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Original Investigation |

National Trends in US Hospital Admissions for Hyperglycemia and Hypoglycemia Among Medicare Beneficiaries, 1999 to 2011

Kasia J. Lipska, MD, MHS1; Joseph S. Ross, MD2,3; Yun Wang, PhD3,4; Silvio E. Inzucchi, MD1; Karl Minges, MPH3; Andrew J. Karter, PhD5; Elbert S. Huang, MD6; Mayur M. Desai, PhD, MPH7; Thomas M. Gill, MD8; Harlan M. Krumholz, MD, SM9,10
[+] Author Affiliations
1Section of Endocrinology, Yale School of Medicine, New Haven, Connecticut
2Section of General Internal Medicine and Robert Wood Johnson Clinical Scholars Program, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
3Center for Outcomes Research and Evaluation, Yale–New Haven Hospital, New Haven, Connecticut
4Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts
5Division of Research, Kaiser Permanente Northern California, Oakland
6Section of General Internal Medicine, University of Chicago, Chicago, Illinois
7Yale School of Public Health and Robert Wood Johnson Clinical Scholars Program, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
8Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
9Section of Cardiovascular Medicine, Robert Wood Johnson Clinical Scholars Program, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
10Center for Outcomes Research and Evaluation, Yale–New Haven Hospital and Section of Health Policy and Administrations, Yale School of Public Health, New Haven, Connecticut
JAMA Intern Med. 2014;174(7):1116-1124. doi:10.1001/jamainternmed.2014.1824.
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Importance  The increasing intensity of diabetes mellitus management over the past decade may have resulted in lower rates of hyperglycemic emergencies but higher rates of hospital admissions for hypoglycemia among older adults. Trends in these hospitalizations and subsequent outcomes are not known.

Objective  To characterize changes in hyperglycemia and hypoglycemia hospitalization rates and subsequent mortality and readmission rates among older adults in the United States over a 12-year period, and to compare these results according to age, sex, and race.

Design, Setting, and Patients  Retrospective observational study using data from 33 952 331 Medicare fee-for-service beneficiaries 65 years or older from 1999 to 2011.

Main Outcomes and Measures  Hospitalization rates for hyperglycemia and hypoglycemia, 30-day and 1-year mortality rates, and 30-day readmission rates.

Results  A total of 279 937 patients experienced 302 095 hospitalizations for hyperglycemia, and 404 467 patients experienced 429 850 hospitalizations for hypoglycemia between 1999 and 2011. During this time, rates of admissions for hyperglycemia declined by 38.6% (from 114 to 70 admissions per 100 000 person-years), while admissions for hypoglycemia increased by 11.7% (from 94 to 105 admissions per 100 000 person-years). In analyses designed to account for changing diabetes mellitus prevalence, admissions for hyperglycemia and hypoglycemia declined by 55.2% and 9.5%, respectively. Trends were similar across age, sex, and racial subgroups, but hypoglycemia rates were 2-fold higher for older patients (≥75 years) when compared with younger patients (65-74 years), and admission rates for both hyperglycemia and hypoglycemia were 4-fold higher for black patients compared with white patients. The 30-day and 1-year mortality and 30-day readmission rates improved during the study period and were similar after an index hospitalization for either hyperglycemia or hypoglycemia (5.4%, 17.1%, and 15.3%, respectively, after hyperglycemia hospitalizations in 2010; 4.4%, 19.9%, and 16.3% after hypoglycemia hospitalizations).

Conclusions and Relevance  Hospital admission rates for hypoglycemia now exceed those for hyperglycemia among older adults. Although admissions for hypoglycemia have declined modestly since 2007, rates among black Medicare beneficiaries and those older than 75 years remain high. Hospital admissions for severe hypoglycemia seem to pose a greater health threat than those for hyperglycemia, suggesting new opportunities for improvement in care of persons with diabetes mellitus.

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Figure 1.
Observed Rates of Hospital Admissions for Hyperglycemia and Hypoglycemia, 1999 to 2011

A, Overall. B and C, Among females and males, respectively. Among age subgroups: D, 65- to 74-year-olds; E, 75- to 84-year-olds; F, those 85 years or older. Among racial subgroups: G, black; H, other race/ethnicity; I, white. Note: To provide consistent axes for all relevant subgroups, the y-axis is on a logarithmic scale. The circles and diamonds indicate observed values; the lines represent the smoothed trend over time.

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Figure 2.
Rates of Estimated Hospital Admissions for Hyperglycemia and Hypoglycemia Among Medicare Beneficiaries With Diabetes Mellitus, 1999 to 2010

The circles and diamonds indicate observed values; the lines represent the smoothed trend over time.

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