Psychiatric and substance use disorders and their association with clinical outcomes in diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome.

BACKGROUND: Diabetic Ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) are life-threatening conditions that send nearly 180,000 patients to the ICU each year, with mortality rates up to 5-10%. Little is known about the impact of concurrent psychiatric disorders on specific DKA/HHS outcomes. Identifying these relationships offers opportunities to improve clinical management, treatment planning, and mitigate associated morbidity and mortality.

METHODS: We conducted a retrospective review including adult DKA/HHS admissions within a large Massachusetts hospital system from 2010 - 2019. We identified patients admitted inpatient for DKA or HHS, then filtered by ICD-9-CM, ICD-10-CM codes for psychiatric diagnoses that were present in patients EMR at any point in this observational period. Outcomes included number of inpatient admissions for DKA/HHS, age of death, rates of discharging against medical advice (AMA) from any inpatient admission, and ESRD/dialysis status. Multivariate regression was conducted using R software to control for variables across patients and evaluate relationships between outcomes and concurrent psychiatric disorders. Significance was set at p <0.05.

RESULTS: 7756 patients were admitted for DKA or HHS, 66.9% of which had a concurrent psychiatric disorder. 54.5% of these patients were male, 70.4% White, and an average age of 61.6 years. This compares with 26.1% with concurrent psychiatric condition within the general diabetes population, 52.1% of which were male, 72.1% White, and an average of 68.2 years . A concurrent psychiatric disorder was associated with increased odds of rehospitalization (aOR= 1.62 95%Cl 1.35 - 1.95, p<0.001), of being diagnosed with end-stage renal disease and on dialysis (aOR = 1.02 95% Cl 1.002 - 1.035, p = 0.02), and in leaving AMA (aOR = 6.44 95%Cl 4.46 - 9.63, p <0.001). The average age of death for those with a concurrent psychiatric disorder had an adjusted mean difference in years of -7.5 years (95% Cl -9.3 5.8) compared to those without a psychiatric disorder.

CONCLUSION: 66.9% of patients with DKA/HHS have a concurrent psychiatric disorder. Patients with a concurrent psychiatric disorder admitted for DKA/HHS were more likely to have multiple admissions, to leave AMA, to be on renal dialysis, and have a lower age of mortality.