Characteristics of California Children With Single Versus Multiple Diabetic Ketoacidosis Hospitalizations (1998–2000)

Diabetic ketoacidosis (DKA) is a frequent reason for hospital admission of children with newly diagnosed diabetes (1,2) and the most frequent cause for rehospitalization of children with poorly controlled diabetes (3). DKA is an ambulatory care-sensitive condition for which timely and appropriate outpatient intervention may reduce the need for hospitalization (4,5). We examined DKA hospitalizations for children 0–18 years using 1998–2000 California Office of Statewide Health Planning and Development (COSHPD) hospital discharge data to determine resource use and prevalence of DKA hospitalization for hospitalized pediatric patients. Using ICD-9 codes, we identified 4,957 DKA hospitalizations.

Pediatric DKA accounted for 14,279 hospital days (median length of stay 2 days; mean 2.9 ± 2.3 days). Hospital charges were reported for 83.6% of hospitalizations. Median charges per hospitalization were $8,440 (mean 11,615 ± $15,537), with an estimated yearly cost of $20 million for pediatric DKA care. Only 28% of these DKA hospitalizations occurred in institutions designated as hospitals providing highly specialized care to children by the National Association of Children’s Hospitals and Related Institutions.

Record linkage numbers, a COSHPD encrypted data element enabling linkage of hospitalizations and thus analyses at the child level, were available for 3,409 (69%) of hospitalizations. We sorted hospitalizations with record linkage numbers into two groups: one DKA hospitalization (1,694) and two or more DKA hospitalizations (1,715). Compared with children with one DKA hospitalization (n = 1,694), children with DKA recurrence (n = 499) were older (14.4 ± 3.5 vs. 12.0 ± 4.9 years; P < 0.001), female (65.1 vs. 49.2%; P < 0.0001), non-Hispanic blacks (16.0 vs. 11.1%; P < 0.001), and publicly insured (49.7 vs. 42.7%; P < 0.01); fewer (27.6 vs. 35.3%; P < 0.001) received care at a designated children’s hospital.

Using public insurance as a marker of poverty (6), we further examined the association of race/ethnicity and health insurance type for children with one versus two or more DKA hospitalizations using goodness-of-fit statistics. Among children with one DKA hospitalization, the proportion of minority children who were publicly insured (non-Hispanic black 59.9%, Hispanic 53.2%, other race 61.1%) was higher than that of non-Hispanic white children (29.4%; P < 0.0001). The same trend was true for children who had recurrent DKA hospitalizations (non-Hispanic black 52.5%, Hispanic 59.8%, other race 64.8% vs. non-Hispanic white 40.5%, P < 0.001). Thus, >50% of minority children in both DKA groups were publicly insured, suggesting an association between poverty and DKA. In addition, the proportion of publicly insured non-Hispanic white children was higher in the recurrent DKA group (40.5 vs. 29.4%), further supporting this association.

Children with poorly controlled diabetes are at risk for long-term complications of diabetes (7–9) and psychiatric comorbidity (10). Comparison of our findings with those of Cohn et al. (11) using 1991 COSHPD data illustrate that both the frequency and demographic characteristics of children hospitalized for DKA events remain essentially unchanged despite implementation of Diabetes Control And Complications Trial Research Group recommendations and improvements in insulin delivery options for pediatric patients over the past decade. Children with recurrent DKA may benefit from comprehensive care provided by a diabetes team including pediatric endocrinologists, diabetes educators, mental health professionals, and social workers to reverse the chain of events resulting in poor self-care. Yet, our data show that only 28% of children with recurrent DKA were hospitalized in designated children’s hospitals. Similarly, Curtis et al. (12) observed that the highest DKA rates were found in regions in Ontario, Canada, lacking academic pediatric centers. DKA hospitalizations are costly. Because access to diabetes teams may decrease the incidence of recurrent DKA, specialist visits may actually be cost saving to society. Compared with single-episode DKA, recurrent DKA is highest among adolescent girls, minority children, and those publicly insured. Opportunities exist to reduce DKA hospitalizations for children with diabetes with clinical and policy interventions targeted to this population.