Diabetes Mellitus and Related Admission Factors Among Hospitalized Patients in King Abdul-Aziz University Hospital in Jeddah, Saudi Arabia

Background Diabetes mellitus (DM) is a rapidly increasing serious health problem that affects the population all over the world. The increasing prevalence of DM in Saudi Arabia is reflected in our hospital admissions as well. This study aimed to assess the proportion of DM (including type 1 and type 2 diabetes) among hospitalized patients and the reasons for admissions to the medical unit at King Abdul-Aziz University Hospital (KAUH) in Jeddah, Saudi Arabia. Methods We conducted a hospital record-based cross-sectional study at KAUH from January to April 2021. The study included all adult patients admitted to the internal medicine wards and isolation unit but excluded patients in the coronary care unit and those with gestational diabetes. We reviewed the medical records to collect demographic data, causes of admission, laboratory results, and outcomes. Results Among the hospitalized patients, 49.9% had DM. The most common associated risk factors and causes of admission among patients with DM were hypertension (HTN; 73.2%) and dyslipidemia (43.1%). Other less common reasons for admission were heart failure (20.6%), coronavirus disease-2019 (COVID-19; 17.8%), chronic kidney disease (CKD; 14.5%), pneumonia (12.3%), and stroke (10%). Dyslipidemia, HTN, CKD, diabetic ketoacidosis, heart failure, and need for intensive care unit (ICU) admission were significantly higher in diabetic patients as compared to patients without diabetes. HTN, dyslipidemia, CKD, heart failure, stroke, acute abdomen, and malignancy were significantly higher in patients with type 2 diabetes. Among diabetic patients, those with non-Saudi nationality, low hemoglobin level, dyslipidemia, pneumonia, sepsis, and requiring ICU admission had a greater risk of death. Conclusions The high burden of DM on the secondary healthcare level in Saudi Arabia highlights the need for effective diabetes prevention and treatment strategies in primary care and hospital outpatient settings. Such measures would help reduce the hospitalization rate and ease the healthcare system’s burden.


Introduction
Diabetes mellitus (DM) is a chronic multisystem disorder influenced by a complex interaction of genetic, socioeconomic, and behavioral factors that impair insulin secretion from the pancreas resulting in insulin resistance [1]. Diabetic patients usually manifest high blood glucose levels and can have various complications that affect their blood vessels and nerves [1]. Complications can be microvascular (e.g., neuropathy, retinopathy, and nephropathy) and macrovascular (e.g., stroke and myocardial infarction [MI]) [1,2]. DM also causes immune dysfunction because hyperglycemia is toxic to cellular immunity. Therefore, patients with uncontrolled DM have a greater risk for morbidity and mortality than patients without DM [2].
Several hospital admissions are related to DM and its complications, and as the global incidence of DM grows, the disease consumes a growing amount of the national healthcare expenditure [2]. The diabetes epidemic will continue to grow if primary prevention is not implemented, and it is expected to become one of the world's leading causes of disability and mortality if left untreated [3][4][5]. According to the International Diabetes Federation, the Middle East and North Africa (MENA) region has the highest DM prevalence [6]. This spike is due to rapid economic development, urbanization, and lifestyle changes.
Furthermore, according to the World Health Organization, the Kingdom of Saudi Arabia (KSA) has the second-highest prevalence of DM in the Middle East region and seventh in the world [4]. In a systematic review, KSA had an incidence of 32.8% of type 2 diabetes in 2015, which is expected to increase to 45.36% by 2030 [5]. Epidemiological studies were done in KSA [1] and Libya [3], and both reported that DM patients had higher admission rates, longer hospital stays, and higher morbidity and mortality than patients without DM. Data regarding the prevalence of DM among patients and their reasons for admission to the KSA are limited. This study aimed to identify the proportion of DM (including type 1 and type 2 diabetes) and the reasons for admission among hospitalized patients in the medical unit at King Abdul-Aziz University Hospital (KAUH) in Jeddah, KSA.

Materials And Methods
We conducted a hospital record-based cross-sectional study to identify the proportion of DM and causes of admission among hospitalized patients in KAUH in Jeddah, KSA, from January to April 2021. The study was ethically approved by the Institutional Review Board (IRB) of KAUH. We reviewed the medical records of all adult patients admitted to internal medicine wards and the isolation units. Patients admitted to the coronary care unit and those with gestational diabetes were excluded from the study as they were not admitted under internal medicine wards. We collected demographic information, such as age, gender, nationality (i.e., Saudi or Non-Saudi), and any known medical issues by history such as diabetes, hypertension (HTN), chronic kidney disease (CKD), and dyslipidemia. We also recorded the reason for the current admission and laboratory results, such as glycated hemoglobin (HbA1c), hemoglobin, creatinine, microalbumin/creatinine ratio, total cholesterol, triglyceride, low-density lipoprotein (LDL), high-density lipoprotein (HDL), and thyroid-stimulating hormone (TSH). We recorded patient outcomes in terms of length of stay, intensive care unit (ICU) admission, surgery, and discharge or in-hospital death.

Statistical analysis
Data were analyzed statistically using IBM SPSS Statistics for Windows, Version 26.0 (IBM Corp., Armonk, NY). To assess the relationship between variables, qualitative data were expressed as numbers and percentages, and the chi-squared test (χ 2 ) was used. Quantitative data were expressed as mean ± standard deviation, and non-parametric variables were tested using the Mann-Whitney test. Multivariate logistic regression analysis was done to assess the independent predictors (risk factors) of death among diabetic patients, and the odds ratio (OR) was determined at a confidence interval of 95%. A p-value of 0.05 was considered statistically significant.
A comparison of comorbidities in patients with DM and those without DM is seen in Table 2. Not surprisingly, DM patients had a significantly increased risk of having dyslipidemia, HTN, CKD, DKA, heart failure, and ICU admissions than the patients without DM (p ≤ 0.05). Patients without DM had more incidence of acute abdomen and malignancy (p ≤ 0.05).  A comparison of comorbidities in type 1 vs. type 2 diabetes patients is depicted in Table 3. HTN, dyslipidemia, CKD, heart failure, stroke, acute abdomen, and malignancy were significantly higher in patients with type 2 diabetes (p ≤ 0.05) than in the patients with type 1 diabetes. Patients with type 1 diabetes had more DKA (p ≤ 0.05), which was expected.      N.B.: Wald = Wald test ("Wald" column) is used to determine the statistical significance of each of the independent variables. B = The regression slope or unstandardized coefficient and is the amount by which we predict that SciSore changes for an increase of one unit in wealth.

Discussion
DM is a rapidly increasing serious health problem that affects the global population. The prevalence of DM in KSA has increased 10-fold in the last 30 years [3]. This increase is reflected in our hospital admissions.
Our study is one of the most comprehensive to date that describes the characteristics of hospitalized patients with and without DM. Overall, dyslipidemia, HTN, CKD, DKA, heart failure, and ICU admission were significantly higher in patients with diabetes as compared to patients without diabetes. In addition to diabetes, these factors increased the risk of hospitalization and longer hospital stays as supported by multiple previous reports [2,7,8].
In the present study, nearly half of the total admissions to the medical unit were patients with DM. This high proportion conveys the impact of diabetes on our community. A similar study in 2000 by Akbar et al. in our hospital reviewed 1006 admitted patients to the medical unit and showed only 17% prevalence of diabetic patients [1]. This remarkable increase in numbers is an alarming sign of a major health crisis, which necessitates prompt additional action to promote comprehensive control programs to prevent the further increase in the diabetic population, harm, and financial burden to the country. Another study from Kuwait Al-Sabah Hospital in 2010 by Al-Adsani et al. showed a 40.6% prevalence of diabetic patients hospitalized. This result is similar to our results [9].
Most of our patients had type 2 diabetes (84.7%), which can be explained by the rapid economic development and lifestyle changes. While only 15.3% of patients admitted had type 1 diabetes, this is more than a three-fold increase from the previous study at the same institution that found only 2% of the patients admitted had type 1 diabetes [1]. In our study, most of the patients (41.3%) were on insulin therapy, which provides an insight into their average HbA1c levels. Furthermore, 31.4% of DM patients used oral antihyperglycemic agents (OAHs), and 19% required insulin in addition to OAHs. Recent guidelines recommend glucagon-like peptide 1 receptor agonists early in the disease course for high-risk patients, but only 0.5% of patients in our study with type 2 diabetes were using this therapy [10].
Unfortunately, 7.3% of DM patients were not receiving any medications related to diabetes, which indicates a poor level of community awareness about diabetes, its complications, and the importance of being on a proper treatment regimen. Only a few DM patients (0.7%) were trying to control their blood glucose using diet alone; a similar proportion was reported by a previous study [11]. In our study, only 31.6% of patients with diabetes had good control with HbA1c < 7. In 2019, a study on outpatient diabetes treatment in our hospital also showed high numbers of poorly controlled diabetes in this population (68.31%) [12].
Patients with diabetes and HTN represented 73.2% of our study population. A study from China on hospitalized older patients with DM also reported a high prevalence of HTN (64.4%) [13]. Another study in older adults with DM also showed a high prevalence of HTN (81.9%) [14]. The prevalence of dyslipidemia among diabetic patients was 43.1%, which was lower than the incidence of dyslipidemia reported in a previous study from the northern region of KSA (66%) [15]. That same study showed that 39.0% of patients with DM had specifically high LDL cholesterol (LDL-C) levels [15]. Lipid profile levels in patients with DM and those without were not significantly different. A study in China showed that 61.1% of diabetes patients had LDL levels < 100 mg/dL [16]. Another report from Nepal demonstrated almost similar results, with 56.3% of DM patients having target LDL levels [17].
Of our diabetic patients, 9.5% had known ESRD on regular dialysis, and 6.8% had new renal failure. A study in the United States on DM patients showed that CKD prevalence was 43.5% [18]. In our study, 52.8% of patients with ESRD were on dialysis. An earlier study in the United Arab Emirates found that 44.0% of patients had moderately increased albuminuria [19]. Another US study showed the prevalence of elevated urine albumin excretion (i.e., >30 mg/g) to be 32.2% [18]. In KSA, a study on dialysis patients at one center in Tabuk found that diabetic nephropathy was the most common cause of ESRD, accounting for 30.4% of cases [20]. The prevalence of nephropathy associated with diabetes is very high in the MENA region [21].
According to our study, the most common reason for admission and risk factors in type 2 DM was dyslipidemia, followed by heart failure. DM is known as a major risk factor for cardiovascular events. These issues are caused by impaired glucose metabolism, and the resultant hypoglycemia or hyperglycemia increases the risk of arrhythmias, sudden death, or other cardiovascular events [22][23][24]. A study demonstrated that the risk of sudden cardiac death was at least two-fold higher in diabetic patients compared to those without diabetes [25]. Another study found that renal failure was the most common cause of admission among diabetic patients [26]. COVID-19 pneumonia was another reason for admission among patients with DM in our study, given that COVID-19 is often more serious in people with different comorbidities. Other studies reported that sepsis was the most common cause of admission among diabetic patients [27].
When we compared hospitalization in DM and non-DM patients, DM patients had longer hospital stays. This result aligns with a previous study [26]. Metabolic derangements, DM severity, and associated complications are predictors for longer hospital stays and mortality [26]. We found no significant association between death and DM, which contrasts with a previous study during the COVID-19 pandemic that found a higher mortality rate among patients with DM [28]. On multivariate logistic regression analysis to assess the risk factors of death among diabetic patients, low hemoglobin levels, dyslipidemia, pneumonia, sepsis, and ICU admission were independent predictors of death among diabetic hospitalized patients. A previous study reported that a history of diabetes was associated with worse outcomes in cardiomyopathy patients and was a predictor of mortality [29].