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Intensive sick day rules to prevent recurrent diabetic ketoacidosis- An intervention that exemplifies health
Alyssa M Dye1, Ramin Alemzadeh1, Jiajing Wang2
1Department of Pediatric Endocrinology, University of Tennessee Health Science Center, Le Bonheur Children's Hospital, 848 Adams Avenue, Memphis, TN, 38103, USA.
Insights
Intensive sick day rules reduced diabetic ketoacidosis (DKA) hospitalizations in youth with type 1 diabetes (T1D). However, the intervention did not eliminate health disparities for minority groups, highlighting the need for further research.
Area of Science:
- Pediatric Endocrinology
- Metabolic Disorders
- Public Health
Background:
- Diabetic ketoacidosis (DKA) is a major cause of morbidity and mortality in children with type 1 diabetes (T1D).
- DKA disproportionately affects ethnic minorities and individuals with lower socioeconomic status.
- Insulin omission or inadequate administration during illness is a common trigger for DKA in established T1D patients.
Purpose of the Study:
- To evaluate the impact of intensive sick day rules on reducing DKA hospitalizations in T1D youth.
- To assess whether the intervention mitigated demographic disparities in DKA incidence.
Main Methods:
- Implementation of intensive sick day rules starting January 2016.
- Chart review of T1D patients seen between January 2015 and December 2017.
- Statistical analysis using Chi-square and t-tests; trend analysis for DKA episodes per 100 patient-years.
Main Results:
- A statistically significant decrease in DKA episodes per 100 patient-years from 19.1 (2015) to 12.4 (2017).
- The decline was significant in a subgroup of patients who experienced DKA in 2015.
- DKA episodes remained associated with African-American race, Medicaid status, and higher HbA1c.
Conclusions:
- Intensive sick day rules effectively reduced overall DKA admissions in T1D youth.
- The intervention did not reduce health disparities, with African-Americans on Medicaid remaining disproportionately affected.
- Further research is needed to develop interventions addressing racial and socioeconomic barriers in T1D management.
Objective:
Diabetic ketoacidosis (DKA) is the leading cause of morbidity and mortality in children with type 1 diabetes (T1D). In established T1D patients, DKA is frequently a result of insulin omission or inadequate insulin administration during illness or stress. Ethnic minorities and patients with lower socioeconomic status are affected disproportionately. We hypothesized that implementation of intensive sick day rules with frequent reinforcement would reduce hospitalizations secondary to DKA in T1D youth irrespective of their demographics.
Methods:
Intensive sick day rules were implemented beginning January 2016. All T1D patients seen in the pediatric endocrinology clinic or hospital between January 1st 2015 through December 31st 2017 were included for chart review. Categorical variables were analyzed with Chi-square test. For the continuous variables, t test was used. Episodes of DKA per 100 patients were compared using the trends test over the three-year period. Patients who had DKA in 2015 were analyzed as a subgroup.
Results:
The frequency of DKA episodes per 100 patient years for 2015 was 19.1, for 2016 was 15.2 and was 12.4 for 2017. This decrease was statistically significant (p=0.006). The decline was also statistically significant for the subgroup of patients who developed DKA in 2015 and followed longitudinally. The decline was not uniform across all patient groups and DKA episodes remained associated with African- American race, Medicaid insurance status and higher HbA1c throughout the years.
Conclusion:
Implementation of intensive sick day rules led to a decrease in total number of DKA admissions in our population with T1D youth. However, this intervention did not reduce the health disparity in this population and African-Americans on Medicaid insurance continued to form the disproportionate majority of admissions with DKA. This study highlights the need for further research into interventions that can improve outcomes across racial and socio-economic barriers.
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