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Original Investigation | Less Is More

National Estimates of Insulin-Related Hypoglycemia and Errors Leading to Emergency Department Visits and Hospitalizations

Andrew I. Geller, MD1; Nadine Shehab, PharmD, MPH1; Maribeth C. Lovegrove, MPH1; Scott R. Kegler, PhD2; Kelly N. Weidenbach, DrPH3; Gina J. Ryan, PharmD, CDE4; Daniel S. Budnitz, MD, MPH1
[+] Author Affiliations
1Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
2Division of Analysis, Research, and Practice Integration, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
3SRA International, Atlanta, Georgia
4College of Pharmacy and Health Sciences, Mercer University, Atlanta, Georgia
JAMA Intern Med. 2014;174(5):678-686. doi:10.1001/jamainternmed.2014.136.
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Importance  Detailed, nationally representative data describing high-risk populations and circumstances involved in insulin-related hypoglycemia and errors (IHEs) can inform approaches to individualizing glycemic targets.

Objective  To describe the US burden, rates, and characteristics of emergency department (ED) visits and emergency hospitalizations for IHEs.

Design, Setting, and Participants  Nationally representative public health surveillance of adverse drug events among insulin-treated patients seeking ED care (National Electronic Injury Surveillance System–Cooperative Adverse Drug Event Surveillance project) and a national household survey of insulin use (the National Health Interview Survey) were used to obtain data from January 1, 2007, through December 31, 2011.

Main Outcomes and Measures  Estimated annual numbers and estimated annual rates of ED visits and hospitalizations for IHEs among insulin-treated patients with diabetes mellitus.

Results  Based on 8100 National Electronic Injury Surveillance System–Cooperative Adverse Drug Event Surveillance cases, an estimated 97 648 (95% CI, 64 410-130 887) ED visits for IHEs occurred annually; almost one-third (29.3%; 95% CI, 21.8%-36.8%) resulted in hospitalization. Severe neurologic sequelae were documented in an estimated 60.6% (95% CI, 51.3%-69.9%) of ED visits for IHEs, and blood glucose levels of 50 mg/dL (to convert to millimoles per liter, multiply by 0.0555) or less were recorded in more than half of cases (53.4%). Insulin-treated patients 80 years or older were more than twice as likely to visit the ED (rate ratio, 2.5; 95% CI, 1.5-4.3) and nearly 5 times as likely to be subsequently hospitalized (rate ratio, 4.9; 95% CI, 2.6-9.1) for IHEs than those 45 to 64 years. The most commonly identified IHE precipitants were reduced food intake and administration of the wrong insulin product.

Conclusions and Relevance  Rates of ED visits and subsequent hospitalizations for IHEs were highest in patients 80 years or older; the risks of hypoglycemic sequelae in this age group should be considered in decisions to prescribe and intensify insulin. Meal-planning misadventures and insulin product mix-ups are important targets for hypoglycemia prevention efforts.

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Data Sources and Descriptions

For the National Health Interview Survey (NHIS), the Core questionnaire (Sample Adult and Sample Child components) was used. Results from persons who answered that they have “borderline” diabetes are treated as unknown. For female NHIS respondents, the first question begins with the phrase “Other than during pregnancy.” For persons younger than 18 years, the questions about diabetes therapy are not asked; for this age group, the prevalence of diagnosed diabetes was used as a proxy for national estimates of insulin treatment. ED indicates emergency department; NEISS-CADES, National Electronic Injury Surveillance System–Cooperative Adverse Drug Event Surveillance.

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