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Variation in use of intensive care for adults with diabetic ketoacidosis*

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

doi: 10.1097/CCM.0b013e31824e9eae
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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.

From the Division of Pulmonary Critical Care, and Sleep Medicine (HBG), Beth Israel Medical Center, Albert Einstein College of Medicine, New York, NY; Division of Pulmonary and Critical Care Medicine (TJI, CRC), University of Michigan, Ann Arbor, MI; VA Center for Clinical Management Research (TJI), Ann Arbor VA Health System, Ann Arbor, MI; Center for Healthcare Outcomes & Policy (CRC), University of Michigan, Ann Arbor, MI; Interdepartmental Division of Critical Care (DCS), University of Toronto, Toronto, ON, Canada; Department of Critical Care Medicine (JMK), University of Pittsburgh School of Medicine, Pittsburgh, PA; Departments of Anesthesiology & Epidemiology (HW),Columbia University, New York, NY.

*See also p. 2227.

Supported, in part, by Award Number K08AG038477 from the National Institute on Aging to Dr. Wunsch; K08HL091249 from the National Heart, Lung and Blood Institute to Dr. Iwashyna; and a New Investigator Award from the Canadian Institutes for Health Research to Dr. Scales.

The authors have not disclosed any potential conflicts of interest.

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© 2012 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins