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Original Investigation
October 2017

Development and Validation of a Tool to Identify Patients With Type 2 Diabetes at High Risk of Hypoglycemia-Related Emergency Department or Hospital Use

Author Affiliations
  • 1Division of Research, Kaiser Permanente Northern California, Oakland
  • 2Department of General Internal Medicine, University of California, San Francisco
  • 3Department of Epidemiology, University of Washington, Seattle
  • 4Department of Health Services, University of Washington, Seattle
  • 5Section of Endocrinology, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
  • 6Kaiser Permanente Washington Health Research Institute, Seattle
  • 7Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, Illinois
  • 8Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts
JAMA Intern Med. 2017;177(10):1461-1470. doi:10.1001/jamainternmed.2017.3844
Key Points

Question  Can electronic medical records be used to reliably categorize risk of future hypoglycemia-related emergency department or hospital use in patients with type 2 diabetes?

Findings  We developed and validated a risk stratification tool that categorized patients’ 12-month risk of hypoglycemia-related utilization using only 6 electronic medical record–based inputs (patient history of hypoglycemia-related utilization, insulin use, sulfonylurea use, emergency department use, chronic kidney disease, and age). Tool performance was validated in 2 fully independent populations.

Meaning  This hypoglycemia risk stratification tool could facilitate efficient targeting of population management interventions to reduce hypoglycemia risk and improve patient safety.


Importance  Hypoglycemia-related emergency department (ED) or hospital use among patients with type 2 diabetes (T2D) is clinically significant and possibly preventable.

Objective  To develop and validate a tool to categorize risk of hypoglycemic-related utilization in patients with T2D.

Design, Setting, and Participants  Using recursive partitioning with a split-sample design, we created a classification tree based on potential predictors of hypoglycemia-related ED or hospital use. The resulting model was transcribed into a tool for practical application and tested in 1 internal and 2 fully independent, external samples. Development and internal testing was conducted in a split sample of 206 435 patients with T2D from Kaiser Permanente Northern California (KPNC), an integrated health care system. The tool was externally tested in 1 335 966 Veterans Health Administration and 14 972 Group Health Cooperative patients with T2D.

Exposures  Based on a literature review, we identified 156 candidate predictor variables (prebaseline exposures) using data collected from electronic medical records.

Main Outcomes and Measures  Hypoglycemia-related ED or hospital use during 12 months of follow-up.

Results  The derivation sample (n = 165 148) had a mean (SD) age of 63.9 (13.0) years and included 78 576 (47.6%) women. The crude annual rate of at least 1 hypoglycemia-related ED or hospital encounter in the KPNC derivation sample was 0.49%. The resulting hypoglycemia risk stratification tool required 6 patient-specific inputs: number of prior episodes of hypoglycemia-related utilization, insulin use, sulfonylurea use, prior year ED use, chronic kidney disease stage, and age. We categorized the predicted 12-month risk of any hypoglycemia-related utilization as high (>5%), intermediate (1%-5%), or low (<1%). In the internal validation sample, 2.0%, 10.7%, and 87.3% were categorized as high, intermediate, and low risk, respectively, with observed 12-month hypoglycemia-related utilization rates of 6.7%, 1.4%, and 0.2%, respectively. There was good discrimination in the internal validation KPNC sample (C statistic = 0.83) and both external validation samples (Veterans Health Administration: C statistic = 0.81; Group Health Cooperative: C statistic = 0.79).

Conclusions and Relevance  This hypoglycemia risk stratification tool categorizes the 12-month risk of hypoglycemia-related utilization in patients with T2D using only 6 inputs. This tool could facilitate targeted population management interventions, potentially reducing hypoglycemia risk and improving patient safety and quality of life.