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Delayed diagnosis of new onset pediatric diabetes leading to diabetic ketoacidosis: a retrospective cohort study

  • Stephanie M. Hadley ORCID logo EMAIL logo and Kenneth A. Michelson ORCID logo
Published/Copyright: June 27, 2024
Diagnosis
From the journal Diagnosis Volume 11 Issue 4

Abstract

Objectives

Patients with a delayed diagnosis of diabetes are more likely to present in diabetic ketoacidosis (DKA). The objective of this study was to assess the prevalence, risk factors, and consequences of missed pediatric diabetes diagnoses in emergency departments (EDs) potentially leading to DKA.

Methods

Cases of children under 19 years old with a first-time diagnosis of diabetes mellitus presenting to EDs in DKA were drawn from the Healthcare Cost and Utilization Project database. A total of 11,716 cases were included. A delayed diagnosis of diabetes leading to DKA was defined by an ED discharge in the 14 days prior to the DKA diagnosis. The delayed diagnosis cases were analyzed using multivariate analysis to identify risk factors associated with delay, with the primary exposure being child opportunity index (COI) and secondary exposure being race/ethnicity. Rates of complications were compared across groups.

Results

Delayed diagnosis of new onset diabetes leading to DKA occurred in 2.9 %. Delayed diagnosis was associated with COI, with 4.5 , 3.5, 1.9, and 1.5 % occurring by increasing COI quartile (p<0.001). Delays were also associated with younger age and non-Hispanic Black race. Patients with a delayed diagnosis were more likely to experience complications (4.4 vs. 2.2 %, p=0.01) including mechanical ventilation, as well as more frequent intensive care unit admissions and longer length of stays.

Conclusions

Among children with new-onset DKA, 2.9 % had a delayed diagnosis. Delays were associated with complications. Children living in areas with lower child opportunity and non-Hispanic Black children were at higher risk of delays.

Keywords: delayed diagnosis; diabetic ketoacidosis; pediatric emergency medicine; child opportunity index
Corresponding Author: Stephanie M. Hadley, MD, Department of Pediatrics, Boston Children’s Hospital, 300 Longwood Ave 02115, Boston, MA, USA, E-mail:

Funding source: Agency for Healthcare Research and Quality

Award Identifier / Grant number: K08HS026503

  1. Research ethics: This study was approved by the Lurie Children’s Hospital’s Independent Review Board (2023–5967).

  2. Informed consent: Not applicable.

  3. Author contributions: Both authors conceptualized and designed the study and critically reviewed and revised the manuscript. SMH carried out the initial analyses and drafted the initial manuscript. KAM coordinated and supervised data collection and analyses and is the guarantor of this work and, as such, had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. The authors have accepted responsibility for the entire content of this manuscript and approved its submission.

  4. Competing interests: The authors state no conflict of interest.

  5. Research funding: This study was supported by the Agency for Healthcare Research and Quality (K08HS026503 to KAM).

  6. Data availability: The raw data can be obtained on request from the corresponding author.

References

1. Duca, LM, Reboussin, BA, Pihoker, C, Imperatore, G, Saydah, S, Mayer-Davis, E, et al.. Diabetic ketoacidosis at diagnosis of type 1 diabetes and glycemic control over time: the search for diabetes in youth study. Pediatr Diabetes 2019;20:172–9. https://doi.org/10.1111/pedi.12809.Search in Google Scholar PubMed PubMed Central

2. Rewers, A, Dong, F, Slover, RH, Klingensmith, GJ, Rewers, M. Incidence of diabetic ketoacidosis at diagnosis of type 1 diabetes in Colorado youth, 1998-2012. JAMA 2015;313:1570–2. https://doi.org/10.1001/jama.2015.1414.Search in Google Scholar PubMed

3. Bowden, SA, Duck, MM, Hoffman, RP. Young children (<5 yr) and adolescents (>12 yr) with type 1 diabetes mellitus have low rate of partial remission: diabetic ketoacidosis is an important risk factor. Pediatr Diabetes 2008;9:197–201. https://doi.org/10.1111/j.1399-5448.2008.00376.x.Search in Google Scholar PubMed

4. Dunger, DB, Sperling, MA, Acerini, CL, Bohn, DJ, Daneman, D, Danne, TPA, et al.. European society for paediatric endocrinology/lawson wilkins pediatric endocrine society consensus statement on diabetic ketoacidosis in children and adolescents. Pediatrics 2004;113:e133–40. https://doi.org/10.1542/peds.113.2.e133.Search in Google Scholar PubMed

5. Duca, LM, Wang, B, Rewers, M, Rewers, A. Diabetic ketoacidosis at diagnosis of type 1 diabetes predicts poor long-term glycemic control. Diabetes Care 2017;40:1249–55. https://doi.org/10.2337/dc17-0558.Search in Google Scholar PubMed

6. Zhang, K, Kan, C, Han, F, Zhang, J, Ding, C, Guo, Z, et al.. Global, regional, and national epidemiology of diabetes in children from 1990 to 2019. JAMA Pediatr 2023;177:837–46. https://doi.org/10.1001/jamapediatrics.2023.2029.Search in Google Scholar PubMed PubMed Central

7. Muñoz, C, Floreen, A, Garey, C, Karlya, T, Jelley, D, Alonso, GT, et al.. Misdiagnosis and diabetic ketoacidosis at diagnosis of type 1 diabetes: patient and caregiver perspectives. Clin Diabetes 2019;37:276–81. https://doi.org/10.2337/cd18-0088.Search in Google Scholar PubMed PubMed Central

8. Usher-Smith, JA, Thompson, MJ, Sharp, SJ, Walter, FM. Factors associated with the presence of diabetic ketoacidosis at diagnosis of diabetes in children and young adults: a systematic review. BMJ 2011;343:d4092. https://doi.org/10.1136/bmj.d4092.Search in Google Scholar PubMed PubMed Central

9. Tas, E, Wooley, K, Tas, V, Wang, YCA. Delayed management of insulin-dependent diabetes mellitus in children. J Pediatr Health Care 2023;37:56–62. https://doi.org/10.1016/j.pedhc.2022.07.004.Search in Google Scholar PubMed PubMed Central

10. Pawłowicz, M, Birkholz, D, Niedźwiecki, M, Balcerska, A. Difficulties or mistakes in diagnosing type 1 diabetes in children?Demographic factors influencing delayed diagnosis. Pediatr Diabetes 2009;10:542–9. https://doi.org/10.1111/j.1399-5448.2009.00516.x.Search in Google Scholar PubMed

11. Bui, H, To, T, Stein, R, Fung, K, Daneman, D. Is diabetic ketoacidosis at disease onset a result of missed diagnosis? J Pediatr 2010;156:472–7. https://doi.org/10.1016/j.jpeds.2009.10.001.Search in Google Scholar PubMed

12. Vicinanza, A, Messaaoui, A, Tenoutasse, S, Dorchy, H. Diabetic ketoacidosis in children newly diagnosed with type 1 diabetes mellitus: role of demographic, clinical, and biochemical features along with genetic and immunological markers as risk factors. A 20-year experience in a tertiary Belgian center. Pediatr Diabetes 2019;20:584–93. https://doi.org/10.1111/pedi.12864.Search in Google Scholar PubMed

13. Daniel, M, Park, S, Seifert, CM, Chandanabhumma, PP, Fetters, MD, Wilson, E, et al.. Understanding diagnostic processes in emergency departments: a mixed methods case study protocol. BMJ Open 2021;11:e044194. https://doi.org/10.1136/bmjopen-2020-044194.Search in Google Scholar PubMed PubMed Central

14. Gross, TK, Lane, NE, Timm, NL, Conners, GP, Hoffmann, J, Hsu, B, et al., COMMITTEE ON PEDIATRIC EMERGENCY MEDICINE. Crowding in the emergency department: challenges and best practices for the care of children. Pediatrics 2023;151. https://doi.org/10.1542/peds.2022-060972.Search in Google Scholar PubMed

15. Michelson, KA, Bachur, RG, Cruz, AT, Grubenhoff, JA, Reeves, SD, Chaudhari, PP, et al.. Multicenter evaluation of a method to identify delayed diagnosis of diabetic ketoacidosis and sepsis in administrative data. Diagnosis 2023;10:383–9. https://doi.org/10.1515/dx-2023-0019.Search in Google Scholar PubMed PubMed Central

16. Iovane, B, Cangelosi, AM, Bonaccini, I, Di Mauro, D, Scarabello, C, Panigari, A, et al.. Diabetic ketoacidosis at the onset of type 1 diabetes in young children Is it time to launch a tailored campaign for DKA prevention in children <5 years? Acta Biomed 2018;89:67–71. https://doi.org/10.23750/abm.v89i1.6936.Search in Google Scholar PubMed PubMed Central

17. Noelke, C, McArdle, N, Baek, M, Huntington, N, Huber, R, Hardy, E, et al. Child opportunity index 2.0 technical documentation. [Internet]. 2020 [cited 2023 May 2]. Available from: diversitydatakids.org/researchlibrary/research-brief/how-we-built-it.Search in Google Scholar

18. Hamman, RF, Bell, RA, Dabelea, D, D’Agostino, RB, Dolan, L, Imperatore, G, et al.. The search for diabetes in youth study: rationale, findings, and future directions. Diabetes Care 2014;37:3336–44. https://doi.org/10.2337/dc14-0574.Search in Google Scholar PubMed PubMed Central

19. Feudtner, C, Feinstein, JA, Zhong, W, Hall, M, Dai, D. Pediatric complex chronic conditions classification system version 2: updated for ICD-10 and complex medical technology dependence and transplantation. BMC Pediatr 2014;14:199. https://doi.org/10.1186/1471-2431-14-199.Search in Google Scholar PubMed PubMed Central

20. Balogh, E, Miller, B, Ball, J. Improving diagnosis in health care; 2015.10.17226/21794Search in Google Scholar PubMed

21. Kaiser, SV, Hall, M, Bettenhausen, JL, Sills, MR, Hoffmann, JA, Noelke, C, et al.. Neighborhood child opportunity and emergency department utilization. Pediatrics 2022;150. https://doi.org/10.1542/peds.2021-056098.Search in Google Scholar PubMed

22. Marin, JR, Rodean, J, Hall, M, Alpern, ER, Aronson, PL, Chaudhari, PP, et al.. Racial and ethnic differences in emergency department diagnostic imaging at US Children’s hospitals, 2016-2019. JAMA Netw Open 2021;4. https://doi.org/10.1001/jamanetworkopen.2020.33710.Search in Google Scholar PubMed PubMed Central

23. Lawrence, JM, Divers, J, Isom, S, Saydah, S, Imperatore, G, Pihoker, C, et al.. Trends in prevalence of type 1 and type 2 diabetes in children and adolescents in the US, 2001-2017. JAMA 2021;326:717–27. https://doi.org/10.1001/jama.2021.11165.Search in Google Scholar PubMed PubMed Central

24. Alonso, GT, Coakley, A, Pyle, L, Manseau, K, Thomas, S, Rewers, A. Diabetic ketoacidosis at diagnosis of type 1 diabetes in Colorado children, 2010–2017. Diabetes Care 2020;43:117–21. https://doi.org/10.2337/dc19-0428.Search in Google Scholar PubMed PubMed Central

25. Zeidan, AJ, Khatri, UG, Aysola, J, Shofer, FS, Mamtani, M, Scott, KR, et al.. Implicit bias education and emergency medicine training: step one? Awareness. AEM Educ Train 2019;3:81–5. https://doi.org/10.1002/aet2.10124.Search in Google Scholar PubMed PubMed Central

26. Fingrut, WB, Davis, E, Chinapen, S, Naputo, K, Politikos, I, Scaradavou, A, et al.. Inaccuracies in assignment of patient race and ethnicity: implications for unrelated donor searches and health care delivery. Blood Adv 2023;7:1996–9. https://doi.org/10.1182/bloodadvances.2022008526.Search in Google Scholar PubMed PubMed Central

Supplementary Material

This article contains supplementary material (https://doi.org/10.1515/dx-2024-0024).

Received: 2024-01-30
Accepted: 2024-05-31
Published Online: 2024-06-27

© 2024 Walter de Gruyter GmbH, Berlin/Boston

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https://doi.org/10.1515/dx-2024-0024
Keywords for this article
delayed diagnosis; diabetic ketoacidosis; pediatric emergency medicine; child opportunity index

Articles in the same Issue

  1. Frontmatter
  2. Editorial
  3. Should APTT become part of thrombophilia screening?
  4. Review
  5. n-3 fatty acids and the risk of atrial fibrillation, review
  6. Guidelines and Recommendations
  7. Root cause analysis of cases involving diagnosis
  8. Opinion Papers
  9. What is diagnostic safety? A review of safety science paradigms and rethinking paths to improving diagnosis
  10. Interprofessional clinical reasoning education
  11. Original Articles
  12. Quality of heart failure registration in primary care: observations from 1 million electronic health records in the Amsterdam Metropolitan Area
  13. Typology of solutions addressing diagnostic disparities: gaps and opportunities
  14. Diagnostic errors and characteristics of patients seen at a general internal medicine outpatient clinic with a referral for diagnosis
  15. Cost-benefit considerations of the biased diagnostician
  16. Delayed diagnosis of new onset pediatric diabetes leading to diabetic ketoacidosis: a retrospective cohort study
  17. Monocyte distribution width (MDW) kinetic for monitoring sepsis in intensive care unit
  18. Are shortened aPTT values always to be attributed only to preanalytical problems?
  19. External Quality Assessment (EQA) scheme for serological diagnostic test for SARS-CoV-2 detection in Sicily Region (Italy), in the period 2020–2022
  20. Recent mortality rates due to complications of medical and surgical care in the US
  21. Short Communication
  22. The potential, limitations, and future of diagnostics enhanced by generative artificial intelligence
  23. Case Report – Lessons in Clinical Reasoning
  24. Lessons in clinical reasoning – pitfalls, myths, and pearls: a case of persistent dysphagia and patient partnership
  25. Letters to the Editor
  26. The ‘curse of knowledge’: when medical expertise can sometimes be a liability
  27. A new approach for identifying innate immune defects
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