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Hypoglycemia is an acute complication of diabetes management that has been linked to increased morbidity. Although current guidelines have called for treatment changes for avoidance of hypoglycemia, it remains a critical issue. Our goal was to examine the socio-demographic and clinical factors for recurrent hypoglycemic encounters across a large metropolitan area. CAPriCORN is a research network which brings together merged, de-duplicated, and de-identified electronic medical health record data from 6 institutions across Chicago. Patients with a diabetes diagnosis and hypoglycemic encounters (HEs) between 2011-18 were identified using ICD-9 and 10 codes. HEs were identified using a validated algorithm. Analysis was performed to evaluate the patient characteristic differences between patients with 1 vs 2-3 vs ≥4 HEs utilizing chi-square for categorical variables and ANOVA for continuous variables. Of 423,643 patients identified with a diagnosis of diabetes, 17,885 (4%) patients had at least one diagnosis of hypoglycemia, which included 30,157 unique encounters (1 HE: 12,886 pts and encounters; 2-3: 3,640 pts and 8,238 encounters, and ≥4: 1,359 pts and 9,033 encounters). The 1,359 patients with ≥4 HEs (8% of all patients with HEs) accounted for over 30% of all HEs. Older adults (65 years and older) comprised 57% of all patients and 62% of patients with HEs. Older adults comprised 63% of those with 1 HE, 61% of those with 2-3, and 52% of those with ≥ 4 (p< 0.001). Adults 80 years and older represented > 20% of those in each group. Whites (N=7,203, 40%) and Blacks (N=6,511, 36%) accounted for most with HE, and within each category. Overall, among those with 1, 2-3, and ≥ 4 HEs there were also significant differences by race and ethnicity. Patients with a HE had significant history of complications, including 54% with nephropathy, 24% with neuropathy, and 23% with ophthalmologic complications. However, a history of diabetic ketoacidosis (DKA) was noted in 53% of all patients with a HE, with 49%, 61%, and 66% of patients in 1, 2-3, and ≥4 HEs groups, respectively (p Of those with medication information (n=8,938), patients on insulin-only therapy represented 47% of patients with a HE, and 44%, 52%, and 65% of patients who had 1, 2-3, and ≥4 HEs, respectively (p Overall, a small diverse group of patients accounted for a large amount of hypoglycemic encounters. Special attention should be paid to subsets of patients, including older adults, those with a history of DKA, and those on high-risk therapy. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

Training of diabetes (DM) skills is critical to assure competency of DM survival skills (e.g. glucose testing) for immediate self-care. While DM assessments exist, we sought to develop a culturally acceptable DM Skills and Knowledge Assessment (DM-SKA) tool. A systematic search of Pubmed/Medline and Scopus (1980-2017) of assessments for DM knowledge was performed. 24 studies were identified, only 33% reported minority populations. Studies were classified by topic: measurement of DM skills, objectives of DM training, assessments of DM education, and other non-patient assessments. Content from existing assessments was adapted to create a 12 question DM-SKA to address 6 domains: DM, blood glucose and self-monitoring, support services, identification management of hypo and hyperglycemia, and insulin administration. To assess cultural acceptance, cognitive evaluations were conducted in individual user sessions and focus groups. The DM-SKA had a baseline Flesch reading score of 81.3 (low complexity language) and Flesch-Kincaid reading grade level of 5.3. Of 39 approached, 85% (N=33) participated (6 inpatients refused, feeling “overwhelmed”). Participants were diverse, including 8 clinicians, 10 patients/caregivers, and 15 laypersons; 46% were non-Hispanic whites, 33% non-Hispanic blacks, 12% Hispanics, and 9% Asian Americans. Mean age of patient/caregiver/laypersons was 57.8±17 (44% > age 65) and 40.1±12 years for clinicians (12.5% > age 65). All clinicians reported that appropriate DM skill domains were included and felt patients would complete the tool. All patients/caregivers and laypersons (N=25) verbalized adequate comprehension of each question; 96% reported willingness to complete the DM-SKA if provided and 88% reported their family, friends or someone in their community would be willing to complete it. However, both providers (N=2) and patients (N=2) reported concerns about assessment format and delivery [e.g. “testing” or “quiz”]. Some younger (65 years. Vision problems and older age were identified as potential barriers. Of those offered the assessment (N = 25), 5 (20%) participants needed assistance [N=2 vision, N=3 English as second language]. Mean DM-SKA score was 10.2±1.7 of 12. Incorrect answers mostly occurred for questions with multiple correct answers. The DM-SKA has acceptable literacy characteristics, cognitive validity, and cultural acceptability by racial/ethnic minority populations, including elderly persons. Future work includes integration into clinical workflows and incorporation of patient preferences.

Objective To characterize the types of hyperglycemia that occur up to 1 year following liver transplant and to clarify the nomenclature for posttransplant hyperglycemia. Design We analyzed 1-year glycemic follow-up data in 164 patients who underwent liver transplant and who had been enrolled in a randomized controlled trial comparing moderate to intensive insulin therapy to determine if patients had preexisting known diabetes, transient hyperglycemia, persistent hyperglycemia, or new-onset diabetes after transplantation (NODAT). Results Of 119 patients with posttransplant hyperglycemia following hospital discharge, 49 had preexisting diabetes, 5 had insufficient data for analysis, 48 had transient hyperglycemia (16 resolved within 30 days and 32 resolved between 30 days and 1 year), 13 remained persistently hyperglycemic out to 1 year and most likely had preexisting diabetes that had not been diagnosed or insulin resistance/insulinopenia prior to transplant, and 4 had NODAT (i.e., patients with transient hyperglycemia after transplant that resolved but then later truly developed sustained hyperglycemia, meeting criteria for diabetes). Conclusions Distinct categories of patients with hyperglycemia following organ transplant include known preexisting diabetes, persistent hyperglycemia (most likely unknown preexisting diabetes or insulin resistance/insulinopenia), transient hyperglycemia, and NODAT. Those with preexisting diabetes for many years prior to transplant may well have very different long-term outcomes compared with those with true NODAT. Therefore, it would be prudent to classify patients more carefully. Long-term outcome studies are needed to determine if patients with true NODAT have the same poor prognosis as patients with preexisting diabetes (diagnosed and undiagnosed) undergoing transplant.

Patients, newly prescribed insulin, being discharged from the hospital are at high risk of adverse outcomes. An electronic enterprise data warehouse (EDW) algorithm was created and validated to identify these inpatients electronically. Qualitative interviews were also conducted to assess barriers in the discharge process. The EDW algorithm to identify inpatients (09/01/18-08/31/19), newly prescribed insulin at discharge, was created by identifying screening indicators (e.g., admission/discharge medication lists, discharge summary). Iterative adjustments to the algorithm were made after chart review and included review of medication reconciliation (med rec), admission/discharge orders, and insulin orders (types/delivery). The EDW list was compared to the list of patients who received insulin teaching from the Certified Diabetes Care and Education Specialist (CDCES), during the same period. Providers (N=8, 3 endocrine attending MDs, 2 fellow MDs, 3 resident MDs) were interviewed in key informant interviews (N=3) and focus groups (N=2); transcripts were independently coded by 2 coders, utilizing a constant comparative method to generate key themes. The EDW list (N=554) was audited by EHR review (n = 42, 8%); 83% (35/42) were correctly identified as newly discharged on insulin. Of the 7 incorrectly identified, 4 likely had incomplete med rec. The EDW algorithm was unable to correctly identify patients with inaccurate/incomplete med rec, patients transferring from outside hospitals or those without e-Rx at discharge (vouchers, call-in). The CDCES list (N=257) was audited (n=25, 10%), and of patients not meeting criteria (n=15), some had prior insulin prescribed (n=5), and most ended up not discharged on insulin after CDCES insulin teaching (n=9). Comparison of the EDW and CDCES lists had 177 patients (32% of EDW list) in common, with 377 on the EDW list with no CDCES consultation. An audit (n=21/377, 5%) of these EDW patients, who did not have CDCES or endocrinology consultation, revealed patients across service lines, with minimal formal documentation of insulin training/education. Key identified themes from interviews identified barriers including lack of availability of a CDCES after-hours and on weekends, low health literacy/numeracy, and lack of time during stay. In training MDs noted variability in discharge prescribing by supervising MDs and the need to assess “chart lore,” given cut and paste documentation in EHR. This study suggests that an EDW algorithm can be used to identify patients newly being discharged on insulin, for whom teaching by a CDCES is recommended. The data suggest the need for more targeted and increased CDCES capacity as only a portion of those eligible for insulin teaching were seen while others were seen but then not discharged on insulin. Additional resources for insulin teaching are needed and standardized training and documentation need to be developed.

Background: Gestational diabetes mellitus (GDM) is defined as “impairment of glucose tolerance with first recognition during pregnancy” and is rarely associated with diabetic ketoacidosis (DKA). The incidence of DKA in pregnancy is about 1-3% in those with type 1 or 2 DM. Complications include preterm birth and fetal demise rate of 10-25%. Clinical case: 35-year-old G2P1 Southeast Asian female diagnosed with GDM at 28 weeks of gestation (wGA) via 3hour oral glucose tolerance test. At 35wGA, she presented with asymptomatic hyperglycemia. Blood glucose (BG) was previously well-controlled on once daily detemir (started at 31wGA). Past medical history is significant for Hashimoto’s thyroiditis; pre-pregnancy BMI 22.5kg/m2. Family history is notable for a sister with GDM and pre-eclampsia and mother with pre-DM. She experienced fasting hypoglycemia (68, 57mg/dL) the 2 preceding mornings, addressed by decreasing detemir dose 20 to 16U QD. The am of her presentation, she awoke asymptomatic with a fasting BG of 200mg/dL and 1 hour post-prandial of 283mg/dL. By lunch, BG rose to 357mg/dL. Physical exam was notable for localized wheal-like reactions on her left thigh and gluteal area, and right arm. Labs demonstrated an anion gap 18, bicarbonate 11mEq/L and beta-hydroxybutyrate (BHB) 7.42mMol/L. The patient was started on intravenous (IV) insulin and was kept NPO per DKA protocol. Urinalysis and culture were negative with no other precipitants identified. C-peptide was undetectable at BG of 260mg/dL and T1DM related antibodies were obtained. After 18 hours on the DKA protocol, BG remained 180-250 mg/dL, bicarbonate 16meq/L, and BHB 1.13mMol/L; the protocol was modified for tighter BG ranges and to allow more frequent feeding for prevention of hypoalimentation ketosis. Allergy team was consulted and diagnosed localized insulin reaction and recommended daily oral H2-blocker, given no true IgE-mediated hypersensitivity or systemic findings. Patient was transitioned to NPH 18u BID and prandial lispro 5u TID (total of 0.88u/kg) on day 2 of admission. Following discharge, only anti-glutamic acid decarboxylase (38IU/ml) and anti-insulin (0.6IU/ml) returned elevated (negative IA-2 and anti-islet cell). At 37wGA, she had prelabor spontaneous rupture of membranes and delivered a 3730g healthy female via repeat cesarean section while receiving IV insulin. Newborn required 2 days of phototherapy for hyperbilirubinemia, no neonatal hypoglycemia. At 6 weeks postpartum, she was breastfeeding, administering 11u NPH BID and 3u of prandial lispro (0.53u/kg). Conclusion: Stress in the third trimester of pregnancy (insulin allergy, starvation ketosis, and physiologic increase in insulin resistance) can result in DKA in a patient with type 1 or 2 DM that initially presents as GDM. Insulin allergy or localized reaction to insulin may contribute to delay in insulin absorption thus precipitating insulinopenia. Unless otherwise noted, all abstracts presented at ENDO are embargoed until the date and time of presentation. For oral presentations, the abstracts are embargoed until the session begins. Abstracts presented at a news conference are embargoed until the date and time of the news conference. The Endocrine Society reserves the right to lift the embargo on specific abstracts that are selected for promotion prior to or during ENDO.

Hypoglycemia is an acute complication of diabetes management that has been linked to increased morbidity and mortality. In this study, we analyzed whether recurrent hypoglycemia is related to fragmentation of care. The Chicago HealthLNK Data Repository (HDR) consists of merged, de-duplicated and de-identified electronic health records from 6 institutions and employs a hashing and matching algorithm to create a unique ID for each patient (pt) so that pt care can be tracked across different institutions without sharing protected health information. The HDR contains pt demographic and clinical information. Hypoglycemia was identified using a validated algorithm using ICD-9 codes. Fragmentation was defined as an emergency department or inpatient hypoglycemia encounter at >1 institution over the 7-year study period 2006-2012. Of 187,644 patients (pts) with a diabetes diagnosis (250.x), 9,741 (5.2%) pts were identified as having hypoglycemia, representing 18,443 unique encounters, with a mortality rate of 27.7%. 1,035 pts (10.6% of all pts with hypoglycemia) had ≥ 4 hypoglycemic encounters and accounted for 40.3% (n=7,434) of all hypoglycemia encounters. Having any hypoglycemia was associated with race (p

There is limited research using real-world data to study differences in the cardiovascular (CV) effects of glucagon-like peptide-1 (GLP-1) agonists. We conducted a retrospective active comparator Type 2 Diabetes (DM) cohort study using 2011-2015 administrative claims data to evaluate the cardiovascular (CV) effectiveness of GLP-1: exenatide extended-release (E-ER), exenatide immediate-release (E-IR), liraglutide, albiglutide, and dulaglutide. We included those with: 1) 1st pharmacy dispensing event (index date); 2) ≥ 2 fills; and 3) no evidence of antidiabetic medication (ADM) fills (besides metformin). Medical diagnoses associated with claims were coded by the International Classification of Diseases, 9th Revision (ICD-9). The primary study outcome was time to 1st major adverse CV event after starting index ADM and composite primary outcome of hospitalization including: ischemic heart disease, stroke, congestive heart failure, or peripheral arterial disease. Chi-square tests were used to examine associations between baseline covariates and the index GLP-1 medication. Cox proportional hazards regression was used to model the association between index GLP-1 and CV events (composite and separate models), adjusting for baseline patient, prescriber, and plan characteristics. Stratified analyses to measure effects on patient subgroups, and a time-varying Cox model, accounting for changes over time, were completed. Because too few patients received albiglutide (n=360) and dulaglutide (n=99), evaluation of CV outcomes was restricted to liraglutide (n=7531), E-ER (n=1451), or E-IR (n=1910). Prescription patterns changed over time; in 2011, 26.6% of patients were prescribed E-IR and dropped to 13.8% by 2015, with more patients prescribed E-ER. Using liraglutide as reference, neither formulation of exenatide was significantly associated with differences in the composite CV outcome [hazard ratios (HRs) for exenatide ER and IR are 1.33 [95% C.I. 0.73-2.39] and 1.30 [0.81-2.09]] respectively. Adjusting for time-varying covariates (i.e. DM and CVD Rx use during the follow up period) produced similar results. For individual CVD categories, there were no significant differences between GLP-1; for ischemic outcomes, the HR for E-IR was 1.85 [95% C.I. 0.97-3.53] relative to liraglutide. Stratified analyses resulted in similar non-significant results. The direction of the HR’s for exenatide differed for patients taking versus those not taking metformin, but were not statistically significant: E-ER with metformin: HR 1.72 [95% C.I. 0.82-3.62]; E-IR with metformin: HR 1.48 [95% C.I. 0.77-2.84]; E-ER without metformin: HR 0.92 [95% C.I. 0.31-2.74]; E-IR without metformin: HR 0.93 [0.43-2.03]. Initiating different GLP1, in comparison to liraglutide, early in the course of DM (as a 1st or 2nd medication to metformin), did not result in differences in CV effects in the real world. Unless otherwise noted, all abstracts presented at ENDO are embargoed until the date and time of presentation. For oral presentations, the abstracts are embargoed until the session begins. Abstracts presented at a news conference are embargoed until the date and time of the news conference. The Endocrine Society reserves the right to lift the embargo on specific abstracts that are selected for promotion prior to or during ENDO.

Learning diabetes mellitus (DM) survival skills is critically important, especially for those newly diagnosed upon discharge. COVID-19 has created new educational challenges, as DM self-management education and support is difficult to deliver remotely and can be time intensive. Content and format have not been re-designed for remote delivery; however, learning sciences research can help us create effective remote education strategies. We conducted interviews with users to identify critical needs in assuming immediate DM self-care at discharge from the hospital. We then mapped these user needs to relevant learning science theories to inform potential re-designs for remote delivery of DM education and survival skills at discharge. We conducted 12 semi-structured interviews with “users,” which included 18 participants (8 minority; 6>65 years): patients newly diagnosed with DM at discharge (N=6 [33%]), their caregivers (N=4 [22%]), and laypersons new to DM (N=8 [45%]). Users were asked about their discharge needs, laypersons about perceived needs. Three investigators performed iterative rounds of inductive coding of the transcripts (using MAXQDA software), utilizing a constant comparative method to identify codes describing dominant user needs. Learning science theory was applied to identify potential re-designs for remote delivery. Dominant user needs during hospitalization included being overwhelmed with DM self-care information (6/12 sessions) and difficulty organizing self-care equipment (5/12 sessions). Dominant user needs at home included remembering DM self-care steps (6/12 sessions), understanding correct insulin dosing (9/12 sessions), feeling fearful injecting insulin (9/12 sessions), with some noting difficulty in tracking glucose (4/12 sessions) and confusing insulin types (4/12 sessions). When learning science theory was applied, analysis mapped to three discrete educational strategies, most dominant of which is the spiral design approach—cycles of teaching the same topic but with increasing complexity. This design follows the pre-teaching principle—curriculum-based conceptual overview of self-care. Self-care at home mapped to the need for segmented learning and goal directed practice and feedback, with the potential need for behavioral therapies to reduce fear. Learning sciences has demonstrated that learning complex procedures and concepts, such as DM self-care, requires time, repetition, and continued support. With short hospital stays and the complexity of learning DM self-care, patients cannot gain needed knowledge structures to organize the information received during hospitalization. This study suggests specific learning science strategies for the design of an effective remote delivery of DM education and skills.