Increasing Trends in Hospitalisation With Diabetic Ketoacidosis at Type 1 Diabetes Diagnosis Among Children and Youth in the United States and England, 2002–2020

BACKGROUND: There is a paucity of population-level data evaluating trends in the proportion of children and youth hospitalised with diabetic ketoacidosis (DKA) at the time of Type 1 diabetes (T1D) diagnosis. METHODS: National Medicaid (US publicly insured claims), MarketScan (US commercially insured claims) and Clinical Practice Research Datalink (CPRD) (English electronic health record) data were used to create cohorts of children with incident T1D. DKA at diagnosis was defined as a DKA hospitalisation occurring within 30 days prior to the diagnosis of T1D. The likelihood of presenting in DKA was modelled using age, sex, race and community-level social vulnerability. Population-level T1D incidence trends were also assessed. RESULTS: Among 116 845 patients (mean [SD] age: 10.4 [4.9]; 46.8% female), 48 291 (41.3%) presented in DKA. These proportions increased between 2002 and 2019, rising by 11.1% (from 34.4% to 45.5%) in Medicaid, 2.8% (from 42.0% to 44.8%) in MarketScan and 18.6% (from 17.9% to 36.5%) in CPRD, and further increasing in 2020 (Medicaid, 52.4%; MarketScan, 52.9%; CPRD, 44.1%). T1D incidence increased from 2002 to 2019 from 10 to 17, 12 to 20 and 5 to 13 per 100 000 children, respectively, reaching 21, 22 and 15 per 100 000 in 2020, respectively. DKA was higher among children aged 6 months to 2 years (70.4%), and among Black (45.4%) and Hispanic (45.4%) backgrounds. An increased relative risk of DKA was evident among children under 2 years: 1.97 (95% CI: 1.92-2.02), Black children: 1.14 (1.06-1.23), Hispanic children: 1.12 (1.10-1.15), and those residing in higher areas of social vulnerability: 1.20 (1.02-1.40). CONCLUSION: This study found a relative increase in the proportion of children presenting with DKA at T1D diagnosis, occurring in parallel with rising T1D incidence. This uptrend, which preceded but was exacerbated by the COVID-19 pandemic, underscores worsening epidemiological trends, especially notable in England and among publicly insured US children.