title: Recurrent diabetic ketoacidosis in inner-city minority patients: behavioral, socioeconomic, and psychosocial factors.
abstract: OBJECTIVE
  To conduct a bedside study to determine the factors driving insulin noncompliance in inner-city patients with recurrent diabetic ketoacidosis (DKA).
  
  
  METHODS
  We analyzed socioeconomic and psychological factors in 164 adult patients with DKA who were admitted to Grady Hospital between July 2007 and August 2010, including demographics, diabetes treatment, education, and mental illness. The Patient Health Questionnaire-9 and the Short Form-36 surveys were used to screen for depression and assess quality of life.
  
  
  RESULTS
  The average number of admissions was 4.5 ± 7 per patient. A total of 73 patients presented with first-time DKA, and 91 presented with recurrent DKA; 96% of patients were African American. Insulin discontinuation was the leading precipitating cause in 68% of patients; other causes were new-onset diabetes (10%), infection (15%), medical illness (4%), and undetermined causes (3%). Among those who stopped insulin, 32% gave no reasons for stopping, 27% reported lack of money to buy insulin, 19% felt sick, 15% were away from their supply, and 5% were stretching insulin. Compared with first-time DKA, those with recurrent episodes had longer duration of diabetes (P < 0.001), were a younger age at the onset of diabetes (P = 0.04), and had higher rates of depression (P = 0.04), alcohol (P = 0.047) and drug (P < 0.001) abuse, and homelessness (P = 0.005). There were no differences in quality-of-life scores, major psychiatric illnesses, or employment between groups.
  
  
  CONCLUSIONS
  Poor adherence to insulin therapy is the leading cause of recurrent DKA in inner-city patients. Several behavioral, socioeconomic, psychosocial, and educational factors contribute to poor compliance. The recognition of such factors and the institution of culturally appropriate interventions and education programs might reduce DKA recurrence in minority populations.
authors.affiliation: Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA.
authors.forename: Lori
authors.initials: L
authors.lastname: Randall
authors.forename: Jovan
authors.initials: J
authors.lastname: Begovic
authors.forename: Megan
authors.initials: M
authors.lastname: Hudson
authors.forename: Dawn
authors.initials: D
authors.lastname: Smiley
authors.forename: Limin
authors.initials: L
authors.lastname: Peng
authors.forename: Njalalia
authors.initials: N
authors.lastname: Pitre
authors.forename: Denise
authors.initials: D
authors.lastname: Umpierrez
authors.forename: Guillermo
authors.initials: G
authors.lastname: Umpierrez
mesh_terms: D000328:Adult; D001741:Black or African American; D003430:Cross-Sectional Studies; D003625:Data Collection; D016883:Diabetic Ketoacidosis / Q000188:drug therapy / Q000209:etiology* / Q000523:psychology*; D005260:Female; D005845:Georgia; D006801:Humans; D007328:Insulin / Q000008:administration & dosage / Q000627:therapeutic use; D008297:Male; D008875:Middle Aged; D011788:Quality of Life; D012959:Socioeconomic Factors; D011795:Surveys and Questionnaires
chemical_list: D007328:Insulin