An observational study of patient characteristics and mortality following hypoglycemia in the community

Abstract

ObjectivesCharacterize patients with diabetes with severe hypoglycemia requiring emergency services intervention at home and investigate 12-month mortality.Research design and methodsEmergency services call-outs for hypoglycemia were recorded between 2005 and 2013 in an area covering 34 000 patients with diabetes. Patient characteristics were documented together with capillary blood glucose (CBG), glycated hemoglobin (HbA1c), and treatment for hypoglycemia; 12-month mortality and variables influencing survival were analyzed.ResultsIn 1835 episodes among 1156 patients, 45% had type 1 diabetes (68.2% males) and 44% had type 2 diabetes (49.4% males), with a minority unclassified. CBG at presentation (mean±SD) was 1.76±0.72 mmol/L in patients with type 1 diabetes and 1.96±0.68 mmol/L in patients with type 2 diabetes (p<0.0001), with a higher HbA1c in the former group (8.3±1.52% (67.5±16.4 mmol/mol) and 7.8±1.74% (61.6±19.0 mmol/mol), respectively; p<0.0001). A third of patients with type 2 diabetes were not on insulin therapy and displayed lower HbA1c compared with insulin users. Glucagon was used in 37% of patients with type 1 diabetes and 28% of patients with type 2 diabetes (p<0.0001). One-year mortality was 4.45% in type 1 diabetes and 22.1% in type 2 diabetes. Age and type of diabetes were predictive of mortality in multivariable analysis, whereas CBG levels/frequency of hypoglycemia had no effect.ConclusionsSevere hypoglycemia in the community is common with a male predominance in type 1 diabetes. Severe hypoglycemia in non-insulin treated patients with type 2 diabetes is associated with lower HbA1c compared with insulin users. Severe hypoglycemia appears to be associated with increased mortality at 12 months, particularly in type 2 diabetes.

Severe Hypoglycemia Requiring Medical Intervention in a Large Cohort of Adults With Diabetes Receiving Care in U.S. Integrated Health Care Delivery Systems: 2005–2011

“…Of particular concern is the link between recurrent hypoglycemic events and cardiovascular risk, cognitive impairment, and depression (35,39,42,43). In addition, an increased risk of mortality in the 12 months after a severe hypoglycemic event in a large community-dwelling population was recently reported (44). These outcomes affect the cost of care as well as patient quality of life and activities of daily living.…”

A new integrated care pathway for ambulance attended severe hypoglycaemia in the East of England: The Eastern Academic Health Science Network (EAHSN) model

“…These selfreported recurring SH patients had significantly more severe hypoglycaemia clinically and biochemically, and were more likely to be insulin treated. As well as self -reported antecedent SH in the previous month, 36.4 % of the calls in this pathway were made by people who made multiple calls to ambulance crew, with a small minority generating a large number of calls (> 3 each) accounting for nearly 18% of all calls, In other SH populations 31% [3], 37 % [11], or 12.7 % [18] of emergency SH ambulance contacts have been generated by repeat calls from the same patient(s), often relatively soon after the initial call, and up to 11% of patients have a further episode within 14 days [27]. These data suggest that while UK Ambulance Crew 'see and treat' policies are highly effective at treating individual SH events, and at keeping patients at home following SH treatment, they are treating and identifying a population with very high rates of recurrent SH events and repeat contact with emergency services.…”

“…This is important, as simple modelling based on ambulance call out rates in the UK and the prevalence of SH calls, suggests there are between 48,400 and 98,736 SH Ambulance call outs per annum [15,27] in the UK, and the scale of this activity has been apparent for some time (15). If we assume that perhaps one -third of these calls are from repeat callers [3,11], then there are perhaps up to 33,000 Ambulance SH calls per annum generated by repeat callers.…”

“…The equivalent data for sulphonylurea treated patients and SH was 0.01 (95% CI 0 to 0.55). Elderly patients with insulin treated Type 2 diabetes and co-morbidities such as cognitive impairment, dementia, or renal impairment are more likely to experience SH [8 -10], and have higher mortality and morbidity following SH [11,12]. Robust glycaemic targets in diabetes management guidelines, or in UK primary care diabetes quality frameworks, do not give enough weight to the risk of SH in the frail elderly, or promote clinically sensible targets relevant to the frail elderly [13,14].…”

Hypoglycaemia, thrombosis and vascular events in diabetes

“…A number of studies have since demonstrated close associations between hypoglycemia, increased rate of cardiovascular disease, and mortality in T2DM patients [7][8][9][10][11][12][13] and possibly T1DM [10,14], further emphasizing the limitations of HbA1c as the sole measure of glycemic control.…”