The effect of deprivation and HbA1c on admission to hospital for diabetic ketoacidosis in type 1 diabetes
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Diabetic ketoacidosis is a potentially life-threatening complication of diabetes and has a strong relationship with HbA1c. We examined how socioeconomic group affects the likelihood of admission to hospital for diabetic ketoacidosis.
The Scottish Care Information – Diabetes Collaboration (SCI-DC), a dynamic national register of all cases of diagnosed diabetes in Scotland, was linked to national data on hospital admissions. We identified 24,750 people with type 1 diabetes between January 2005 and December 2007. We assessed the relationship between HbA1c and quintiles of deprivation with hospital admissions for diabetic ketoacidosis in people with type 1 diabetes adjusting for patient characteristics.
We identified 23,479 people with type 1 diabetes who had complete recording of covariates. Deprivation had a substantial effect on odds of admission to hospital for diabetic ketoacidosis (OR 4.51, 95% CI 3.73, 5.46 in the most deprived quintile compared with the least deprived). This effect persisted after the inclusion of HbA1c and other risk factors (OR 2.81, 95% CI 2.32, 3.39). Men had a reduced risk of admission to hospital for diabetic ketoacidosis (OR 0.71, 95% CI 0.63, 0.79) and those with a history of smoking had increased odds of admission to hospital for diabetic ketoacidosis by a factor of 1.55 (95% CI 1.36, 1.78).
Women, smokers, those with high HbA1c and those living in more deprived areas have an increased risk of admission to hospital for diabetic ketoacidosis. The effect of deprivation was present even after inclusion of other risk factors. This work highlights that those in poorer areas of the community with high HbA1c represent a group who might be usefully supported to try to reduce hospital admissions.
KeywordsDeprivation Diabetes Diabetic ketoacidosis HbA1c Record linkage
International Classification of Diseases
Information Services Division
Scottish Care Information – Diabetes Collaboration
Scottish Diabetes Research Network
Scottish Index of Multiple Deprivation
Scottish Morbidity Records
We have previously demonstrated that, among people with type 1 diabetes, HbA1c is an important indicator of risk of admission to hospital, independent of other predictors, with a particularly strong relationship to admissions coded as diabetic ketoacidosis . Deprivation is a further important potential indicator of disease risk in the population, although previous analysis of data from a smaller Scottish population suggests that deprivation has a relatively weak relationship with HbA1c in people with type 1 diabetes .
This study examines how socioeconomic group affects likelihood of admission to hospital for diabetic ketoacidosis among people with type 1 diabetes, and whether this relationship may be explained by HbA1c.
Information on diabetes was obtained from the Scottish Care Information – Diabetes Collaboration (SCI-DC) database – a dynamic national clinical information system of all diagnosed cases of diabetes in Scotland (www.diabetesinscotland.org.uk). This database contains records for over 99% of diagnosed cases of diabetes  with detailed clinical information including BMI, creatinine, age, sex and HbA1c. For the current analysis, HbA1c was measured using a variety of clinical methods, all of which were DCCT aligned. Type 1 diabetes was identified using an algorithm that incorporated age, drug prescription and clinical description of the type of diabetes. Those whose type diagnosis was not known were excluded from the analysis. Deprivation was defined using the Scottish Index of Multiple Deprivation (SIMD) , which provides a composite index of relative area deprivation across Scotland. Smoking status was defined as whether or not a person was a current or ex-smoker.
Information on hospital admissions was obtained using Scottish Morbidity Records (SMR01), national data on hospital admissions from the Information Services Division (ISD) of NHS National Services, Scotland. The SMR01 contain information on over 95% of Scotland’s hospital admissions and include administrative data and demographic information such as age, sex and postcode of the patient. Individual episodes of care are recorded within each admission entry with up to six International Classification of Diseases (ICD) diagnosis codes (1997–present: ICD-10 [www.who.int/classifications/icd/en/]).
Data were linked within the ISD using probabilistic methods based on name, sex, date of birth and postcode, as previously described . No personal identifiers were released to researchers and all subsequent analyses were conducted on anonymised datasets.
The outcome of interest was recording of diabetic ketoacidosis as a reason for admission to hospital at least 180 days after the diagnosis of diabetes. Outcome was determined if the ICD codes for diabetic ketoacidosis were present in any position of diagnosis. Parametric relationships between mean HbA1c (as measured between 2005 and 2007) and admission to hospital for diabetic ketoacidosis were investigated using the fractional polynomial methods in Stata, version 11 (Stata, College Station, TX, USA). Natural log of mean HbA1c was found to provide the best fit to the data. Logistic regression models were used to estimate the association between admissions to hospital for diabetic ketoacidosis, log mean HbA1c, deprivation quintiles (referent quintile 1, least deprived) and history of smoking. Analysis was adjusted for potential confounding factors including age, sex, previous vascular disease (ICD-9 [www.icd9data.com/2007/Volume1/240-279/250-259/250/default.htm]: 410–414, 430–438, 443; ICD-10: I20–I25, I60–I69, I73), creatinine, BMI and diabetes duration.
Coefficients, ORs and 95% CIs obtained from the logistic regression model for admissions to hospital for diabetic ketoacidosis
OR (95% CI)
0.71 (0.63, 0.79)
0.97 (0.96, 0.97)
Previous admission for vascular reasons
2.61 (1.96, 3.49)
Creatinine (μmol/l)a, b
1.003 (1.002, 1.004)
BMI (kg/m2)a, b
0.94 (0.93, 0.95)
Diabetes duration (years)a, b
0.98 (0.98, 0.99)
1.55 (1.36, 1.78)
1.58 (1.53, 1.63)
Quintile 1 – least deprived
1.31 (1.05, 1.62)
1.67 (1.38, 2.03)
2.00 (1.64, 2.42)
Quintile 5 – most deprived
2.82 (2.33, 3.42)
There was a strong association between deprivation and odds of admission to hospital for diabetic ketoacidosis, with people in more deprived areas having an odds of admission 4.5 times higher than those in the least deprived areas. Higher HbA1c also increased the odds of admission to hospital. Although the inclusion of HbA1c and other risk factors reduced the size of the effect of deprivation, a substantial effect remained. This suggests that only some of the effect of deprivation can be explained by these other risk factors in people with type 1 diabetes. Those who had a history of smoking, previous vascular admissions and women also had an increased risk of admission associated with diabetics ketoacidosis.
We have taken advantage of the linked data for both hospital admissions (SMR01) and clinical information (SCI-DC), providing almost 100% coverage of all data for people with diagnosed type 1 diabetes in Scotland between 2005 and 2007. This allowed us to avoid under-reporting in hospital discharge information as found in other studies [6, 7]. Some limitations of our study have also been identified. First, an algorithm that incorporated age, drug prescription and clinical description of the type of diabetes was used to determine the type of diabetes. As with nearly all cohorts of this size and type, there is potential for misclassification of diabetes type. However, we believe those misclassified will be an extremely small percentage. Second, we used the annual average of HbA1c, chosen as the best measure of prevailing HbA1c for each person. This yearly average does not capture the variability in HbA1c and a measurement taken before admission for diabetic ketoacidosis could be argued to be more appropriate. However, HbA1c was measured locally in diabetes clinics during routine clinic visits. Using the last measurement of HbA1c instead of the average did not change the conclusions of our study. In addition, the number of recordings of HbA1c per person was not significantly associated with odds of admission to hospital for diabetic ketoacidosis. Third, in determining the reason for an admission to hospital we relied on hospital admission data, which are dependent on the accuracy (around 90%) of coding of ICD in hospital diagnosis codes . However, hyperglycaemia codes are often underused in discharge coding . The codes used do not include people admitted with coma (ICD10 E10.0, E14.0) as these categories include, but do not distinguish between, those with ketoacidotic, hyperosmolar or hypoglycaemic coma. We also did not include those with multiple complications potentially including ketoacidosis (ICD10 E10.7, E14.7) since ketoacidosis could not be separately identified within these codes.
Our results show that people in more deprived areas are at a greater risk of admission to hospital for diabetics ketoacidosis, and it is important to discuss why this effect exists. We can speculate that those in more deprived areas have poorer control of their diabetes resulting in increased risk of hospital admission for diabetics ketoacidosis. As discussed, however, deprivation score is not a strong predictor of HbA1c in our population, and much of the effect of deprivation score appears independent of HbA1c.
Despite universal health coverage that is free at point of care, social deprivation is also associated with reduced engagement with health services, such as retinal screening , and deprivation is in turn associated with higher risk of complications . Admission to hospital for diabetic ketoacidosis will also relate to other comorbidities, social and medical support and relevant education in diabetes management during intercurrent illness and other crises. In that context, the relationship between smoking and admission to hospital for diabetic ketoacidosis is of interest. This relationship is unlikely to be causal but smoking may act as a marker of other health behaviours and thus increased risk of admission to hospital for diabetic ketoacidosis.
There is an increasing emphasis on structured education programmes as a means of improving health outcomes in type 1 diabetes. Our analysis shows that socioeconomic group carries a risk of admission to hospital for diabetic ketoacidosis over and above that predicted by HbA1c. An important implication of our work is that where programmes are directed towards prevention of expensive and distressing complications, such as diabetic ketoacidosis, consideration of their relevance to those patients with diabetes who are most at risk (including consideration of socioeconomic group) is vital.
These data were available for analysis by members of the SDRN thanks to the hard work and dedication of NHS staff across Scotland who enter the data and also the people and organisations (the SCI-DC Steering Group, the Scottish Diabetes Group, the Scottish Diabetes Survey Group, the managed clinical network managers and staff in each Health Board) involved in setting up, maintaining and overseeing the SCI-DC. The SDRN receives core support from the Chief Scientist’s Office at the Scottish Government Health Department.
The costs of data linkage were covered by the Scottish Government Health Department. This work was funded by the Wellcome Trust through the Scottish Health Informatics Programme (SHIP) Grant (Ref. WT086113). SHIP is a collaboration between the Universities of Aberdeen, Dundee, Edinburgh, Glasgow and St Andrews and the ISD of NHS Scotland.
Duality of interest
H. Colhoun has financial relationships with Pfizer, Roche, Astra Zeneca and Eli Lilly. The authors declare that there is no duality of interest associated with this manuscript.
All authors contributed to the data provision and/or quality. LG and EM carried out the data analysis. LG, EM, BT, RL, OW and AB contributed to study design and analysis. CF, GL, JM, AM, NS, SW contributed to the interpretation of results. LG wrote the initial draft of the manuscript. All authors reviewed and edited the manuscript and approved the final version.
- 4.Scottish Government (2009) Scottish Index of Multiple Deprivation 2009: general report. www.scotland.gov.uk/Publications/2009/10/28104046/0, accessed October 2011
- 8.ISD Scotland. SMR01 and associated data quality assurance 2004–2006. www.isdscotlandarchive.scot.nhs.uk/isd/2737.html. Accessed 21 May 2012 (archived)