Risk Factors for Hyperosmolar Hyperglycemic State in Pediatric Type 2 Diabetes.

Background: There is a paucity of data on the risk factors for the hyperosmolar hyperglycemic state (HHS) compared with diabetic ketoacidosis (DKA) in pediatric type 2 diabetes (T2D). Methods: We used the national Kids' Inpatient Database to identify pediatric admissions for DKA and HHS among those with T2D in the years 2006, 2009, 2012, and 2019. Admissions were identified using ICD codes. Those aged <9yo were excluded. We used descriptive statistics to summarize baseline characteristics and Chi-squared test and logistic regression to evaluate factors associated with admission for HHS compared with DKA in unadjusted and adjusted models. Results: We found 8,961 admissions for hyperglycemic emergencies in youth with T2D, of which 6% were due to HHS and 94% were for DKA. These admissions occurred mostly in youth 17-20 years old (64%) who were non-White (Black 31%, Hispanic 20%), with public insurance (49%) and from the lowest income quartile (42%). In adjusted models, there were increased odds for HHS compared to DKA in males (OR 1.77, 95% CI 1.42-2.21) and those of Black race compared to those of White race (OR 1.81, 95% CI 1.34-2.44). Admissions for HHS had 11.3-fold higher odds for major or extreme severity of illness and 5.0-fold higher odds for mortality. Conclusion: While DKA represents the most admissions for hyperglycemic emergencies among pediatric T2D, those admitted for HHS had higher severity of illness and mortality. Male gender and Black race were associated with HHS admission compared to DKA. Additional studies are needed to understand the drivers of these risk factors.

A Longitudinal View of Disparities in Insulin Pump Use Among Youth with Type 1 Diabetes: The SEARCH for Diabetes in Youth Study.

Objective: To evaluate changes in insulin pump use over two decades in a national U.S. sample. Research Design and Methods: We used data from the SEARCH for Diabetes in Youth study to perform a serial cross-sectional analysis to evaluate changes in insulin pump use in participants <20 years old with type 1 diabetes by race/ethnicity and markers of socioeconomic status across four time periods between 2001 and 2019. Multivariable generalized estimating equations were used to assess insulin pump use. Temporal changes by subgroup were assessed through interactions. Results: Insulin pump use increased from 31.7% to 58.8%, but the disparities seen in pump use persisted and were unchanged across subgroups over time. Odds ratio for insulin pump use in Hispanic (0.57, confidence interval [95% CI] 0.45-0.73), Black (0.28, 95% CI 0.22-0.37), and Other race (0.49, 95% CI 0.32-0.76) participants were significantly lower than White participants. Those with ≤high school degree (0.39, 95% CI 0.31-0.47) and some college (0.68, 95% CI 0.58-0.79) had lower use compared to those with ≥bachelor's degree. Those with public insurance (0.84, 95% CI 0.70-1.00) had lower use than those with private insurance. Those with an annual household income <$25K (0.43, 95% CI 0.35-0.53), $25K-$49K (0.52, 95% CI 0.43-0.63), and $50K-$74K (0.79, 95% CI 0.66-0.94) had lower use compared to those with income ≥$75,000. Conclusion: Over the past two decades, there was no improvement in the racial, ethnic, and socioeconomic inequities in insulin pump use, despite an overall increase in use. Studies that evaluate barriers or test interventions to improve technology access are needed to address these persistent inequities.

Insulin Pump-related Inpatient Admissions in a National Sample of Youth With Type 1 Diabetes.

BACKGROUND: Insulin pump use in type 1 diabetes management has significantly increased in recent years, but we have few data on its impact on inpatient admissions for acute diabetes complications. METHODS: We used the 2006, 2009, 2012, and 2019 Kids' Inpatient Database to identify all-cause type 1 diabetes hospital admissions in those with and without documented insulin pump use and insulin pump failure. We described differences in (1) prevalence of acute diabetes complications, (2) severity of illness during hospitalization and disposition after discharge, and (3) length of stay (LOS) and inpatient costs. RESULTS: We identified 228 474 all-cause admissions. Insulin pump use was documented in 7% of admissions, of which 20% were due to pump failure. The prevalence of diabetic ketoacidosis (DKA) was 47% in pump nonusers, 39% in pump users, and 60% in those with pump failure. Admissions for hyperglycemia without DKA, hypoglycemia, sepsis, and soft tissue infections were rare and similar across all groups. Admissions with pump failure had a higher proportion of admissions classified as major severity of illness (14.7%) but had the lowest LOS (1.60 days, 95% CI 1.55-1.65) and healthcare costs ($13 078, 95% CI $12 549-$13 608). CONCLUSIONS: Despite the increased prevalence of insulin pump in the United States, a minority of pediatric admissions documented insulin pump use, which may represent undercoding. DKA admission rates were lower among insulin pump users compared to pump nonusers. Improved accuracy in coding practices and other approaches to identify insulin pump users in administrative data are needed, as are interventions to mitigate risk for DKA.

Relationships Between Socioeconomic Status, Insurance Coverage for Diabetes Technology and Adverse Health in Patients With Type 1 Diabetes.

INTRODUCTION: Insulin pumps and continuous glucose monitors (CGM) have many benefits in the management of type 1 diabetes. Unfortunately disparities in technology access occur in groups with increased risk for adverse effects (eg, low socioeconomic status [SES], public insurance). RESEARCH DESIGN & METHODS: Using 2015 to 2016 data from 4,895 participants from the T1D Exchange Registry, a structural equation model (SEM) was fit to explore the hypothesized direct and indirect relationships between SES, insurance features, access to diabetes technology, and adverse clinical outcomes (diabetic ketoacidosis, hypoglycemia). SEM was estimated using the maximum likelihood method and standardized path coefficients are presented. RESULTS: Higher SES and more generous insurance coverage were directly associated with CGM use (ß = 1.52, SE = 0.12, P < .0001 and ß = 1.21, SE = 0.14, P < .0001, respectively). Though SES displayed a small inverse association with pump use (ß = -0.11, SE = 0.04, P = .0097), more generous insurance coverage displayed a stronger direct association with pump use (ß = 0.88, SE = 0.10, P < .0001). CGM use and pump use were both directly associated with fewer adverse outcomes (ß = -0.23, SE = 0.06, P = .0002 and ß = -0.15, SE = 0.04, P = .0002, respectively). Both SES and insurance coverage demonstrated significant indirect effects on adverse outcomes that operated through access to diabetes technology (ß = -0.33, SE = 0.09, P = .0002 and ß = -0.40, SE = 0.09, P < .0001, respectively). CONCLUSIONS: The association between SES and insurance coverage and adverse outcomes was primarily mediated through diabetes technology use, suggesting that disparities in diabetes outcomes have the potential to be mitigated by addressing the upstream disparities in technology use.

National Trends in Pediatric Admissions for Diabetic Ketoacidosis, 2006-2016.

BACKGROUND AND OBJECTIVES: Diabetic ketoacidosis (DKA) rates in the United States are rising. Prior studies suggest higher rates in younger populations, but no studies have evaluated national trends in pediatric populations and differences by subgroups. As such, we sought to examine national trends in pediatric DKA. METHODS: We used the 2006, 2009, 2012, and 2016 Kids' Inpatient Database to identify pediatric DKA admissions among a nationally representative sample of admissions of youth ≤20 years old. We estimate DKA admission per 10 000 admissions and per 10 000 population, charges, length of stay (LOS), and trends over time among all hospitalizations and by demographic subgroups. Regression models were used to evaluate differences in DKA rates within subgroups overtime. RESULTS: Between 2006 and 2016, there were 149 535 admissions for DKA. Unadjusted DKA rate per admission increased from 120.5 (95% CI, 115.9-125.2) in 2006 to 217.7 (95% CI, 208.3-227.5) in 2016. The mean charge per admission increased from $14 548 (95% CI, $13 971-$15 125) in 2006 to $20 997 (95% CI, $19 973-$22 022) in 2016, whereas mean LOS decreased from 2.51 (95% CI, 2.45-2.57) to 2.28 (95% CI, 2.23-2.33) days. Higher DKA rates occurred among 18- to 20-year-old females, Black youth, without private insurance, with lower incomes, and from nonurban areas. Young adults, men, those without private insurance, and from nonurban areas had greater increases in DKA rates across time. CONCLUSIONS: Pediatric DKA admissions have risen by 40% in the United States and vulnerable subgroups remain at highest risk. Further studies should characterize the challenges experienced by these groups to inform interventions to mitigate their DKA risk and to address the rising DKA rates nationally.