Development and validation of a tool to identify patients with type 2 diabetes at high risk of hypoglycemia-related emergency department or hospital use

Karter, Andrew J.; Warton, E. Margaret; Lipska, Kasia J.; Ralston, James D.; Moffet, Howard H.; Jackson, Geoffrey G.; Huang, Elbert S.; Miller, Donald R.

doi:10.1001/jamainternmed.2017.3844

Cited by 150Diabetes Management and ResearchDiabetes Treatment and ManagementPatient Safety and Medication Errors

Development and validation of a tool to identify patients with type 2 diabetes at high risk of hypoglycemia-related emergency department or hospital use

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Karter, Andrew J., Warton, E. Margaret, Lipska, Kasia J., Ralston, James D., Moffet, Howard H., Jackson, Geoffrey G., Huang, Elbert S., Miller, Donald R.·2017·JAMA Internal Medicine

DOI 10.1001/jamainternmed.2017.3844PMC PMC5624849

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Abstract

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.

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Older adults can be stratified for future risk for hypoglycemia with validated risk calculators such as the Kaiser Hypoglycemia Model and with consideration of hypoglycemia risk factors.
“Older adults can also be stratified for future risk for hypoglycemia with validated risk calculators (e.g., Kaiser Hypoglycemia Model) (34) and with consideration of hypoglycemia risk factors (Table 6.5).”
From 13. Older Adults: Standards of Care in Diabetes—2024 (2024) · cites this paper as [34]
The Introduction and Model selection sections describe a validated tool that uses patient risk factors, including age, to stratify adults with type 2 diabetes by future hypoglycemia-related risk. The claim is broader than the outcome studied: the tool predicts hypoglycemia-related emergency department or hospital use over 12 months, not hypoglycemia events generally. The separate reference to risk factors in Table 6.5 is not attributed to this source. (LLM, conf=0.84)
Experimental — accuracy not yet measured
Older adults can be stratified for future risk for hypoglycemia with validated risk calculators (e.g., Kaiser Hypoglycemia Model for adults with type 2 diabetes) and with consideration of hypoglycemia risk factors.
“Older adults can also be stratified for future risk for hypoglycemia with validated risk calculators (e.g., Kaiser Hypoglycemia Model for adults with type 2 diabetes) (40) and with consideration of hypoglycemia risk factors (Table 6.5).”
From 13. Older Adults: Standards of Care in Diabetes—2026 (2026) · cites this paper as [40]
The Methods (Study Design) and Abstract (Results) describe a validated Kaiser Permanente tool that stratifies adults with type 2 diabetes by predicted 12-month risk. Its outcome is specifically hypoglycemia-related emergency department or hospital use, not hypoglycemia of any severity; the study population was adults generally, rather than older adults specifically. The separate reference to considering risk factors is tied to Table 6.5, not this citation. (LLM, conf=0.82)
Experimental — accuracy not yet measured
Validated tools have been developed to estimate hypoglycemia risk using predominantly electronic health record data.
“Validated tools have been developed to estimate hypoglycemia risk using predominantly electronic health record data (101-103).”
From 6. Glycemic Goals, Hypoglycemia, and Hyperglycemic Crises: Standards of Care in Diabetes-2026. (2026) · cites this paper as [101]

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Authors: Karter, A. J., Warton, E. M., Lipska, K. J., Ralston, J. D., Moffet, H. H., Jackson, G. G., Huang, E. S., & Miller, D. R.
Affiliations: University of California, San Francisco (US)
Kaiser Permanente (US)
Yale University (US)
Kaiser Permanente Washington Health Research Institute (US)
University of Chicago (US)
Veterans Health Administration (US)
Corresponding author: Karter, Andrew J.
ORCID: Karter, Andrew J.
Warton, E. Margaret
Lipska, Kasia J.
Ralston, James D.
Moffet, Howard H.
Huang, Elbert S.
Miller, Donald R.
Venue: JAMA Internal Medicine
Publisher: American Medical Association (AMA)
Published: 2017-10-01
Volume: 177
Issue: 10
Pages: 1461
ISSN: 2168-6106 (ISSN-L)
DOI: 10.1001/jamainternmed.2017.3844
PMC: PMC5624849
OpenAlex: W2749343537
Semantic Scholar: 865993e54ca35e1a709ba058bb73942c855a57a4
Cited by: 150
References: 62
Citations by year: 2026: 7 · 2025: 18 · 2024: 21 · 2023: 18 · 2022: 16 · 2021: 17 · 2020: 19 · 2019: 17 · 2018: 14 · 2017: 3
FWCI: 11.47
Type: journal article
Language: en
Open access: green
europepmc.org
Locations: JAMA Internal Medicine (publishedVersion)
Europe PMC (PubMed Central) (publishedVersion)
PubMed Central (publishedVersion)
PubMed (publishedVersion)
Funders: National Institutes of Health (UL1TR001863)
National Institute on Aging (K23AG048359)
National Institute of Diabetes and Digestive and Kidney Diseases (K24DK105340, R01DK103721, R01DK081796, P30DK092949, P30DK092924)
National Center for Advancing Translational Sciences
Topics: Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Research
Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Treatment and Management
Health Sciences › Health Professions › Emergency Medical Services › Patient Safety and Medication Errors
Keywords: type 2 diabetes, hypoglycemia, hospital utilization, risk stratification tools, classification trees, insulin use, chronic kidney disease, risk prediction model, external validation, Kaiser Permanente, Veterans Health Administration, Group Health Cooperative, electronic health records, hypoglycemia prevention
MeSH terms: Diabetes Mellitus, Type 2, Emergency Service, Hospital, Female, Follow-Up Studies, Humans, Hypoglycemia, Hypoglycemic Agents, Male, Prospective Studies, Quality of Life, Risk Factors, United States, Incidence, Risk Assessment, Delivery of Health Care, Integrated, Electronic Health Records

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Development and validation of a tool to identify patients with type 2 diabetes at high risk of hypoglycemia-related emergency department or hospital use

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