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. 2014 Aug 19;11(8):e1001708.
doi: 10.1371/journal.pmed.1001708. eCollection 2014 Aug.

Stress Hyperglycaemia in Hospitalised Patients and Their 3-year Risk of Diabetes: A Scottish Retrospective Cohort Study

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Free PMC article

Stress Hyperglycaemia in Hospitalised Patients and Their 3-year Risk of Diabetes: A Scottish Retrospective Cohort Study

David A McAllister et al. PLoS Med. .
Free PMC article

Abstract

Background: Hyperglycaemia during hospital admission is common in patients who are not known to have diabetes and is associated with adverse outcomes. The risk of subsequently developing type 2 diabetes, however, is not known. We linked a national database of hospital admissions with a national register of diabetes to describe the association between admission glucose and the risk of subsequently developing type 2 diabetes.

Methods and findings: In a retrospective cohort study, patients aged 30 years or older with an emergency admission to hospital between 2004 and 2008 were included. Prevalent and incident diabetes were identified through the Scottish Care Information (SCI)-Diabetes Collaboration national registry. Patients diagnosed prior to or up to 30 days after hospitalisation were defined as prevalent diabetes and were excluded. The predicted risk of developing incident type 2 diabetes during the 3 years following hospital discharge by admission glucose, age, and sex was obtained from logistic regression models. We performed separate analyses for patients aged 40 and older, and patients aged 30 to 39 years. Glucose was measured in 86,634 (71.0%) patients aged 40 and older on admission to hospital. The 3-year risk of developing type 2 diabetes was 2.3% (1,952/86,512) overall, was <1% for a glucose ≤ 5 mmol/l, and increased to approximately 15% at 15 mmol/l. The risks at 7 mmol/l and 11.1 mmol/l were 2.6% (95% CI 2.5-2.7) and 9.9% (95% CI 9.2-10.6), respectively, with one in four (21,828/86,512) and one in 40 (1,798/86,512) patients having glucose levels above each of these cut-points. For patients aged 30-39, the risks at 7 mmol/l and 11.1 mmol/l were 1.0% (95% CI 0.8-1.3) and 7.8% (95% CI 5.7-10.7), respectively, with one in eight (1,588/11,875) and one in 100 (120/11,875) having glucose levels above each of these cut-points. The risk of diabetes was also associated with age, sex, and socio-economic deprivation, but not with specialty (medical versus surgical), raised white cell count, or co-morbidity. Similar results were obtained for pre-specified sub-groups admitted with myocardial infarction, chronic obstructive pulmonary disease, and stroke. There were 25,193 deaths (85.8 per 1,000 person-years) over 297,122 person-years, of which 2,406 (8.1 per 1,000 person-years) were attributed to vascular disease. Patients with glucose levels of 11.1 to 15 mmol/l and >15 mmol/l had higher mortality than patients with a glucose of <6.1 mmol/l (hazard ratio 1.54; 95% CI 1.42-1.68 and 2.50; 95% CI 2.14-2.95, respectively) in models adjusting for age and sex. Limitations of our study include that we did not have data on ethnicity or body mass index, which may have improved prediction and the results have not been validated in non-white populations or populations outside of Scotland.

Conclusion: Plasma glucose measured during an emergency hospital admission predicts subsequent risk of developing type 2 diabetes. Mortality was also 1.5-fold higher in patients with elevated glucose levels. Our findings can be used to inform patients of their long-term risk of type 2 diabetes, and to target lifestyle advice to those patients at highest risk. Please see later in the article for the Editors' Summary.

Conflict of interest statement

The authors have declared that no competing interests exist.

Figures

Figure 1
Figure 1. CONSORT style flowchart of patients included in analysis.
* This group of 86,634 patients includes the n = 122 whose glucose was >20 mmol/l and so were assumed to have prevalent diabetes.
Figure 2
Figure 2. 3-year risk of type 2 diabetes by admission glucose.
The solid line represents the estimate and the ribbon represents the 95% CI obtained from a logistic regression model of incident type 2 diabetes on glucose, glucose-squared, and glucose-cubed. Points represent the risk of diabetes for patients categorised according to admission glucose, with the x-axis indicating the mean glucose level and the point size indicating the number of patients for each category.
Figure 3
Figure 3. 3-year risk of type 2 diabetes by admission glucose, age, and sex.
The solid lines represent the estimates with ribbons indicating 95% CIs obtained from a logistic regression model of incident type 2 diabetes on glucose, glucose-squared, and glucose-cubed, adjusting for age and sex.
Figure 4
Figure 4. 3-year risk of type 2 diabetes by glucose for patients in sub-groups.
Predicted 3-year risks of type 2 diabetes by glucose level obtained from logistic regression models. All models adjust for age, sex, and a main term and interaction term with glucose for the relevant grouping variable (e.g., admission to ICU). Lines represent estimates and ribbons indicate 95% CIs with blue used to indicate membership of the relevant sub-group and red used to describe the remainder of the population.
Figure 5
Figure 5. Receiver operator characteristic curve for development and validation cohorts.
The ribbon represents the 95% CIs.
Figure 6
Figure 6. Cumulative incidence of mortality and type 2 diabetes by admission glucose.
Non-parametric estimates of cumulative incidence of mortality and incident type 2 diabetes according to admission glucose. The ribbon represents the 95% CIs.
Figure 7
Figure 7. 3-year risk of type 2 diabetes and competing risks.
Estimates of 3-year risk of type 2 diabetes in women aged 60 obtained by multiplying the risk in women aged 60 with a glucose of 5 mmol/L (1.0%, obtained from the logistic regression model in Table 4) by the csHR and the sdHR, respectively.
Figure 8
Figure 8. 3-year risk and 5-year risk of type 2 diabetes by admission glucose among patients with 5 or more years of follow-up.
The solid lines represent the predicted risk with ribbons indicating the 95% CIs obtained from a logistic regression model of each outcome on glucose, glucose-squared, and glucose-cubed, adjusting for age and sex.

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