Cross-sectional studyindependent cross-checkabstract checked★ key study I-INS-109 in-depth review

Why people with diabetes end up in hospital with ketoacidosis again and again

Recurrent diabetic ketoacidosis in inner-city minority patients: behavioral, socioeconomic, and psychosocial factors.

Overview

Randall L et al.. Diabetes Care 2011 · PMID 21775761 · DOI 10.2337/dc11-0701

In 164 adults admitted with ketoacidosis, stopping insulin was the main trigger in 68%.

Does the study support the specific claim? No · Methodological quality: moderate

Study explained simply

What did the researchers want to find out?: Find the drivers of recurrent DKA.
How was the study done?: Bedside interviews.
How many people, animals or samples were studied?: 164 adults.
What was actually found?: Insulin stopped in 68%.
How large was the observed effect?: 68% (about 60-74%).
What do the results mean in everyday life?: Stopping insulin is dangerous.
What are the study's limitations?: Single centre.
What does it say about Elawady's specific claim?: Contradicts insulin-free management of DKA.
Do the results apply to Germany and Europe?: Mechanism universal.
What can explicitly not be concluded from this study?: Cannot give population incidence.

What drives insulin non-adherence in recurrent DKA?

Study design: Cross-sectional study – Bedside cross-sectional study of consecutive admitted DKA patients
Population: Adults admitted with DKA to Grady Hospital
Country: USA (Atlanta)
Period: 2007-2010
Sample size: 164
Inclusion and exclusion criteria: Adults with DKA admission

Results: Insulin discontinuation was the leading cause in 68% of patients; other causes: new-onset diabetes 10%, infection 15%, medical illness 4%, undetermined 3%. Reasons for stopping: no reason 32%, lack of money 27%, felt sick 19%, away from supply 15%, stretching insulin 5%.
Absolute risks: not reported
Authors' conclusion: Poor adherence to insulin therapy is the leading cause of recurrent DKA.

68% (Wilson 95% CI about 60-74%, count reconstructed; stats/C-INS-08_insulin_omission_and_fluids.py).

Stopping insulin, including when 'feeling sick', is the main cause of DKA.

Directly applicable; same biology and clinical standards in Europe.

Consistent with Musey 1995 and with guideline statements on insulin omission.

Multidimensional assessment
Multidimensional assessment
Authenticity of the source	verified
Methodological quality	moderate
Risk of bias	some concerns
Precision of results	moderate
Directness	direct
Reproducibility	replicated
Consistency with the overall evidence	consistent
Regional transferability	moderate
Adequacy of the interpretation (by the archive)	not applicable