CDC Reports Rise in DKA Hospitalizations in the United States – What’s behind this change?


Latest statistics from the CDC show that rates of hospitalization from diabetic ketoacidosis (DKA) steadily increased from 2009 to 2014. Prior to this, rates had been on the decline. So what changed?

The Centers for Disease Control and Prevention (CDC) Morbidity and Mortality Weekly Report might not be part of your weekly reading list, but the March 30, 2018 publication is one to take a close look at.

First Up – What’s DKA?

Diabetic ketoacidosis (DKA) is a life-threatening but often preventable complication of diabetes. It occurs when the body is not receiving enough insulin to break down glucose, forcing the body to break down fat as fuel. This releases ketones into the bloodstream, which can cause the blood to become acidic, resulting eventually in system failure and even death. Early symptoms include: elevated ketones in urine, high blood glucose levels, frequent urination and thirst. More extreme warning signs include: fatigue, flushed skin, nausea, vomiting, shortness of breath, and fruity breath smell. Read more here on how to test for ketones and when to seek help.

Okay – back to the data.

From 2009 to 2014 the rate of DKA hospitalizations increased a total of 54.9%, from 19.5 to 30.2 hospitalizations per 1,000 people with diabetes. Each year between 2009 and 2014, there was a more than 6% rise in DKA hospitalizations annually across all age groups, with highest rates among people under 45 years old.

But while the CDC report does break out DKA hospitalizations by age, that’s about as far as the data segmentation goes. What’s missing? Importantly, the differences between DKA hospitalization rates at diagnosis versus during management. And equally important: DKA hospitalization rates broken down by Type 1 diabetes versus Type 2 diabetes.

In their report, the CDC takes a stab at explaining the rising trend. They offer that perhaps DKA hospitalization is on the rise because people are more aware of the dangerous and even deadly nature of DKA and are therefore more likely to seek hospital care. If that’s true, it’s potentially good news – maybe awareness campaigns are working! Perhaps people experiencing DKA symptoms are recognizing them, testing for ketones, and seeking immediate medical care.

Unfortunately, this is not the only possible explanation for rising DKA hospitalizations. And without more descriptive data, it’s impossible to decisively conclude anything. The CDC report states that “DKA is more common among persons with type 1 diabetes, it also occurs among persons with type 2 diabetes” – but what do the numbers really look like?

The best study we could find looked at 226 patients admitted to the hospital for DKA, and found that 47% had known Type 1 diabetes, 26% had known Type 2 diabetes and 27% had newly diagnosed diabetes. This represents a small data set taken over 20 years ago. But it’s clear that DKA hospitalizations happen in all three of these groups. Effective prevention of DKA requires better information about who, exactly, is impacted – so we can better understand why.

Beyond Type 1 has called upon the CDC to segment data by diabetes type in the past. This is a perfect example of why segmented data matters. More detailed data allows us to take aim at a possible cause, hone a more effective prevention campaign. This data leaves us with more questions than answers.

If the primary driver of this rise is DKA at onset of diabetes, we have an awareness problem. 41% of people with Type 1 diabetes in the USA are in DKA at the time of diagnosis. This number could be growing. Or the number of diagnoses overall could be growing – overall rates of Type 1 diabetes are, in fact, on the rise.

If rates of DKA hospitalization are primarily rising among people with known Type 1 diabetes in the United States, we should indeed be alarmed. 

The very basis of diabetic ketoacidosis is not enough insulin in the body. List prices for popular fast-acting insulins Humalog and Novolog have both risen 290% over the past decade. People with Type 1 diabetes without health insurance (or with high-deductible health insurance) face monthly costs upwards of $600 – sometimes much more – simply for the insulin needed to stay alive.

Insulin pricing and access advocate Laura Marston was quick to point out this trend in the data. Put simply in a tweet: “when insulin prices skyrocket, so do DKA hospital admissions. Notice the similar upward trajectories beginning in 2009.”

Endocrinologists have spoken up in articles and penned op-eds, explaining the insulin access issues their patients face. “I continually see patients who try to stretch their [insulin] prescription with the hope that it will last longer,” said Dr. Joshua Miller, an assistant professor of medicine and endocrinology at Stony Brook University School of Medicine in an interview for NewsDay.

This paints an alarming picture – high out-of-pocket costs for insulin in the United States have left some with Type 1 diabetes rationing insulin in an attempt to save money and make ends meet. One dangerous side effect of limiting insulin intake? Hospitalization due to DKA.

The CDC report doesn’t give us strong enough data to make a decisive call on why DKA hospitalization rates are on the rise. But it’s certainly enough to know that we should be asking critically important questions. It is not enough for the CDC to solely conclude that rates are rising because of “lower thresholds for hospitalization.” We need to know – is this the result of insulin access challenges? Of an increase in diagnoses of Type 1 diabetes? Are more people with Type 2 diabetes transitioning to insulin dependency and landing in the hospital with DKA as a result?

Maybe the rise is a result of all of these issues. Maybe several. Maybe other variables entirely. Join us in calling on the CDC to segment DKA data by diabetes Type. And in the absence of conclusive data, we must keep pushing on all fronts: raising awareness for DKA symptoms at diabetes onset, advocating for access to insulin for everyone living with diabetes, and demanding data that serves all diabetes communities.  

Learn more about Beyond Type 1’s DKA Awareness Campaign, sign the petition for CDC to segment diabetes data, and read more access coverage.

WRITTEN BY Dana Howe, POSTED 04/27/18, UPDATED 09/07/21

Dana was diagnosed with Type 1 in 2002 at the age of 8. Driven by her T1D, Dana studied Biology and Community Health as an undergraduate and went on to complete an MS in Health Communication from Tufts University. In the past, Dana has worked as a communications specialist with major hospitals as well as small nonprofits on topics ranging from cancer to pediatric device innovation. At Beyond Type 1, Dana strives to use social and digital media to amplify community voices and inspire everyone to #LiveBeyond.