Increase in hypoglycemic admissions: California hospital discharge data.

Abstract

To compare the percentage of diabetics admitted to the hospital due to hypoglycemia in 1990-1993 (period 1) to that in 1997-2000 (period 2).
We analyzed data from the California Hospital Discharge Data Program. Eligibility included diabetic (ICD code 250) subjects aged > or =25 years old who were hospitalized due to hypoglycemia (ICD Codes 250.8) during the periods 1990-1993 and 1997-2000. Data were analyzed by demographics and health insurance status.
Of the 2,905,091 hospitalized diabetics, 50,017 (1.7%) were due to hypoglycemia. The percentage of hospitalization due to hypoglycemic varied by sex, age, race/ethnicity, and insurance status (P = .0001). Male, Hispanic, age 25-64 years, with Medical/Medicare insurance had higher odds of being hospitalized due to hypoglycemia relative to other groups (P < .001). The percentage of diabetics hospitalized due to hypoglycemia increased from period 1 to period 2 (1.3% vs. 2.0%, P = .0001). Diabetics hospitalized in period 2 had higher adjusted odds of being hospitalized due to hypoglycemia relative to those admitted in period 1 (OR = 1.6, P < .0001).
Our data show an increase in the hospitalization due to hypoglycemia in diabetic patients. Enhanced patient education about self-monitoring of blood sugar and recognizing and treating the symptoms of hypoglycemia may help to minimize hypoglycemic hospitalizations.

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INCREASE IN HYPOGLYCEMIC ADMISSIONS: CALIFORNIA HOSPITAL DISCHARGE DATA
Merlyn M Asuncion, MD; Magda Shaheen, MD, PhD;
Kalpana Ganesan, MD; Joseph Velasques, MD;
Senait Teklehaimanot, MPH; Deyu Pan, MS; Keith Norris, MD
Objectives: To compare the percentage of
diabetics admitted to the hospital due to
hypoglycemia in 1990–1993 (period 1) to that
in 1997–2000 (period 2).
Methods: We analyzed data from the Califor-
nia Hospital Discharge Data Program. Eligibility
included diabetic (ICD code 250) subjects
aged $25 years old who were hospitalized
due to hypoglycemia (ICD Codes 250.8)
during the periods 1990–1993 and 1997–
2000. Data were analyzed by demographics
and health insurance status.
Results: Of the 2,905,091 hospitalized dia-
betics, 50,017 (1.7%) were due to hypoglyce-
mia. The percentage of hospitalization due to
hypoglycemic varied by sex, age, race/ethnic-
ity, and insurance status (P5.0001). Male,
Hispanic, age 25–64 years, with Medical/
Medicare insurance had higher odds of being
hospitalized due to hypoglycemia relative to
other groups (P,.001). The percentage of
diabetics hospitalized due to hypoglycemia
increased from period 1 to period 2 (1.3% vs
2.0%, P5.0001). Diabetics hospitalized in
period 2 had higher adjusted odds of being
hospitalized due to hypoglycemia relative to
those admittedin
P,.0001).
period1 (OR51.6,
Conclusion: Our data show an increase in the
hospitalization due to hypoglycemia in diabetic
patients. Enhanced patient education about
self-monitoring of blood sugar and recognizing
and treating the symptoms of hypoglycemia
may help to minimize hypoglycemic hospitali-
zations. (Ethn Dis. 2007;17:536–540)
Key Words:
sions, Diabetes
Hypoglycemia, Hospital Admis-
INTRODUCTION
The cardiac, eye, renal, peripheral
vascular and other complications of
diabetes mellitus (DM), type 1 and/or
type 2 have been steadily increasing.
The economic cost of diabetes in the
United States in 2003 was approximate-
ly $132 billion and continues to rise.1
Tighter glucose control has been dem-
onstrated to reduce clinical complica-
tions and ultimately reduce overall
health care costs (Diabetes Control
and Complications Trial [DCCT], the
United Kingdom Prospective Diabetes
Study Research Group [UKPDS] cost
estimates).2,3The recommendations
from these studies have been widely
implemented within the last few years.
Iatrogenic hypoglycemia often causes
morbidity and sometimes mortality
and is a not uncommon complication
of, and barrier to, tight control of DM.4
Many hospital admissions with hy-
poglycemia in diabetic elderly patients
have been identified to be due to drug-
drug interactions.5Severe hypoglycemia
is a major problem for patients with
diabetes due to limited patient awareness
of signs and symptoms. Cohabitants of
patients recallsignificantlymoreepisodes
of severe hypoglycemia than the patients
do.6In Germany, diabetes-related emer-
gencies are frequent and potentially life
threatening. A study in Germany re-
ported that emergency medical service
personnel provided pre-hospital care for
patients with diabetes-related emergen-
cies including hypoglycemia. This, in
addition to patient education, reduced
mortality from 4.9% to 0%.7
While hypoglycemia in neonates
and children has been extensively re-
viewed in the literature,6–10limited data
exists regarding hospital admission due
to severe hypoglycemia in adults. To
better understand the impact of more
aggressive glucose control on significant
hypoglycemia, we examined the trends
of hospital admissions due to hypogly-
cemia in diabetics from 1990–1993 and
1997–2000 in the state of California.
METHODS
This study was a secondary database
analysis of the public California Hospi-
tal Discharge Database for the years
1990 to 1993 and 1997 to 2000. This
database includes comprehensive rec-
ords of most of the hospital inpatient
discharges from the acute care hospi-
tals.11We identified patients who had
hypoglycemia as the primary diagnosis
for the hospitalization using the ICD-9
code 250.8. We identified patients who
had diabetes mellitus in the other
diagnosis fields. The diagnosis of di-
abetes mellitus was based on inpatient
hospital diagnosis codes 250 from the
International Classification of Diseases,
Ninth Revision (ICD-9). The ICD-9
code of 250 does not include gestational
diabetes, hyperglycemia or non- clinical
diabetes. The percentage of hospitalized
diabetics due to hypoglycemia was
calculated by dividing the number of
hospitalizations due to hypoglycemia by
the total number of diabetic hospitaliza-
tions and is reported as a percentage.
From the Divisions of General Internal
Medicine and Geriatrics, Charles R. Drew
University of Medicine and Science (MMA,
KG, JV) and the Research Center for
Minority Institutions, Charles R. Drew Uni-
versity of Medicine and Science (MS, ST,
DP, KN).
Address correspondence and reprints
requests to Merlyn M. Asuncion, MD;
Department of Internal Medicine; King/
Drew Medical Center; 12021 S. Wilming-
ton Ave; Los Angeles, CA 90059; 310-668-
4574; 310-763-8929; measunci@cdrewu.
edu
The economic cost of diabetes
in the United States was
approximately $132 billion
in 2003 and continues to
rise.1
536
Ethnicity & Disease, Volume 17, Summer 2007

Page 2

From each subject diagnosed with di-
abetes in the hospital record, we
identified age, race, sex, year of admis-
sion, diagnosis of hypoglycemia, and
payment source (insurance). Diagnosis
of hypoglycemia was categorized into
two categories (yes, no). The socio-
demographic variables included in this
study were: age 25 to 64 years,
$65 years); sex (male and female);
race/ethnicity (White, African Ameri-
can, Hispanic and Asian/others); and
insurance status (Medicare/Medical and
other insurance). Data were collapsed
over the hospitalization years into two
time periods: period 1 (1990 to 1993)
and period 2 (1997 to 2000). We
calculated the percentage of diabetics
admitted to the hospital due to hypo-
glycemia and compared this percentage
for the two time periods. The change in
the percentage of diabetic hospitaliza-
tion due to hypoglycemia over the two
time periods is calculated using the
formula:[(percent in period 2 - percent
in period 1) /percent in period 1]*100.
Data are reported by sex, race/ethnicity,
age categories, and insurance status.
Chi-square tests were used to assess the
difference in hospitalization due to
hypoglycemia in the two time periods.
Logistic regression analyses were con-
ducted to examine the relationship
between hospitalization periods due to
hypoglycemia, adjusting for pre-speci-
fied potential confounding variables
(age, sex, and race/ethnicity, and in-
surance). Logistic regression analysis is
presented as odds ratios and 95%
confidence intervals. In all cases, a two-
tailed P,0.05 was considered statisti-
cally significant. Data were analyzed
using SPSS, version 13.0 (Statistical
Package for Social Science, Chicago,
Ill).
RESULTS
The study includes 2,905,091 di-
abetic hospitalizations for patients
$25 years of age, with 39% occurring
during 1990–1993 and 61% recorded
during 1997–2000. Of all diabetic
hospitalizations, 50,017 (1.7%) hospi-
talizations were due to hypoglycemia.
Most (71.1%) of the diabetes-related
hypoglycemia hospitalizations occurred
during the period 1997–2000. The
percentage of hospitalizations due to
hypoglycemia increased over time:
hospitalizations were 0.7% higher in
period 2 compared to period 1 (2.0%
vs 1.3%, P5.0001; Table 1). Over the
two study time periods, we found
a 56% increase in the total number
of diabetic hospitalizations and a 146%
increase in diabetic hospitalizations due
to hypoglycemia. The corresponding
increase in the percentage of diabetic
hospitalizations due to hypoglycemia is
58% between the two time periods
(Table 1). It is apparent from Table 1
that overall diabetic hospitalizations
due to hypoglycemia were higher in
1997–2000 period and hypoglycemic
hospitalizations vary across sex, age,
race/ethnicity, and insurance status
(P5.0001).
Comparing the two time periods of
this study, there was a 58% increase in
the percentage of diabetic hospitaliza-
tions due to hypoglycemia. The highest
percent change in diabetic hospitaliza-
tions due to hypoglycemia was found
among patients $65 years of age
(113%), Asian/other patients (113%),
female (80%), African American pa-
tients (79%), and those with Medicare/
Medical health insurance (73%) (Ta-
ble 2).
Multiple logistic regression analysis
in Table 3 revealed that age (25–
64 years), sex (male), race/ethnicity
(Hispanics), and insurance status
(Medicare/Medical) were significant
predictors for diabetic hospitalizations
due to hypoglycemia. After controlling
for the confounders in the model, the
overall odds of diabetic hospitalization
due to hypoglycemia in the time period
1997–2000 was about one and a half
times (OR51.6) the odds in 1990–
1993 time period (Table 3).
DISCUSSION
Our data show that within the
inclusive years there had been an in-
creasing trend in the hospitalization of
diabetics with significant hypoglycemia.
Of the 2,905,091 diabetic hospitaliza-
tions, 50,017 (1.7%) were due to
Table 1.
admission time period, demographic variables and insurance status
Number and percent of diabetic admissions due to hypoglycemia by
VariableDiabetesHypoglycemiaPercentP-value
Admission year
1990 to 1993
1997 to 2000
1,134,022
1,771,069
14,438
35,579
1.3
2.0
.0001
Sex
Male
Female
1,348,171
1,556,860
27,318
22,696
2.0
1.5
.0001
Age group
25 to 64 years
$65 years
1,185,120
1,719,971
26,849
23,168
2.3
1.4
.0001
Ethnicity
White
African American
Hispanic
Asian/Other
1,684,211
340,559
628,984
251,249
25,349
6,863
14,312
3,491
1.5
2.0
2.3
1.4
.0001
Insurance
Medical/Medicare
Other
2,078,171
826,025
33,672
16,321
1.6
2.0
.0001
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Page 3

hypoglycemia. The percentage of di-
abetic hospitalization due to hypoglyce-
mia increased significantly from period
1 to period 2 (1.3% vs 2.01%).
However, the overall prevalence is low
and the absolute increase is small.
Although the study was not designed
to explain why there was a significant
increase in hypoglycemic hospitalization
from 1990 to 2000, certain facts may
explain the increase. In the last decade,
we have experienced a significant para-
digm shift in the management of
diabetes. In 1995, new target levels of
fasting plasma glucose (less than
7.8 mmol/L [140 mg/dL]) and HbA1C
levels (below 7.0%) were proposed.12
At the same time, in late 1996, the
American Diabetes Association’s (ADA)
expert committee changed the diagnos-
tic criteria for diabetes (fasting plasma
glucose level of 7 mmol/L [126 mg/dL]
or more), thereby effectively increasing
the number of diagnosed diabetics.10,12
This might have increased the total
number of diabetic patients admitted
with a diagnosis of diabetes but is
unlikely to have increased the number
of patients under strict control with
pharmacologic intervention.
In addition, newer medications for
diabetes, including the combination of
oral hypoglycemic agents and insulin,
are being used.13Also, healthcare pro-
viders are more aggressive in achieving
tight glycemic control, which can po-
tentially cause hypoglycemic episodes.14
Furthermore, many diabetic patients
have associated hypertension and are
on antihypertensive medications that
can potentially decrease blood glucose
levels.15Increased use of herbal pre-
parations may also potentially cause
drug interactions leading to hypoglyce-
Table 2.
1997–2000) by demographic variables and insurance status
Percentage of diabetic admissions due to hypoglycemia comparing the two time periods of admission (1990–1993 vs
Variables
1990 to 19931997 to 2000
Percent change
(difference/ initial)*100Diabetes Hypoglycemia Initial %DiabetesHypoglycemia%
Sex
Male
Female
516,994
617,009
8,304
6,133
1.6
1.0
831,177
939,851
19,014
16,563
2.3
1.8
43.7
80.0
Age group
25 to 64 years
$65 years
474,456
659,566
9,106
5,332
1.9
0.8
710,664
1,060,405
17,743
17,836
2.5
1.7
31.6
112.5
Ethnicity
White
Black
Hispanic
Asian/Other
697,560
137,051
220,383
79,028
8,340
1,846
3,652
600
1.2
1.4
1.7
0.8
986,651
203,508
408,601
172,221
17,009
5,017
10,660
2,891
1.7
2.5
2.6
1.7
41.7
78.6
52.9
112.5
Insurance
Medical/ Medicare
Other
79,814
33,5871
8,835
5,603
1.1
1.7
1,280,027
490,154
24,837
10,718
1.9
2.2
72.7
29.4
Table 3.
to hypoglycemia*
Odds ratio and 95% confidence interval (CI) of diabetic admissions due
VariableOdds Ratio95% CIP-value
Admission year
1990 to 1993
1997 to 2000
Reference
1.58
–
1.55–1.61 .0001
Sex
Male
Female
Reference
0.72
–
0.71–0.74 .0001
Age group
25 to 64 years
$ 65 years
Reference
0.61
–
0.60–0.62.0001
Ethnicity
White
African American
Hispanic
Asian/Other
Reference
1.25
1.39
0.88
–
1.22–1.29
1.36–1.42
0.85–0.91
.0001
.0001
.0001
Insurance
Medical/Medicare
Other
Reference
0.95
–
0.93–0.97 .0001
* For all data across each period, except for the comparisons by admission year.
The percentage of diabetic
hospitalization due to
hypoglycemia increased
significantly from period 1 to
period 2 (1.3% vs 2.01%).
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Page 4

mia.16Several reports have found elder-
ly patients with diabetes being hospital-
ized due to hypoglycemia secondary to
drug-drug interactions.16–19Co-trimox-
azole and floroquinolones were some of
the antibiotics that have been associated
with hypoglycemia in elderly pa-
tients.15,18We did not find an increase
in the percentage of hospitalizations due
to hypoglycemia in the elderly com-
pared to younger patients in our study.
Our data showed that hospitaliza-
tion due to hypoglycemia had increased
across all adults. However, males, com-
pared to females, had even higher odds
to be hospitalized due to hypoglycemia
(P5.0001). Among the different races,
Whites had the highest number of
hospitalizations due to hypoglycemia,
followed by the Hispanics, then Blacks
and Asians/other. The highest percent-
age of hospitalizations due to hypogly-
cemia was among Hispanics followed
by African American. The ethnic differ-
ences may be due to different lifestyles,
insurance availability, utilization of
medical services and other factors.
The hypoglycemic data from pub-
lished studies showed varying frequency
or incidence. The Diabetes Control and
Complications Trial (DCCT), for ex-
ample, recorded the incidence of type 1
diabetics who suffer severe hypoglyce-
mia to be only 0.62 episodes per patient
per year for patients in the intensively
treated arm, which is much lower than
the European figures of 1.0 to 1.6.10In
the UKPDS study, the significant major
hypoglycemic episodes occurred only in
0.8%, 0.5% and 1.4% of patients per
year among patients on sulfonylureas,
metformin, and insulin, respectively,
and 0.2% in patients with diet thera-
py.10,20,21Direct comparisons with
DCCT and UKPDS trials cannot be
made because of difference in study
design and sampling methods.
Miller et al, in a specialized diabetic
clinic that serves a predominantly Afri-
can American population in urban
Atlanta Georgia, found the prevalence
of severe hypoglycemia among type 2
diabetics who were treated with insulin
to be only 0.5%.22The patients in this
study were closely followed by dietitians
and intensively educated on hypoglyce-
mia by diabetic nurse specialists, and
adequately adhered to a strict follow-up
regimen with specialists. In an earlier
study in England, Leese et al2utilized
a large population-based study that
found that the prevalence of severe
hypoglycemia in insulin-treated patients
with type 2 diabetes was much higher
than that reported previously.22The
prevalence of severe hypoglycemia was
7.1% for type 1 diabetics, 7.3% for type
2 diabetics treated with insulin and
0.8% for type 2 diabetics treated with
sulfonylurea tables. The risk factors for
severe hypoglycemia in this study were
age, duration of diabetes and socioeco-
nomic status.2In our study of the
general population, the percentage of
hypoglycemia was higher than the pre-
vious controlled studies and showed an
increasing trend over the study period
from 1.3% to 2.0%. The factors
associated with hospitalization due to
hypoglycemia in our study were sex,
age, race/ethnicity and insurance status.
Previous studies have reported fre-
quencies and incidence of hypoglycemia
in treated type 1 and type 2 diabetics.
Our study is unique because it exam-
ined the trend of hospitalization due to
hypoglycemia. Our study had several
limitations. Since we used the admission
diagnosis variables from California
Hospital Discharge Database, other
variables such as medications, duration
of diabetes, level of education, lifestyles
and comorbid conditions were not
available. Head-to-head comparison be-
tween our study and others described in
literature may not be possible because of
non-uniformity of study design, meth-
odological variations and, above all,
difference in population characteristics.
In addition, our study findings were
limited to a population able to go to the
hospital and living in the state of
California. Causal inference can not be
drawn from our data because of the
temporal ambiguity and our inability to
identify the actual causes of hypoglyce-
mia from this retrospective data. There
is a possibility of underreporting of the
hypoglycemia cases in our study prob-
ably because of under coding of diabetes
in the hospital discharge data, and lack
of information on patients with hypo-
glycemia who were discharged from the
emergency room.
In conclusion, our study shows
a significant increase in the number of
hospitalizations due to hypoglycemia
among treated diabetics over the two
periods studied, period 1(1990–1993)
and period 2 (1997–2000). The in-
crease in hospitalization due to hypo-
glycemia was more evident among older
patients ($65 years), Asian/other race,
female, African American, and those
who had Medical/Medicare health in-
surance. While aggressive diabetes care
remains important, the clinical and
financial implications of severe hypo-
glycemia should not be ignored. Patient
education regarding diet, self-monitor-
ing of blood sugar, recognizing the
symptoms of hypoglycemia, and treat-
ment of symptoms can help to mini-
mize the hospitalizations due to hypo-
glycemia. Future studies should address
these issues to minimize hospitalizations
due to hypoglycemia.
ACKNOWLEDGMENTS
This project was supported in part by G12-
RR03026, P20-RR11145, U54 RR019234,
and U54 RR14616 from NIH/NCRR and
P20MD000182 from the NIH/NCMHD.
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AUTHOR CONTRIBUTIONS
Design concept of study: Asuncion, Shaheen,
Ganesan, Velasques, Norris
Acquisition of data: Ganesan, Velasques,
Teklehaimanot, Pan
Data analysis and interpretation: Shaheen,
Velasques, Teklehaimanot, Pan, Norris
Manuscript draft: Asuncion, Shaheen, Velas-
ques, Teklehaimanot, Norris
Statisticalexpertise:
Teklehaimanot, Pan, Norris
Acquisition of funding: Velasques, Norris
Administrative, technical, or material assis-
tance: Velasques, Norris
Supervision: Asuncion, Velasques, Norris
Shaheen, Velasques,
INCREASE IN HYPOGLYCEMIC ADMISSIONS - Asuncion et al
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Ethnicity & Disease, Volume 17, Summer 2007