Is acid suppression associated with the increased length of stay in diabetic ketoacidosis patients? A nationwide analysis

Abstract

Background Diabetic ketoacidosis (DKA) patients present with low serum bicarbonate (HCO3−${\rm{HCO}}_{3}^{-} $), and an increase in its level to ≥15 mEq/L is considered one of the criteria for DKA resolution. Both proton pump inhibitors and histamine‐2 receptor antagonists inhibit downstream functioning of H+/K+ ATPase in the gastric parietal cells, which results in the decreased secretion of HCO3−${\rm{HCO}}_{3}^{-} $ into the bloodstream. Objectives We aimed to introduce the hypothesis that DKA patients on acid‐suppressive medications may have a delayed rise in serum HCO3−${\rm{HCO}}_{3}^{-} $ to >15 mEq/L that may cause increased hospital length of stay (LOS) and sought to compare the outcomes of such patients. For the sake of simplicity, conditions requiring acid suppression are grouped under the term peptic ulcer disease (PUD) in this study. Methods This is a retrospective study using Nationwide Inpatient Sample employing International Classification of Diseases (ICD‐10) codes for adult patients with a primary diagnosis of DKA. Analyses were performed using STATA, proportions were compared using Fisher exact test, and continuous variables using Student's t‐test. Confounding variables were adjusted using propensity matching, multivariate logistic, and linear regression analyses. Results DKA patients with PUD had higher adjusted LOS, intensive care unit admission, and total hospital costs. Mortality and morbidity indicators were similar in both groups. The variables found to be independent predictors of increased LOS were malnutrition, Clostridium difficile infection, pneumonia, Glasgow Coma Scale score of 3–8, and higher Charlson comorbidity score. Conclusion We found that Clostridium difficile and pneumonia predicted longer LOS in DKA patients with concomitant PUD, hinting at the possible role of acid suppression in prolonging the LOS in such patients. However, further studies are needed to examine the effect of lesser HCO3−${\rm{HCO}}_{3}^{-} $ generation on LOS.

Clinical and biochemical determinants of length of stay, readmission and recurrence in patients admitted with diabetic ketoacidosis

“…This translates into an increased risk of developing DKA, or its recurrence, as shown in this study. Similarly, it is evident from the literature that young patients with diabetes tend to have a longer LOS in DKA admissions [ 8 ]. Therefore, young patients with diabetes, mainly newly diagnosed, should be the target population to address the rising healthcare resource utilization issues concerning DKA.…”

“…Numerous studies linked a high comorbidity burden with the development of DKA; however, data are limited regarding the effect of a high comorbidity burden on LOS in DKA admissions [ 28 ]. A recent study published in 2022 also reported an association of higher CCI with prolonged LOS in DKA patients [ 8 ]. It has shown clinical significance in predicting various diseases’ short-term and long-term clinical outcomes [ 29 ].…”

“…recently (February 2022) studied the effect of acid suppression with a prolonged LOS in a large cohort of DKA patients. Although they mainly studied the effect of peptic ulcer disease on DKA, they also analysed some factors affecting the LOS common to our data [ 8 ]. These included age, gender, and metabolic risks.…”

“…Although metabolic risks, male gender, and lower age were associated with a longer LOS in this study, the association could not be retained in the multivariate regression. This variation in results can be due to the difference in the study population; a predominantly male multi-ethnic younger population in this study compared to a relatively older population with a balanced gender distribution [ 8 ]. Other than the events of index admission, readmission with any cause and DKA recurrence is clinically meaningful and commonly encountered outcomes associated with an increased healthcare burden and poor patient outcomes.…”

“…One study from the USA showed increased medical bills despite a reduced LOS among DKA patients [ 3 ]. Whereas another nationwide analysis showed reduced hospitalization cost (which is partly reflected by lower LOS) as a marker of resource utilization in DKA hospitalizations [ 8 ]. DKA protocols have shown a well-evident decrease in LOS among admitted patients with DKA [ 9 , 10 ].…”