Variation in use of intensive care for adults with diabetic ketoacidosis

Hayley B. Gershengorn, Theodore J. Iwashyna, Colin R. Cooke, Damon C. Scales, Jeremy M. Kahn, Hannah Wunsch

Research output: Contribution to journalArticle

63 Citations (Scopus)

Abstract

Objective: Intensive care unit beds are limited, yet few guidelines exist for triage of patients to the intensive care unit, especially patients at low risk for mortality. The frequency with which low-risk patients are admitted to intensive care units in different hospitals is unknown. Our objective was to assess variation in the use of intensive care for patients with diabetic ketoacidosis, a common condition with a low risk of mortality. Design: Observational study using the New York State In-patient Database (2005-2007). Setting: One hundred fifty-nine New York State acute care hospitals. Patients: Fifteen thousand nine hundred ninety-four adult (≥ 18) hospital admissions with a primary diagnosis of diabetic ketoacidosis (International Classification of Diseases, Ninth Revision, Clinical Modification 250.1x). Interventions: None. Measurements and Main Results: We calculated reliability-and risk-adjusted intensive care unit utilization, hospital length of stay, and mortality. We identified hospital-level factors associated with increased likelihood of intensive care unit admission after controlling patient characteristics using multilevel, mixed-effects logistic regression analyses; we assessed the amount of residual variation in intensive care unit utilization using the intraclass correlation coefficient. Use of intensive care for diabetic ketoacidosis patients varied widely across hospitals (adjusted range: 2.1% to 87.7%), but was not associated with hospital length of stay or mortality. After multilevel adjustment, hospitals with a high volume of diabetic ketoacidosis admissions admitted diabetic ketoacidosis patients to the intensive care unit less often (odds ratio 0.40, p = .002, highest quintile compared to lowest), whereas hospitals with higher rates of intensive care unit utilization for all nondiabetic ketoacidosis in-patients admitted diabetic ketoacidosis patients to the intensive care unit more frequently (odds ratio 1.31, p = .001, for each additional 10% increase). In the multilevel model, more than half (58%) of the variation in the intensive care unit admission practice attributable to hospitals remained unexplained. Conclusions: We observed variations across hospitals in the use of intensive care for diabetic ketoacidosis patients that was not associated with differences in-hospital length of stay or mortality. Institutional practice patterns appear to impact admission decisions and represent a potential target for reduction of resource utilization in higher use institutions.

Original languageEnglish (US)
Pages (from-to)2009-2015
Number of pages7
JournalCritical Care Medicine
Volume40
Issue number7
DOIs
StatePublished - Jul 2012

Fingerprint

Diabetic Ketoacidosis
Critical Care
Intensive Care Units
Length of Stay
Hospital Mortality
Institutional Practice
Odds Ratio
Ketosis
Mortality
Triage
International Classification of Diseases
Observational Studies
Logistic Models

Keywords

  • Delivery of health care
  • Diabetic ketoacidosis
  • Physician's practice patterns

ASJC Scopus subject areas

  • Critical Care and Intensive Care Medicine

Cite this

Gershengorn, H. B., Iwashyna, T. J., Cooke, C. R., Scales, D. C., Kahn, J. M., & Wunsch, H. (2012). Variation in use of intensive care for adults with diabetic ketoacidosis. Critical Care Medicine, 40(7), 2009-2015. https://doi.org/10.1097/CCM.0b013e31824e9eae

Variation in use of intensive care for adults with diabetic ketoacidosis. / Gershengorn, Hayley B.; Iwashyna, Theodore J.; Cooke, Colin R.; Scales, Damon C.; Kahn, Jeremy M.; Wunsch, Hannah.

In: Critical Care Medicine, Vol. 40, No. 7, 07.2012, p. 2009-2015.

Research output: Contribution to journalArticle

Gershengorn, HB, Iwashyna, TJ, Cooke, CR, Scales, DC, Kahn, JM & Wunsch, H 2012, 'Variation in use of intensive care for adults with diabetic ketoacidosis', Critical Care Medicine, vol. 40, no. 7, pp. 2009-2015. https://doi.org/10.1097/CCM.0b013e31824e9eae
Gershengorn HB, Iwashyna TJ, Cooke CR, Scales DC, Kahn JM, Wunsch H. Variation in use of intensive care for adults with diabetic ketoacidosis. Critical Care Medicine. 2012 Jul;40(7):2009-2015. https://doi.org/10.1097/CCM.0b013e31824e9eae
Gershengorn, Hayley B. ; Iwashyna, Theodore J. ; Cooke, Colin R. ; Scales, Damon C. ; Kahn, Jeremy M. ; Wunsch, Hannah. / Variation in use of intensive care for adults with diabetic ketoacidosis. In: Critical Care Medicine. 2012 ; Vol. 40, No. 7. pp. 2009-2015.
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