Original Article
Is Diabetic Ketoacidosis at Disease Onset a Result of Missed Diagnosis?

https://doi.org/10.1016/j.jpeds.2009.10.001Get rights and content

Objective

To determine the frequency of medical encounters before diagnosis of diabetes in children in Ontario, Canada; to determine risk factors for diabetic ketoacidosis (DKA).

Research design

All medical encounters within 4 weeks before date of diagnosis for all new cases of diabetes in children <18 years were identified from April 1994 to March 2000 by use of administrative databases. The main outcome measure was the frequency of medical encounters before diagnosis in children presenting with and without DKA.

Results

A total of 3947 new cases of diabetes were identified, 735 (18.6%) with DKA. DKA rates were 39.7% for children ≤3 years and 16.3% for children >3 years (P < .001). During the week before diagnosis, 285 children with DKA (38.8%) and 1104 children with diabetes without DKA (34.4%; P = .026) had at least 1 medical visit. Children with diabetes overall had more medical encounters before diagnosis than control subjects. Children with DKA were less likely to have had relevant laboratory testing before diagnosis than children with diabetes without DKA.

Conclusions

Children with diabetes presenting with DKA more frequently had a medical encounter before diagnosis compared with children with diabetes without DKA. These data have important implications for enhancing public and physician awareness of diabetes in children.

Section snippets

Methods

Data sources included: (1) the Ontario Health Insurance Plan (OHIP), which includes information pertaining to health services provided by Ontario physicians; (2) the Registered Persons Data Base of the Ontario Ministry of Health and Long-Term Care, which provides information about individuals registered for OHIP such as their health care number, surname, date of birth, sex, address, and date of death, if applicable; and (3) the Canadian Institutes for Health Information Discharge Abstract

Results

We identified a total of 3947 new cases of diabetes in Ontario children during the study period. With 1996 census data16 we calculated an approximate average annual incidence of 29.7 new cases per 100 000 children, similar to that reported previously for this region in the same period.17, 18 Of these, 735 patients presented with DKA, representing 18.6% of the total study population. The incidence of diabetes increased on average by 4.3% per year. The proportion of children presenting with DKA

Discussion

Our index case detection algorithm was based on a method described by Blanchard et al.19 Because the prevalence of diabetes is relatively low in children as compared with the adults, it is possible that our algorithm detected some false-positive cases, which would produce a lower detected DKA rate. This is likely to be a small effect in our study. Hux et al17 found that inclusion of any CIHI records of hospitalization in the algorithm led to a decrease in specificity to 94%, presumably because

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    Supported by the Institute for Clinical Evaluative Sciences, an independent non-profit organization funded by the Ontario Ministry of Health and Long-Term Care, with provision of population-based data. H.B. was supported by a fellowship award from the Canadian Pediatric Endocrine Group (CPEG), the national professional pediatric endocrinology association. T.T. is supported by the Dales Award, University of Toronto, and D.D. by the RS McLaughlin Foundation Chair in Paediatrics. The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; or preparation, review, or approval of the manuscript. The opinions, results and conclusions are those of the authors and no endorsement by the Ontario Ministry of Health and Long-Term Care or by the Institute for Clinical Evaluative Sciences is intended or should be inferred. The authors declare no conflicts of interest.

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