Increased length of stay and hospital charges in adolescents with type 1 diabetes and psychiatric illness.

OBJECTIVES: Type I diabetes mellitus (T1DM) is one of the most common chronic diseases of childhood. Diabetic ketoacidosis (DKA) in this population contributes to significant healthcare utilization, including emergency room visits, hospitalizations, and ICU care. Comorbid psychiatric illnesses (CPI) are additional risks for increased healthcare utilization. While CPI increased risk for DKA hospitalization and readmission, there are no data evaluating the relationship between CPI and hospital outcomes. We hypothesized that adolescents with T1DM and CPI admitted for DKA have increased length of stay (LOS) and higher charges compared to those without CPI. METHODS: Retrospective review of 2000-2012 Healthcare Cost and Utilization Project's (HCUP) Kids' Inpatient Databases (KID). Patients 10-21 years old admitted with ICD-9 codes for DKA or severe diabetes (250.1-250.33) with and without ICD-9 codes for depression (296-296.99, 311) and anxiety (300-300.9). Comparisons of LOS, mortality, and charges between groups (No CPI, Depression and Anxiety) were made with one way ANOVA with Bonferroni correction, independent samples Kruskal-Wallis test with Bonferroni correction and χ2. RESULTS: There were 79,673 admissions during the study period: 68,573 (86%) No CPI, 8,590 (10.7%) Depression and 12,510 (15.7%) Anxiety. Female patients comprised 58.2% (n=46,343) of total admissions, 66% of the Depression group, and 71% of the Anxiety group. Patients with depression or anxiety were older and had longer LOS and higher mean charges (p<0.001 for both). CONCLUSION: Comorbid depression or anxiety are associated with significantly longer LOS and higher charges in adolescents with T1DM hospitalized for DKA. This study adds to the prior findings of worse outcomes for patients with both T1DM and CPI, emphasizing the importance of identifying and treating these comorbid conditions.

Temporal patterns of hospitalizations for diabetic ketoacidosis in children and adolescents.

OBJECTIVES: To examine the temporal patterns of hospitalizations with diabetic ketoacidosis (DKA) in the pediatric population and their associated fiscal impact. METHODS: The Texas Inpatient Public Use Data File was used to identify hospitalizations of state residents aged 1month-19 years with a primary diagnosis of DKA during 2005-2014. Temporal changes of population-adjusted hospitalization rates and hospitalization volumes were examined for the whole cohort and on stratified analyses of sociodemographic attributes. Changes in the aggregate and per-hospitalization charges were assessed overall and on stratified analyses. RESULTS: There were 24,072 DKA hospitalizations during the study period. The population-adjusted hospitalization rate for the whole cohort increased from 31.3 to 35.9 per 100,000 between 2005-2006 and 2013-2014. Hospitalization volume increased by 30.2% over the same period, driven mainly by males, ethnic minorities, those with Medicaid insurance and uninsured patients. The aggregate hospital charges increased from approximately $69 million to $130 million between 2005-2006 and 2013-2014, with 66% of the rise being due to increased per-hospitalization charges. CONCLUSIONS: There was progressive rise in pediatric DKA hospitalizations over the last decade, with concurrent near-doubling of the associated fiscal footprint. Marked disparities were noted in the increasing hospitalization burden of DKA, born predominantly by racial and ethnic minorities, as well as by the underinsured and the uninsured. Further studies are needed to identify scalable preventive measures to achieve an equitable reduction of pediatric DKA events.

Efficacy and Safety of Commonly Used Insulin Analogues in the Treatment of Diabetic Ketoacidosis: A Bayesian Indirect Treatment Comparison.

PURPOSE: Insulin analogues (IAs) are the mainstay for the management of diabetic ketoacidosis (DKA). However, the relative efficacy of newer IAs is uncertain. The aim of this study was to compare the relative efficacy and safety of IAs for the management of DKA using an indirect treatment comparison (ITC). METHODS: PubMed, EMBASE, Scopus, the Cochrane Library, and ClinicalTrials.gov were searched for randomized controlled trials (RCTs) comparing short-, rapid-, and long-acting IAs in patients with DKA. The primary outcomes of interest were time taken to normalize DKA and time taken to normalize blood glucose levels. The secondary outcomes of interest were the amount of insulin needed to normalize DKA, the length of hospital stay, and the number of hypoglycemic events in the intervention and comparator groups. Bayesian ITC was performed by using the gemtc package in the R program. Continuous outcomes are reported as mean difference (MD), and binary outcomes are reported as odds ratios (ORs), with 95% credible intervals (CrIs). The Cochrane risk of bias tool was used to assess the risk of bias in the included RCTs. FINDINGS: Ten RCTs randomizing 435 participants to treatment were included in this ITC. A total of 5 interventions (lispro, glargine with regular insulin [RI], glulisine, aspart, and regular insulin) were compared for both safety and efficacy outcomes in DKA. Glargine co-administered with regular insulin showed superiority for clinical outcomes compared with regular insulin: consuming less time (MD, -3.1 h; 95% CrI, -7.9 to 1.8), amount of insulin required (MD, -32 U; 95% CrI, 83.0 to 18.0), and the length of hospitalization (MD, -0.82 day; 95% CrI, -2.7 to 1.0) to normalize DKA. However, these results were not statistically significant. Insulin aspart had fewer reports of hypoglycemic events (OR, 1.7; 95% CrI, 0.34 to 9.3) than regular insulin. IMPLICATIONS: Newer IAs were found to be equally effective and safe as regular insulin in the treatment of DKA. Thus, administering these IAs can be considered a safe and cost-effective alternative for DKA management in non-ICU settings. Cost-effective analysis of the newer IAs is needed because these agents are expensive compared with regular insulin.

Cost and Cost-effectiveness of Large-scale Screening for Type 1 Diabetes in Colorado.

OBJECTIVE: To assess the costs and project the potential lifetime cost-effectiveness of the ongoing Autoimmunity Screening for Kids (ASK) program, a large-scale, presymptomatic type 1 diabetes screening program for children and adolescents in the metropolitan Denver region. RESEARCH DESIGN AND METHODS: We report the resource utilization, costs, and effectiveness measures from the ongoing ASK program compared with usual care (i.e., no screening). Additionally, we report a practical screening scenario by including utilization and costs relevant to routine screening in clinical practice. Finally, we project the potential cost-effectiveness of ASK and routine screening by identifying clinical benchmarks (i.e., diabetic ketoacidosis [DKA] events avoided, HbA1c improvements vs. no screening) needed to meet value thresholds of $50,000-$150,000 per quality-adjusted life-year (QALY) gained over a lifetime horizon. RESULTS: Cost per case detected was $4,700 for ASK screening and $14,000 for routine screening. To achieve value thresholds of $50,000-$150,000 per QALY gained, screening costs would need to be offset by cost savings through 20% reductions in DKA events at diagnosis in addition to 0.1% (1.1 mmol/mol) improvements in HbA1c over a lifetime compared with no screening for patients who develop type 1 diabetes. Value thresholds were not met from avoiding DKA events alone in either scenario. CONCLUSIONS: Presymptomatic type 1 diabetes screening may be cost-effective in areas with a high prevalence of DKA and an infrastructure facilitating screening and monitoring if the benefits of avoiding DKA events and improved HbA1c persist over long-run time horizons. As more data are collected from ASK, the model will be updated with direct evidence on screening effects.

Medical Costs Among Youth Younger Than 20 Years of Age With and Without Diabetic Ketoacidosis at the Time of Diabetes Diagnosis.

OBJECTIVE: While diabetic ketoacidosis (DKA) is common in youth at the onset of the diabetes, the excess costs associated with DKA are unknown. We aimed to quantify the health care services use and medical care costs related to the presence of DKA at diagnosis of diabetes. RESEARCH DESIGN AND METHODS: We analyzed data from the U.S. MarketScan claims database for 4,988 enrollees aged 3-19 years insured in private fee-for-service plans and newly diagnosed with diabetes during 2010-2016. Youth with and without DKA at diabetes diagnosis were compared for mean health care service use (outpatient, office, emergency room, and inpatient visits) and medical costs (outpatient, inpatient, prescription drugs, and total) for 60 days prior to and 60 days after diabetes diagnosis. A two-part model using generalized linear regression and logistic regression was used to estimate medical costs, controlling for age, sex, rurality, health plan, year, presence of hypoglycemia, and chronic pulmonary condition. All costs were adjusted to 2016 dollars. RESULTS: At diabetes diagnosis, 42% of youth had DKA. In the 60 days prior to diabetes diagnosis, youth with DKA at diagnosis had less health services usage (e.g., number of outpatient visits: -1.17; P < 0.001) and lower total medical costs (-$635; P < 0.001) compared with youth without DKA at diagnosis. In the 60 days after diagnosis, youth with DKA had significantly greater health care services use and health care costs ($6,522) compared with those without DKA. CONCLUSIONS: Among youth with newly diagnosed diabetes, DKA at diagnosis is associated with significantly higher use of health care services and medical costs.

Complications of Serious Pediatric Conditions in the Emergency Department: Definitions, Prevalence, and Resource Utilization.

OBJECTIVES: To define and measure complications across a broad set of acute pediatric conditions in emergency departments using administrative data, and to assess the validity of these definitions by comparing resource utilization between children with and without complications. STUDY DESIGN: Using local consensus, we predefined complications for 16 acute conditions including appendicitis, diabetic ketoacidosis, ovarian torsion, stroke, testicular torsion, and 11 others. We studied patients under age 18 years using 3 data years from the Healthcare Cost and Utilization Project Statewide Databases of Maryland and New York. We measured complications by condition. Resource utilization was compared between patients with and without complications, including hospital length of stay, and charges. RESULTS: We analyzed 27 087 emergency department visits for a serious condition. The most common was appendicitis (n = 16 794), with 24.3% of cases complicated by 1 or more of perforation (24.1%), abscess drainage (2.8%), bowel resection (0.3%), or sepsis (0.9%). Sepsis had the highest mortality (5.0%). Children with complications had higher resource utilization: condition-specific length of stay was longer when complications were present, except ovarian and testicular torsion. Hospital charges were higher among children with complications (P < .05) for 15 of 16 conditions, with a difference in medians from $3108 (testicular torsion) to $13 7694 (stroke). CONCLUSIONS: Clinically meaningful complications were measurable and were associated with increased resource utilization. Complication rates determined using administrative data may be used to compare outcomes and improve healthcare delivery for children.

Comparison of outcomes and costs between adult diabetic ketoacidosis patients admitted to the ICU and step-down unit.

PURPOSE: There is wide variation in the utilization of Intensive Care Unit (ICU) beds for treatment and monitoring of adult patients with Diabetic Ketoacidosis (DKA). We sought to compare the outcomes and hospital costs of adult DKA patients admitted to ICUs as compared to those admitted to step-down units. MATERIALS AND METHODS: We included consecutive adult patients from two hospitals with a diagnosis of DKA. Patients were either admitted to the ICU, or a step-down unit, which has a nurse-to-patient ratio of 2:1, but does not have capability for mechanical ventilation or administration of vasoactive agents. The primary outcome was in-hospital mortality. RESULTS: We included 872 patients in the analysis. 71 (8.1%) were admitted to ICU, while 801 (91.9%) were admitted to a step-down unit. We found no difference in in-hospital mortality between patients admitted to the ICU and those admitted to the step-down unit (adjusted odds ratio [OR]: 1.14, 95% confidence interval [CI]: 0.87-2.64). Mean total hospital costs were significantly higher for patients admitted to the ICU ($20,428 vs. $6484, P < 0.001). CONCLUSIONS: Adult DKA patients admitted to a step-down unit had comparable in-hospital mortality and lower hospital costs as compared to those admitted to the ICU.

The cost of treating diabetic ketoacidosis in an adolescent population in the UK: a national survey of hospital resource use.

AIMS: Adolescents with Type 1 diabetes commonly experience episodes of ketoacidosis. In 2014, we conducted a nationwide survey on the management of diabetic ketoacidosis in young people. The survey reported how individual adolescents with diabetes were managed. However, the costs of treating diabetic ketoacidosis were not reported. METHODS: Using this mixed population sample of adolescents, we took a 'bottom-up' approach to cost analysis aiming to determine the total expense associated with treating diabetic ketoacidosis. The data were derived using the information from the national UK survey of 71 individuals, collected via questionnaires sent to specialist paediatric diabetes services in England and Wales. RESULTS: Several assumptions had to be made when analysing the data because the initial survey collection tool was not designed with a health economic model in mind. The mean time to resolution of diabetic ketoacidosis was 15.0 h [95% confidence interval (CI) 13.2, 16.8] and the mean total length of stay was 2.4 days (95% CI 1.9, 3.0). Based on data for individuals and using the British Society of Paediatric Endocrinology and Diabetes (BSPED) guidelines, the cost analysis shows that for this cohort, the average cost for an episode of diabetic ketoacidosis was £1387 (95% CI 1120, 1653). Regression analysis showed a significant cost saving of £762 (95% CI 140, 1574; P = 0.04) among those treated using BSPED guidelines. CONCLUSION: We have used a bottom-up approach to calculate the costs of an episode of diabetic ketoacidosis in adolescents. These data suggest that following treatment guidelines can significantly lower the costs for managing episodes of diabetic ketoacidosis.

Health Care Utilization and Burden of Diabetic Ketoacidosis in the U.S. Over the Past Decade: A Nationwide Analysis.

OBJECTIVE: Diabetes is one of the most common chronic diseases and a leading cause of morbidity and mortality in the U.S. Although our ability to treat diabetes and its associated complications has significantly improved, presentation with uncontrolled diabetes leading to ketoacidosis remains a significant problem. RESEARCH DESIGN AND METHODS: We aimed to determine the incidence and costs of hospital admissions associated with diabetic ketoacidosis (DKA). We reviewed the National Inpatient Sample database for all hospitalizations in which DKA (ICD-9 codes 250.10, 250.11, 250.12, and 250.13) was the principal discharge diagnosis during 2003-2014 and calculated the population incidence by using U.S. census data. Patients with ICD-9 codes for diabetic coma were excluded because the codes do not distinguish between hypoglycemic and DKA-related coma. We then analyzed changes in temporal trends of incidence, length of stay, costs, and in-hospital mortality by using the Cochrane-Armitage test. RESULTS: There were 1,760,101 primary admissions for DKA during the study period. In-hospital mortality for the cohort was 0.4% (n = 7,031). The total number of hospital discharges with the principal diagnosis of DKA increased from 118,808 in 2003 to 188,965 in 2014 (P < 0.0001). The length of stay significantly decreased from an average of 3.64 days in 2003 to 3.24 days in 2014 (P < 0.01). During this period, the mean hospital charges increased significantly from $18,987 (after adjusting for inflation) per admission in 2003 to $26,566 per admission in 2014. The resulting aggregate charges (i.e., national bill) for diabetes with ketoacidosis increased dramatically from $2.2 billion (after adjusting for inflation) in 2003 to $ 5.1 billion in 2014 (P < 0.001). However, there was a significant reduction in mortality from 611 (0.51%) in 2003 to 620 (0.3%) in 2014 (P < 0.01). CONCLUSIONS: Our analysis shows that the population incidence for DKA hospitalizations in the U.S. continues to increase, but the mortality from this condition has significantly decreased, indicating advances in early diagnosis and better inpatient care. Despite decreases in the length of stay, the costs of hospitalizations have increased significantly, indicating opportunities for value-based care intervention in this vulnerable population.

The cost of treating diabetic ketoacidosis in the UK: a national survey of hospital resource use.

AIM: Diabetic ketoacidosis is a commonly encountered metabolic emergency. In 2014, a national survey was conducted looking at the management of diabetic ketoacidosis in adult patients across the UK. The survey reported the clinical management of individual patients as well as institutional factors that teams felt were important in helping to deliver that care. However, the costs of treating diabetic ketoacidosis were not reported. METHODS: We used a 'bottom up' approach to cost analysis to determine the total expense associated with treating diabetic ketoacidosis in a mixed population sample. The data were derived from the source data from the national UK survey of 283 individual patients collected via questionnaires sent to hospitals across the country. RESULTS: Because the initial survey collection tool was not designed with a health economic model in mind, several assumptions were made when analysing the data. The mean and median time in hospital was 5.6 and 2.7 days respectively. Based on the individual patient data and using the Joint British Diabetes Societies Inpatient Care Group guidelines, the cost analysis shows that for this cohort, the average cost for an episode of diabetic ketoacidosis was £2064 per patient (95% confidence intervals: 1800, 2563). CONCLUSION: Despite relatively short stays in hospital, costs for managing episodes of diabetic ketoacidosis in adults were relatively high. Assumptions made in the calculations did not consider prolonged hospital stay due to comorbidities or costs incurred as a loss of productivity. Therefore, the actual costs to the healthcare system and society in general are likely to be substantially higher.

Type 1 diabetes mellitus care and education in China: The 3C study of coverage, cost, and care in Beijing and Shantou.

AIMS: The paucity of data on Type 1 diabetes in China hinders progress in care and policy-making. This study compares Type 1 diabetes care and clinical outcomes in Beijing and Shantou with current clinical guidelines. METHODS: The 3C Study was a cross-sectional study of the clinical practices and outcomes of people with Type 1 diabetes. The study sequentially enrolled 849 participants from hospital records, inpatient wards, and outpatient clinics. Data were collected via face-to-face interviews with patients and health professionals, the Summary of Diabetes Self-Care Activities, medical records, and venous blood samples. Care was audited using ISPAD/IDF indicators. Data underwent descriptive analysis and tests for association. RESULTS: The median age was 22years (IQR=13-34years), and 48.4% of the sample had diabetes less than six years. The median HbA1c was 8.5% (69mmol/mol) (IQR 7.2-10.5%), with significant regional variance (p=0.002). Insulin treatment was predominantly two injections/day (45% of patients). The highest incidence of diabetic ketoacidosis was 14.4 events/100 patient years among adolescents. Of the 57.3% of patients with LDL-C>2.6mmol/L, only 11.2% received treatment. Of the 10.6% considered hypertensive, 47.1% received treatment. Rates of documented screening for retinopathy, nephropathy, and peripheral neuropathy were 35.2%, 42.3%, and 25.0%, respectively. The median number of days of self-monitoring/week was 3.0 (IQR=1.0-7.0). There were significant differences in care practices across regions. CONCLUSIONS: The study documented an overall deficit in care with significant regional differences noted compared to practice guidelines. Modifications to treatment modalities and the structure of care may improve outcomes.

Incidence, recurrence and cost of hyperglycaemic crises requiring emergency treatment in Andalusia, Spain.

AIMS: Hyperglycaemic crises (diabetic ketoacidosis and hyperosmolar hyperglycaemic state) are medical emergencies in people with diabetes. We aimed to determine their incidence, recurrence and economic impact. METHODS: An observational study of hyperglycaemic crises cases using the database maintained by the out-of-hospital emergency service, the Healthcare Emergency Public Service (EPES) during 2012. The EPES provides emergency medical services to the total population of Andalusia, Spain (8.5 million inhabitants) and records data on the incidence, resource utilization and cost of out-of-hospital medical care. Direct costs were estimated using public prices for health services updated to 2012. RESULTS: Among 1 137 738 emergency calls requesting medical assistance, 3157 were diagnosed with hyperglycaemic crises by an emergency coordinator, representing 2.9 cases per 1000 persons with diabetes [95% confidence intervals (CI) 2.8 to 3.0]. The incidence of diabetic ketoacidosis was 2.5 cases per 1000 persons with diabetes (95% CI 2.4 to 2.6) and the incidence of hyperosmolar hyperglycaemic state was 0.4 cases per 1000 persons with diabetes (95% CI 0.4 to 0.5). In total, 17.7% (n = 440) of people had one or more hyperglycaemic crisis. The estimated total direct cost was €4 662 151, with a mean direct cost per episode of €1476.8 ± 217.8. CONCLUSIONS: Hyperglycaemic crises require high resource utilization of emergency medical services and have a significant economic impact on the health system.

Incidence, prevalence, costs and quality of care of type 1 diabetes in Italy, age 0-29 years: The population-based CINECA-SID ARNO Observatory, 2002-2012.

BACKGROUND AND AIMS: To assess temporal trend in incidence (2003-12) and prevalence (2002-12) of type 1 diabetes in children and young adults, direct costs and selected indicators of quality of care under the coverage of the universalistic Italian National Health System (NHS). METHODS AND RESULTS: The ARNO Observatory, a healthcare monitoring system based on administrative data, identified a population-based multiregional cohort of subjects aged 0-29 years. Type 1 diabetes was defined by at least two prescriptions of insulin over 12 months and continuous insulin-treatment in the following year. Indicators of quality of care and directs costs were assessed in persons with diabetes and in people without diabetes, individually matched for age, gender and health unit (1:4 ratio). We identified 2357 incident cases of type 1 diabetes aged 0-29 years (completeness of ascertainment, 99%). Incidence rates were similar in ages 0-14 (15.8, 95% CI 14.9-16.8) and 15-29 years (16.3, 15.4-17.2), with no significant trend. Prevalence increased from 137 to 166.9/100,000, particularly in the age 15-29 years. Direct costs accounted for € 2117 in persons with diabetes and € 292 in control individuals. A statistically significant decreasing trend in hospitalization for acute complications was evident (p < 0.001), which was almost completely due to ketoacidosis. People with at least one HbA1c measurement over the year were 48.5%. CONCLUSION: We showed high incidence and increasing prevalence of type 1 diabetes in young adults in Italy, which impact on direct costs under the universalistic coverage of the NHS.

Association Between Intensive Care Unit Utilization During Hospitalization and Costs, Use of Invasive Procedures, and Mortality.

IMPORTANCE: Maximizing the value of critical care services requires understanding the relationship between intensive care unit (ICU) utilization, clinical outcomes, and costs. OBJECTIVE: To examine whether hospitals had consistent patterns of ICU utilization across 4 common medical conditions and the association between higher use of the ICU and hospital costs, use of invasive procedures, and mortality. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study of 156 842 hospitalizations in 94 acute-care nonfederal hospitals for diabetic ketoacidosis (DKA), pulmonary embolism (PE), upper gastrointestinal bleeding (UGIB), and congestive heart failure (CHF) in Washington state and Maryland from 2010 to 2012. Hospitalizations for DKA, PE, UGIB, and CHF were identified from the presence of compatible International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Multilevel logistic regression models were used to determine the predicted hospital-level ICU utilization during hospitalizations for the 4 study conditions. For each condition, hospitals were ranked based on the predicted ICU utilization rate to examine the variability in ICU utilization across institutions. MAIN OUTCOMES AND MEASURES: The primary outcomes were associations between hospital-level ICU utilization rates and risk-adjusted hospital mortality, use of invasive procedures, and hospital costs. RESULTS: The 94 hospitals and 156 842 hospitalizations included in the study represented 4.7% of total hospitalizations in this study. ICU admission rates ranged from 16.3% to 81.2% for DKA, 5.0% to 44.2% for PE, 11.5% to 51.2% for UGIB, and 3.9% to 48.8% for CHF. Spearman rank coefficients between DKA, PE, UGIB, and CHF showed significant correlations in ICU utilization for these 4 medical conditions among hospitals (ρ ≥ 0.90 for all comparisons; P < .01 for all). For each condition, hospital-level ICU utilization rate was not associated with hospital mortality. Use of invasive procedures and costs of hospitalization were greater in institutions with higher ICU utilization for all 4 conditions. CONCLUSIONS AND RELEVANCE: For medical conditions where ICU care is frequently provided, but may not always be necessary, institutions that utilize ICUs more frequently are more likely to perform invasive procedures and have higher costs but have no improvement in hospital mortality. Hospitals had similar ICU utilization patterns across the 4 medical conditions, suggesting that systematic institutional factors may influence decisions to potentially overutilize ICU care. Interventions that seek to improve the value of critical care services will need to address these factors that lead clinicians to admit patients to higher levels of care when equivalent care can be delivered elsewhere in the hospital.

Integrative traditional Chinese medicine therapy reduces the risk of diabetic ketoacidosis in patients with type 1 diabetes mellitus.

ETHNOPHARMACOLOGICAL RELEVANCE: Life-long insulin is the standard treatment for type 1 diabetes mellitus (T1DM). The role of traditional Chinese medicine (TCM) in T1DM is still not clear. The aim of this study is to explore the prescription pattern of TCM and its impact on the risk of diabetic ketoacidosis (DKA) in patients with T1DM. MATERIALS AND METHODS: We retrieved samples from the registry for catastrophic illness patients from the National Health Insurance Research Database (NHIRD). Based on a frequency (1:4) matched case-control design, patients with T1DM in 2000-2011 were designated as cases (TCM users) and controls (non-TCM users). TCM treatment for patients with T1DM was analyzed. The incidence of DKA and the annual costs of emergency visits and hospitalizations were evaluated for all causes. RESULTS: Overall, 416 subjects were TCM users, whereas a total of 1608 matched subjects were classified as non-TCM users. The most common Chinese herbal formula and single herb is Liu-wei-di-huang-wan (Six-ingredient pill of Rehmannia) and Huang-qi (Radix Astragali; Astragalus membranaceus (Fisch.) Bunge, Astragalus membranaceus var. mongholicus (Bunge) P.K.Hsiao), respectively. Compared with non-TCM users, we found a 33% reduction in DKA incidence for all TCM users (aHR 0.67, 95% CI 0.56-0.81, p <0.000) and a 40% reduction for users receiving TCM treatment for more than 180 days (aHR 0.58, 95% CI 0.41-0.82, p <0.01). There were no significant differences between TCM users and non-users in the frequency and medical costs of emergency visits and hospitalizations. CONCLUSIONS: Integrative TCM use may reduce the risk of DKA in patients with T1DM. Our results suggest that TCM may have a substantial positive impact on the management of TIDM.

Incidence, Trends, and Outcomes of Cerebral Edema Among Children With Diabetic Ketoacidosis in the United States.

INTRODUCTION: There are limited data regarding the incidence, trends, and outcomes of cerebral edema among patients with diabetic ketoacidosis (DKA). METHODS: NIS database was used from year 2002 to 2012. Cases with primary diagnosis of DKA were identified using International Classification of Diseases, Ninth Revision-Clinical Modification (ICD-9 CM) code 250.1 x. Cerebral edema patients were identified using ICD-9 CM code 348.5. We compared the baseline characteristics of both groups to estimate differences using the χ(2) test, Student's t test, Wilcoxon rank-sum test, and survey regression depending on the distributions of variables. For trend analysis, the χ(2) test of trend for proportions was used using the Cochrane Armitage test via the "trend" command in Statistical Analysis Software (SAS). Multivariate odds ratios were calculated. P value for <0.05 was considered as significant for all analysis. RESULTS: In all, 205 (weighted n = 974) cases of cerebral edema were identified among 52 049 (weighted n = 246 925) DKA patients, which estimates the incidence of cerebral edema at 0.39%. Trends of incidence of developing cerebral edema increased almost 2 times, from 0.34 in 2002 to 0.64 in 2012 (P < 0.001). Univariate analysis showed that both length of stay (LOS; 3 vs 2; P < 0.001) and cost of hospitalization ($10 530 vs $3953; P < 0.001) were statistically higher among those who developed cerebral edema. CONCLUSION: Our study shows that over the study period, trend in incidence of cerebral edema among DKA patients has increased. Patients with cerebral edema were found to have longer LOS and higher cost of hospitalization.

Blood Ketones: Measurement, Interpretation, Limitations, and Utility in the Management of Diabetic Ketoacidosis.

Diabetic ketoacidosis (DKA) remains a common medical emergency. Over the last few years, new national guidelines have changed the focus in managing the condition from being glucose-centered to ketone-centered. With the advent of advancing technology and the increasing use of hand-held, point-of-care ketone meters, greater emphasis is placed on making treatment decisions based on these readings. Furthermore, recent warnings about euglycemic DKA occurring in people with diabetes using sodium-glucose co-transporter 2 (SGLT-2) inhibitors urge clinicians to inform their patients of this condition and possible testing options. This review describes the reasons for a change in treating DKA, and outlines the benefits and limitations of using ketone readings, in particular highlighting the difference between urine and capillary readings.

Screening for T1D risk to reduce DKA is not economically viable.

BACKGROUND: Children at high risk for developing type 1 diabetes (T1D) can be identified on the basis of human leukocyte antigen (HLA) genotype and the subsequent development of islet cell autoantibodies. Several studies have documented reduced incidence of diabetic ketoacidosis (DKA) in new-onset T1D when high-risk children are identified at an early age. Many have questioned whether general population screening for T1D risk should be standard of practice. We sought to perform a purely economic, cost-benefit analysis to determine if a screening program to reduce the incidence of DKA at diagnosis in children less than 5 yr is cost effective. METHODS: We compared the cost of population screening with the benefit of preventing DKA. The cost of screening included one-time HLA typing on the entire population followed by islet cell autoantibody testing in high-risk children every 6 months until age 5 yr. The potential benefits of screening included reductions in parental lost income, medical expenses, morbidity, and mortality. RESULTS: Screening for T1D risk for the sole purpose of reducing the cost of DKA at onset of T1D was not economically viable unless HLA testing and autoantibody testing could be performed for less than $1 and $0.03, respectively. CONCLUSIONS: Current screening costs far outweigh the economic benefits of preventing new-onset DKA in children under 5 yr of age.