Association of Cumulative Multimorbidity, Glycemic Control, and Medication Use With Hypoglycemia-Related Emergency Department Visits and Hospitalizations Among Adults With Diabetes

This cohort study examines the associations of age, cumulative multimorbidity, glycated hemoglobin level, and use of glucose level-lowering medication with hypoglycemia-related emergency department visits and hospitalizations among adults with diabetes. Key PointsQuestionAmong adults with diabetes, what is the association of multimorbidity with the risk of severe hypoglycemia in the context of other frequently encountered hypoglycemia risk factors, such as age, diabetes type, prior hypoglycemia, glycemic control, and high-risk medication use? FindingsIn this cohort study of 201705 adults with diabetes in the United States, most individuals had additional chronic health conditions. Cumulative multimorbidity was associated with hypoglycemia-related emergency department visits and hospitalizations independent of other factors. MeaningClinicians may want to consider a broad range of hypoglycemia risk factors, particularly cumulative multimorbidity, when developing a diabetes treatment plan and prioritize prescribing medications with a lower risk for hypoglycemia. ImportanceSevere hypoglycemia is a serious and potentially preventable complication of diabetes, with some of the most severe episodes requiring emergency department (ED) care or hospitalization. A variety of health conditions increase the risk of hypoglycemia. People with diabetes often have multiple comorbidities, and the association of such multimorbidity with hypoglycemia risk in the context of other risk factors is uncertain. ObjectiveTo examine the associations of age, cumulative multimorbidity, glycated hemoglobin (HbA(1c)) level, and use of glucose level-lowering medication with hypoglycemia-related ED visits and hospitalizations. Design, Setting, and ParticipantsCohort study of claims and laboratory data from OptumLabs Data Warehouse, an administrative claims database of commercially insured and Medicare Advantage beneficiaries in the United States. Participants were adults (aged >= 18 years) with diabetes who had an available HbA(1c) level result in 2015. Data from January 1, 2014, to December 31, 2016, were analyzed. Final analyses were conducted from December 2017 to September 2018. Main Outcomes and MeasuresThis study calculated rates of hypoglycemia-related ED visits and hospitalizations during the year after the index HbA(1c) level was obtained, stratified by patient demographic characteristics, diabetes type, comorbidities (from 16 guideline-specified high-risk conditions), index HbA(1c) level, and glucose level-lowering medication use. The association of each variable with hypoglycemia-related ED and hospital care was examined using multivariable Poisson regression analysis overall and by diabetes type. ResultsThe study cohort was composed of 201705 adults with diabetes (mean [SD] age, 65.8 [12.1] years; 102668 [50.9%] women; 118804 [58.9%] white; mean [SD] index HbA(1c) level, 7.2% [1.5%]). Overall, there were 9.06 (95% CI, 8.64-9.47) hypoglycemia-related ED visits and hospitalizations per 1000 persons per year. The risk of hypoglycemia-related ED visits and hospitalizations was increased by age 75 years or older (incidence rate ratio [IRR], 1.56 [95% CI, 1.23-2.02] vs 18-44 years), black race/ethnicity (IRR, 1.30 [95% CI, 1.16-1.46] vs white race/ethnicity), lower annual household income (IRR, 0.63 [95% CI, 0.53-0.74] for >= $100000 vs <$40000), number of comorbidities (increasing from IRR of 1.66 [95% CI, 1.42-1.95] in the presence of 2 comorbidities to IRR of 4.12 [95% CI, 3.07-5.51] with >= 8 comorbidities compared with <= 1), prior hypoglycemia-related ED visit or hospitalization (IRR, 6.60 [95% CI, 5.77-7.56]), and glucose level-lowering treatment regimen (IRR, 6.73 [95% CI, 4.93-9.22] for sulfonylurea; 12.53 [95% CI, 8.90-17.64] for basal insulin; and 27.65 [95% CI, 20.32-37.63] for basal plus bolus insulin compared with other medications). Independent of these factors, having type 1 diabetes was associated with a 34% increase in the risk of hypoglycemia-related ED visits or hospitalizations (IRR, 1.34 [95% CI, 1.15-1.55]). The index HbA(1c) level was associated with hypoglycemia-related ED visits and hospitalizations when both low (IRR, 1.45 [95% CI, 1.12-1.87] for HbA(1c) level <= 5.6% vs 6.5%-6.9%) and high (IRR, 1.24 [95% CI, 1.02-1.50] for HbA(1c) level >= 10%). Conclusions and RelevanceIn this cohort study of adults with diabetes, the risk of an ED visit or hospitalization for hypoglycemia appeared to be highest among patients with type 1 diabetes, multiple comorbidities, prior severe hypoglycemia, and sulfonylurea and/or insulin use. At-risk patients may benefit from individualized treatment regimens to decrease their risk of hypoglycemia.