Diabetic Ketoacidosis at Diagnosis of Type 1 Diabetes in Colorado Children, 2010–2017

OBJECTIVE We examined trends in diabetic ketoacidosis (DKA) at diagnosis of type 1 diabetes at a large pediatric diabetes center between 2010 and 2017, overlapping with the Affordable Care Act’s overhaul of U.S. health care. RESEARCH DESIGN AND METHODS Colorado residents <18 years old who were diagnosed with type 1 diabetes from 2010 to 2017 and subsequently followed at the Barbara Davis Center for Diabetes were included. Logistic regression models were used to test associations among age, sex, race/ethnicity, insurance, language, year of diagnosis, and rural/nonrural residence and DKA at diagnosis. Linear regression models were used to test the association of each predictor with HbA1c at diagnosis. RESULTS There were 2,429 subjects who met the inclusion criteria. From 2010 to 2017, the rate of DKA increased from 41 to 58%. It increased from 35.3 to 59.6% among patients with private insurance (odds ratio 1.10 [95% CI 1.05–1.15]; P < 0.0001) but remained unchanged (52.2–58.8%) among children with public insurance (1.03 [0.97–1.09]; P = 0.36). In the multivariable model, public insurance (1.33 [1.08–1.64]; P = 0.007), rural address (1.42 [1.08–1.86]; P = 0.013), and HbA1c (1.32 [1.26–1.38]; P < 0.0001) were positively associated with DKA, whereas age, race/ethnicity, sex, and primary language were not. CONCLUSIONS The increase in the rate of DKA in patients with newly diagnosed type 1 diabetes was driven by patients with private insurance. This paradoxically occurred during a time of increasing health insurance coverage. More study is needed to understand the factors driving these changes.