Dictionary Series - Health: diabetes

Diabetic ketoacidosis (DKA), a complication of type 1 diabetes, is one of the most serious and potentially preventable conditions affecting children with diabetes today. A new national study led by Seattle Children’s found a wide variation in cost, length of stay and readmission rates for children with DKA.

“Delivery of care for diabetic ketoacidosis in the U.S. is not ideal,” said Joel Tieder, MD, MPH, of Seattle Children’s Research Institute. “One out of five diabetic ketoacidosis admissions are potentially preventable. Hospitals and doctors and nurses who care for children with diabetes should take a look at our data to see if there’s room for improving healthcare delivery on their home turf.”

Hospital costs, length of stay, readmission rates

This study, published July 22 in Pediatrics, is one of the first and largest of its kind to look at readmission rates for DKA and costs per patient for hospital rooms, nursing, laboratory testing, clinical therapies, pharmacy, supplies and imaging. Researchers looked at data from 38 children’s hospitals in the U.S. between 2004 and 2009. Short-term complications from type 1 diabetes, including DKA, account for more than $67 million in hospital costs per year.

“Some hospitals in this study had really high rates of readmission, whereas, some had very low rates,” said Tieder. “This study has broader implications for national healthcare delivery at children’s hospitals.”

The cost for DKA admissions—nearly 25,000—at these 38 hospitals ranged from $4,125 to $11,916. Length of stay varied between 1.5 to nearly four days. There were 24,890 DKA admissions, and 20.3 percent of these were readmissions within one year. The one-year readmission rate at one hospital was six percent; at another hospital it was 40 percent.

What is diabetic ketoacidosis?

DKA occurs due to a problem with the production of insulin in the body. Patients with type 1 diabetes must monitor carbohydrates in their diet, frequently check blood sugar, and take multiple injections of insulin every day. If they don’t manage these things well enough, their blood can become acidic.

Too much acid in the blood throws off the body’s chemical imbalance and can lead to DKA, which can become a life-threatening disorder, requiring emergency treatment with intravenous fluids and insulin infusions. Children with DKA often need to go to the intensive care unit to manage this complication.

“When we think about where systems are broken in delivery of healthcare, this is the canary in the coalmine, so to speak,” said Tieder. “If rates for repeat DKA hospitalizations are comparatively low, then, in theory, the healthcare system is adequately teaching families, providing access to care, and giving them the resources to do self-management. Failure to do that leads to higher rates of repeat hospitalization, which is easily measured and seen in this study.”

Standardizing healthcare an important step to improve care

Seattle Children’s was among the first children’s hospitals in the country to tackle this topic several years ago, when hospital leaders created a process to help prevent readmissions for DKA. This pathway, as the guidelines are known, is one of many in place at the hospital.

Clinical pathways are meant to improve the quality of care by standardizing treatment and, as a result, reduce differences in healthcare delivery. Ildiko Koves, MD, an endocrinologist at Seattle Children’s, said her team is in the process of finalizing data related to the DKA clinical standard work pathway. They’ve already noted a decrease in the number of CT (computed tomography) scans performed in children with DKA.

If you’d like to arrange an interview with Dr. Tieder or talk with a patient family who has dealt with DKA, please contact Seattle Children’s PR team at 206-987-4500 or at press@seattlechildrens.org.

Study coauthors include: Lisa McLoed, MD, MSCE; Ron Keren, MD, MPH; Xianqun Luan, MS, and Russell Localio, PhD (Children’s Hospital of Philadelphia); Sanjay Mahant, MD, MSc (Hospital for Sick Children, University of Toronto); Faisal Malik, MD (Seattle Children’s Hospital), Samir Shah, MD, MSCE (Cincinnati Children’s Hospital Medical Center); Karen Wilson, MD, MPH (Children’s Hospital, Colorado) and Rajendu Srivastava, MD, FRCP, MPH (University of Utah Health Sciences Center, Intermountain Healthcare, Inc.).

Resources:

• “Variation in Resource Use and Readmission for Diabetes Ketoacidosis in Children’s Hospitals” from Pediatrics.
Diabetes: When to call the doctor
• What is Ketoacidosis?
Clinical Standard Work Pathways and Tools at Seattle Children’s