and healthcare leaders to compare their performance with that of their peers and identify and mitigate barriers to improvement."

One limitation to these data is that they couldn't capture the proportion of patients with diabetic ketoacidosis who had new-onset type 1 diabetes vs those with an already-established diagnosis. And there's a wide variation in approaches to in-hospital diabetes education for both patients with new-onset and established type 1 diabetes, he said.

Traditionally, most self-management teaching has been done inpatient at first diagnosis and revisited for subsequent hospitalizations for diabetic ketoacidosis. However, there has been recent pressure to do this on an outpatient basis. Some single-center studies have shown that outpatient teaching can work in the right environment, Dr. Tieder told Medscape Medical News.

Dr. Tieder and his colleagues are now working on identifying the groups of patients most at risk for readmission so that interventions can be targeted to those at highest risk.

The investigators hope to provide these data in the form of "report cards" to the healthcare communities for these patients. They're also interested in forming hospital collaboratives to help drive local improvement efforts, he explained.

The research was supported by a Health Research Formula Grant from the Pennsylvania Department of Public Health Commonwealth Universal Research Enhancement Program and a grant from Children’s Hospital Association. Dr. Tieder has disclosed no relevant financial relationships. Disclosures for the coauthors are listed in the article.

Pediatrics. Published online July 22, 2013. Abstract

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