The cost of treating diabetic ketoacidosis in an adolescent population in the UK: a national survey of hospital resource use.

AIMS: Adolescents with Type 1 diabetes commonly experience episodes of ketoacidosis. In 2014, we conducted a nationwide survey on the management of diabetic ketoacidosis in young people. The survey reported how individual adolescents with diabetes were managed. However, the costs of treating diabetic ketoacidosis were not reported. METHODS: Using this mixed population sample of adolescents, we took a 'bottom-up' approach to cost analysis aiming to determine the total expense associated with treating diabetic ketoacidosis. The data were derived using the information from the national UK survey of 71 individuals, collected via questionnaires sent to specialist paediatric diabetes services in England and Wales. RESULTS: Several assumptions had to be made when analysing the data because the initial survey collection tool was not designed with a health economic model in mind. The mean time to resolution of diabetic ketoacidosis was 15.0 h [95% confidence interval (CI) 13.2, 16.8] and the mean total length of stay was 2.4 days (95% CI 1.9, 3.0). Based on data for individuals and using the British Society of Paediatric Endocrinology and Diabetes (BSPED) guidelines, the cost analysis shows that for this cohort, the average cost for an episode of diabetic ketoacidosis was £1387 (95% CI 1120, 1653). Regression analysis showed a significant cost saving of £762 (95% CI 140, 1574; P = 0.04) among those treated using BSPED guidelines. CONCLUSION: We have used a bottom-up approach to calculate the costs of an episode of diabetic ketoacidosis in adolescents. These data suggest that following treatment guidelines can significantly lower the costs for managing episodes of diabetic ketoacidosis.

METASTATIC HÜRTHLE CELL CARCINOMA PRESENTING WITH LOW FREE THYROXINE, SEVERE HYPERCALCEMIA AND SPURIOUS GROWTH HORMONE PRODUCTION.

OBJECTIVE: Hürthle cell tumors constitute about 5% of thyroid neoplasms. They have malignant potential, behaving very aggressively compared to other differentiated thyroid cancers. The objective of this case report is to describe a case of a Hürthle cell carcinoma with a single large metastasis in the liver presenting almost 17 years after hemithyroidectomy. We highlight the difficulties in making a histologic diagnosis and the unpredictable nature of this cancer. METHODS: The patient history and biochemistry were detailed. Thyroid function tests analyzed on multiple platforms (single-photon emission computed tomography, dynamic magnetic resonance imaging, technetium-99m bone scan, and radioactive iodine) were used to aid biochemical and radiologic diagnosis. RESULTS: The patient's thyroid function test showed persistently low free thyroxine concentrations with normal thyroid stimulating hormone and free triiodothyronine, suggesting rapid deiodination in the context of a large liver lesion. Radiologic and morphologic appearances of the liver lesion led to an initial misdiagnosis of primary hepato-cellular carcinoma, revised to metastatic Hürthle cell carcinoma after positive immunochemistry. Nonparathyroid hormone-related intractable hypercalcemia of malignancy with an unusual pattern of elevated 1,25-dihydroxyvitamin D and raised fibroblast growth factor 23 concentrations culminated in his demise. CONCLUSIONS: In Hürthle cell carcinomas treated with partial thyroidectomy, subsequent abnormal thyroid functions tests may herald a more sinister underlying diagnosis. The management of Hürthle cell carcinoma relies heavily on the initial histology results. Histologic diagnosis should be sought earlier in abnormal and suspicious distant masses. Malignant hypercalcemia poses a great challenge in delayed presentations and can prove resistant to conventional treatments.

The cost of treating diabetic ketoacidosis in the UK: a national survey of hospital resource use.

AIM: Diabetic ketoacidosis is a commonly encountered metabolic emergency. In 2014, a national survey was conducted looking at the management of diabetic ketoacidosis in adult patients across the UK. The survey reported the clinical management of individual patients as well as institutional factors that teams felt were important in helping to deliver that care. However, the costs of treating diabetic ketoacidosis were not reported. METHODS: We used a 'bottom up' approach to cost analysis to determine the total expense associated with treating diabetic ketoacidosis in a mixed population sample. The data were derived from the source data from the national UK survey of 283 individual patients collected via questionnaires sent to hospitals across the country. RESULTS: Because the initial survey collection tool was not designed with a health economic model in mind, several assumptions were made when analysing the data. The mean and median time in hospital was 5.6 and 2.7 days respectively. Based on the individual patient data and using the Joint British Diabetes Societies Inpatient Care Group guidelines, the cost analysis shows that for this cohort, the average cost for an episode of diabetic ketoacidosis was £2064 per patient (95% confidence intervals: 1800, 2563). CONCLUSION: Despite relatively short stays in hospital, costs for managing episodes of diabetic ketoacidosis in adults were relatively high. Assumptions made in the calculations did not consider prolonged hospital stay due to comorbidities or costs incurred as a loss of productivity. Therefore, the actual costs to the healthcare system and society in general are likely to be substantially higher.

New horizons in the understanding of the causes and management of diabetic foot disease: report from the 2017 Diabetes UK Annual Professional Conference Symposium.

Diabetes-related foot disease remains a common problem. For wounds, classic teaching recommends the treatment of any infection, offloading the wound and ensuring a good blood supply, as well as ensuring that the other modifiable risk factors are addressed and optimized. There remain, however, several questions about these and other aspects of the care of diabetes-related foot disease. Some of these questions are addressed in the present report; in particular, the impact of newer technologies in the identification of any organisms present in a wound, as well as the use of novel approaches to treat infections. The use of new remote sensing technology to identify people at risk of developing foot ulceration is also considered, in an attempt to allow early intervention and prevention of foot ulcers. The psychological impact of foot disease is often overlooked, but with an increasing number of publications on the subject, the cause-and-effect role that psychology plays in foot disease, such as ulcers and Charcot neuroarthropathy, is considered. Finally, because of heterogeneity in diabetic foot studies, comparing results is difficult. A recently published document focusing on ensuring a standardized way of reporting foot disease trials is discussed.

Diabetic ketoacidosis in an adolescent and young adult population in the UK in 2014: a national survey comparison of management in paediatric and adult settings.

AIMS: To assess the management of diabetic ketoacidosis in young people, which differs in the UK between paediatric and adult services, and to evaluate outcomes and extent to which national guidelines are used. METHODS: A standardized questionnaire was sent to all paediatric and adult diabetes services in England, requesting details of all diabetic ketoacidosis admissions in young people aged > 14 years in paediatric services ('paediatric' patients), and in young adults up to the age of 22 years in adult services ('adult' patients). RESULTS: A total of 64 adult patients aged ≤ 22 years (mean age 19.2 years) were reported, of whom seven were aged between 10 and 16 years. A total of 71 paediatric patients were reported [mean (range) age 14.9 (11-18) years]. We found that 85% of paediatric and 69% of adult patients were treated according to national guidelines, 99% of paediatric and 89% of adult patients were treated with 0.9% saline and fixed-rate insulin infusions and 16% of adult patients received an insulin bolus. Insulin treatment was initiated later in paediatric patients than in adult patients (100 vs 39 min; P < 0.001). In 23% of adult patients and 8.8% of paediatric patients, potassium levels were < 3.5 mmol/l (P < 0.005). The lowest mean potassium levels were 3.8 mmol/l in paediatric and 3.5 mmol/l in adult patients (P < 0.005). Hypoglycaemia occurred in 42.3% of paediatric and 36% of adult patients. Time to resolution was similar in paediatric and adult patients (16.0 vs 18.2 h), as was duration of hospital stay (2.35 vs 2.53 days). CONCLUSIONS: Young people were treated according to national guidelines, but the quality of monitoring was variable in both paediatric and adult settings. The incidence of hypoglycaemia and hypokalaemia was unacceptably high.

National survey of the management of Diabetic Ketoacidosis (DKA) in the UK in 2014.

AIM: To examine, in a national survey, the outcomes of adult patients presenting with DKA in 2014, mapped against accepted UK national guidance. METHODS: Data were collected in a standardized form covering clinical and biochemical outcomes, risk and discharge planning. The form was sent to all UK diabetes specialist teams (n = 220). Anonymized data were collected on five consecutive patients admitted with DKA between 1 May 2014 and 30 November 2014. RESULTS: A total of 283 forms were received (n = 281 patients) from 72 hospitals, of which 71.4% used the national guidelines. The results showed that 7.8% of cases occurred in existing inpatients, 6.1% of admissions were newly diagnosed diabetes and 33.7% of patients had had at least one episode of DKA in the preceding year. The median times to starting 0.9% sodium chloride and intravenous insulin were 41.5 and 60 min, respectively. The median time to resolution was 18.7 h and the median length of hospital stay was 2.6 days. Significant adverse biochemical outcomes occurred, with 27.6% of patients developing hypoglycaemia and 55% reported as having hypokalaemia. There were also significant issues with care processes. Initial nurse-led observations were carried out well, but subsequent patient monitoring remained suboptimal. Most patients were not seen by a member of the diabetes specialist team during the first 6 h, but 95% were seen before discharge. A significant minority of discharge letters to primary care did not contain necessary information. CONCLUSION: Despite widespread adoption of national guidance, several areas of management of DKA are suboptimal, being associated with avoidable biochemical and clinical risk.

Determining in-patient diabetes treatment satisfaction in the UK--the DIPSat study.

AIMS: To measure in-patient diabetes treatment satisfaction and its relationship to in-patient diabetes care. METHODS: In a cross-sectional study, diabetes in-patient specialist nurses at 58 UK hospitals asked insulin-treated in-patients with diabetes to complete the recently updated Diabetes Treatment Satisfaction Questionnaire for In-patients and a general questionnaire; 1319 in-patients completed these questionnaires. RESULTS: Satisfaction with the general diabetes treatment items in the Diabetes Treatment Satisfaction Questionnaire for In-patients was high, but there were high levels of extreme dissatisfaction with meal choices, meal quality and lack of similarity of hospital meals to normal domestic choices--23% would never or rarely have made similar meal choices at home. Hyperglycaemia or hypoglycaemia was reported for much of the in-patient stay (20% and 7%, respectively) and 26% reported at least one severe hypoglycaemic episode; these groups had lower satisfaction with the timing of medication in relation to meals (P < 0.003). More frequent in-patient hyperglycaemia or hypoglycaemia were associated with significantly poorer overall satisfaction scores and negative well-being scores (both P < 0.0001). Previous experience of a multiple daily insulin injection regimen was associated with more dissatisfaction than other regimens (P < 0.01). Multiple regression models explained 36% of variability in overall treatment satisfaction, with most (22.4%) accounted for by satisfaction with time spent with a diabetes in-patient specialist nurse (P < 0.0001). Self-administration of insulin was independently associated with higher treatment satisfaction (P < 0.006) in this model. CONCLUSIONS: The DIPSat programme describes the complex relationships between diabetes in-patient treatment satisfaction and in-patient diabetes care.

Assessing the relationship between admission glucose levels, subsequent length of hospital stay, readmission and mortality.

This study aimed to investigate relationships between dysglycaemia and length of hospital stay, short-term mortality and readmission in an unselected population in an acute medical unit (AMU). The rate of follow up in non-diabetic individuals with hyperglycaemia was also measured. We analysed data from all 1,502 patients admitted through our AMU in February 2010 to assess blood glucose levels on admission, length of stay, 28-day readmissions and mortality, and to determine whether blood glucose > or = 11.1 mmol/l on admission in non-diabetic individuals was followed up. In total, blood glucose was measured on admission for 893 patients. Mean length of stay was 8.8 (standard deviation 11.9) days, for patients with blood glucose < 6.5 mmol/l on admission; 11.3 (13.6) days, for 6.5-7 mmol/l; 10.2 (14.5) days, for 7.1-9 mmol/l; 10.6 (14.9) days, for 9.1-11 mmol/l; 12 (18.4) days, for 11.1-20 mmol/l and 9.1 (11.2) days, for > 20.1 mmol/l. Length of stay for patients with blood glucose > 6.5 mmol/l on admission was significantly longer (p = 0.002). The 28-day readmission rates were 6.4%, 6%, 9.7%, 12.5%, 10% and 15%, respectively, and 28-day death rates were 4.8%, 6%, 5.8%, 17.2%, 17.1% and 6.1%, respectively. Overall, 51.4% of non-diabetic individuals with blood glucose > 11.1 mmol/l on admission were followed up. The study showed that blood glucose > 6.5 mmol/l on admission is associated with significantly longer length of stay. Hyperglycaemia was associated with increased 28-day mortality and readmissions, and is frequently underinvestigated.

Joint British Diabetes Societies guideline for the management of diabetic ketoacidosis.

The Joint British Diabetes Societies guidelines for the management of diabetic ketoacidosis (these do not cover Hyperosmolar Hyperglycaemic Syndrome) are available in full at: (i) http://www.diabetes.org.uk/About_us/Our_Views/Care_recommendations/The-Management-of-Diabetic-Ketoacidosis-in-Adults; (ii) http://www.diabetes.nhs.uk/publications_and_resources/reports_and_guidance; (iii) http://www.diabetologists-abcd.org.uk/JBDS_DKA_Management.pdf. This article summarizes the main changes from previous guidelines and discusses the rationale for the new recommendations. The key points are: Monitoring of the response to treatment (i) The method of choice for monitoring the response to treatment is bedside measurement of capillary blood ketones using a ketone meter. (ii) If blood ketone measurement is not available, venous pH and bicarbonate should be used in conjunction with bedside blood glucose monitoring to assess treatment response. (iii) Venous blood should be used rather than arterial (unless respiratory problems dictate otherwise) in blood gas analysers. (iv) Intermittent laboratory confirmation of pH, bicarbonate and electrolytes only. Insulin administration (i) Insulin should be infused intravenously at a weight-based fixed rate until the ketosis has resolved. (ii) When the blood glucose falls below 14 mmol/l, 10% glucose should be added to allow the fixed-rate insulin to be continued. (iii) If already taking, long-acting insulin analogues such as insulin glargine (Lantus(®), Sanofi Aventis, Guildford, Surry, UK) or insulin detemir (Levemir(®), Novo Nordisk, Crawley, West Sussex, UK.) should be continued in usual doses. Delivery of care (i) The diabetes specialist team should be involved as soon as possible. (ii) Patients should be nursed in areas where staff are experienced in the management of ketoacidosis.

Psychometric validation and use of a novel diabetes in-patient treatment satisfaction questionnaire.

AIMS: To develop the first psychometrically validated Diabetes Treatment Satisfaction Questionnaire for in-patients (DTSQ-IP) and examine determinants of in-patient diabetes treatment satisfaction. METHODS: We studied 366 in-patients with insulin-treated diabetes at a single UK centre. We developed a 19-item DTSQ-IP to assess in-patient diabetes treatment satisfaction, and collected data on in-patient length of stay (LOS) and in-patient care at the same time. RESULTS: Psychometric analyses including Principal Components Analysis and Cronbach's alpha reliability coefficient showed that a single satisfaction score (excluding two items scored individually) can be computed for the entire DTSQ-IP, indicating very good internal consistency reliability (0.92). The DTSQ-IP detected considerable dissatisfaction with meal choice and timing (13.7% of in-patients would never have chosen similar meals at home), and with in-patient hypoglycaemia (35.3% felt that their blood glucose was too low most of the time). In-patients on surgical wards, women, and those long established on insulin were significantly more dissatisfied, particularly with competence of hospital staff. Patients who administered their own insulin were not significantly less dissatisfied overall, but were so with the choice of meals (P = 0.005). Multiple regression analysis produced a model accounting for 8.2% of variability in DTSQ-IP (r = 0.29; P = 0.0058) and 21.7% of variability in LOS (r = 0.46; P = 0.0001). CONCLUSIONS: The DTSQ-IP is a novel, psychometrically validated and sensitive tool that adds to the DTSQ portfolio. The DTSQ-IP facilitates efforts to assess and improve treatment satisfaction in in-patients with diabetes.