Table of Contents

Introduction …………………………………………………………………………………………………………. 1
Diabetes and its Complications…………………………………………………………………………… 1
Hospital-Acquired Diabetic Ketoacidosis ……………………………………………………………. 2
Severe Outpatient Hypoglycemia ……………………………………………………………………….. 4
Implications of this Research ……………………………………………………………………………… 5
Statement of Purpose and Hypotheses …………………………………………………………………….. 8
Aim 1: Hospital-Acquired DKA …………………………………………………………………………. 8
Aim 2: Severe Outpatient Hypoglycemia …………………………………………………………….. 9
Methods…………………………………………………………………………………………………………….. 11
Aim 1: Hospital-Acquired DKA ……………………………………………………………………….. 11
Overall Design: Root Cause vs Common Cause Analysis ………………………………… 11
Setting and Participants………………………………………………………………………………… 12
Main Outcome Measures ……………………………………………………………………………… 13
Statistical Analysis ………………………………………………………………………………………. 14
Aim 2: Severe Outpatient Hypoglycemia …………………………………………………………… 15
Overall Design: Directed Acyclic Graphs and Mediation Analysis ……………………. 15
Mediator Variable Selection …………………………………………………………………………. 18
Inverse Probability Weighting and Counterfactual Disparity Measures ……………… 18
Setting and Study Population ………………………………………………………………………… 20
Statistical Analysis ………………………………………………………………………………………. 22
Results ………………………………………………………………………………………………………………. 23
Aim 1: Hospital-Acquired DKA ……………………………………………………………………….. 23
Aim 2: Severe Outpatient Hypoglycemia …………………………………………………………… 28
Study Population …………………………………………………………………………………………. 28
Rate of Severe Hypoglycemia, Overall and by Race ………………………………………… 28
Insulin Use, Overall and by Race ………………………………………………………………….. 29
Directed Acyclic Graphs ………………………………………………………………………………. 31
Future Results …………………………………………………………………………………………….. 36
Discussion …………………………………………………………………………………………………………. 37
Aim 1: Hospital Acquired DKA ……………………………………………………………………….. 37
1. Transition to inpatient management………………………………………………………… 37
2. Communication between co-managing teams ………………………………………….. 39
3. Labile blood sugars ………………………………………………………………………………. 40
Limitations …………………………………………………………………………………………………. 41
Next Steps ………………………………………………………………………………………………….. 42
Aim 2: Severe Outpatient Hypoglycemia …………………………………………………………… 43
Limitations …………………………………………………………………………………………………. 45
Next Steps ………………………………………………………………………………………………….. 45
Conclusions ……………………………………………………………………………………………………. 46
Appendices ………………………………………………………………………………………………………… 47