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The American Journal of Managed Care April 2018
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Progress of Diabetes Severity Associated With Severe Hypoglycemia in Taiwan
Edy Kornelius, MD; Yi-Sun Yang, MD; Shih-Chang Lo, MD; Chiung-Huei Peng, DDS, PhD; Yung-Rung Lai, PharmD; Jeng-Yuan Chiou, PhD; and Chien-Ning Huang, MD, PhD
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Progress of Diabetes Severity Associated With Severe Hypoglycemia in Taiwan

Edy Kornelius, MD; Yi-Sun Yang, MD; Shih-Chang Lo, MD; Chiung-Huei Peng, DDS, PhD; Yung-Rung Lai, PharmD; Jeng-Yuan Chiou, PhD; and Chien-Ning Huang, MD, PhD
Rapid progression of diabetes complications was associated with higher risk of severe hypoglycemia.
Strengths and Limitations

This study has several strengths, most notably its large sample size and long-term follow-up. Our data are representative of Taiwan’s general population. To minimize the risk of selection bias and overdiagnosis of severe hypoglycemia, we included only patients who required hospitalization or an ED visit with a primary diagnosis of hypoglycemia. 

The potential limitations of this study should also be noted. First, because the NHIRD is primarily maintained for reimbursement purposes, there were no data on patients’ personal information, such as smoking history, body weight, and body mass index; laboratory data, including glucose level, glycated hemoglobin, and lipid profile; and dosage of medications, such as insulin, which may each potentially influence the risk of hypoglycemia. Second, patients with self-reported severe hypoglycemia who did not have an ED visit or hospital admission were not included in this study. Third, the retrospective nature of the study itself may have potentially resulted in selection bias. Finally, this study included only Taiwanese patients, and thus the results might not be generalizable to other populations.

Because the data set used in the present study was derived from the whole population without applying a sampling procedure, potential selection bias related to sampling error was not a concern. Although disease diagnosis might have been misclassified, the likelihood of such an occurrence was low because miscategorized diagnoses influence reimbursement, which would not be tolerated by hospitals and clinics. Taiwan’s NHI program also conducts stringent monitoring of claims and imposes strict penalties to avoid overdiagnosis and prevent financial irregularities.


The current guideline of the American Diabetes Association recommends frequent self-monitoring of blood glucose for patients receiving intensive insulin treatment (multiple-dose insulin or insulin pump) to monitor and prevent hypoglycemia. Patients should receive education to increase their awareness of certain situations that might increase the risk of hypoglycemia, such as vigorous exercise, fasting for medical tests or procedures, and during sleep.27

Finally, this study demonstrated that patients with rapid progression of diabetes complications had a higher risk of developing severe hypoglycemia. Therefore, it is important for treating physicians to slow the progression of diabetes complications and identify patients with increases in aDCSI score per year. At-risk patients should be given proper hypoglycemia education, prevention, and treatment. 


The authors thank Yu-Hsun Wang of Chung Shan Medical University Hospital for his support and contribution. 

The interpretation and conclusions contained herein do not represent those of the Bureau of National Health Insurance, the Ministry of Health and Welfare, or the National Health Research Institutes.

Author Affiliations: Division of Endocrinology and Metabolism, Department of Internal Medicine (EK, Y-SY, S-CL, C-NH), and Department of Pharmacy (Y-RL), Chung Shan Medical University Hospital, Taichung, Taiwan; School of Health Policy and Management (J-YC), Institute of Medicine of Chung Shan Medical University (EK, Y-SY, S-CL, C-NH), Taichung, Taiwan; Institute of Biotechnology, HungKuang University (C-HP), Taichung, Taiwan.

Source of Funding: This work was supported by grants from the Chung Shan Medical University Hospital (CSH-2013-C-002).

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article. 

Authorship Information: Concept and design (EK, Y-SY, S-CL, C-HP, Y-RL, J-YC, C-NH); acquisition of data (EK, Y-SY, S-CL, C-HP, Y-RL, J-YC, C-NH); analysis and interpretation of data (EK, Y-SY, S-CL, C-HP, Y-RL, J-YC, C-NH); drafting of the manuscript (C-NH); critical revision of the manuscript for important intellectual content (EK, Y-SY, S-CL, C-HP, C-NH); statistical analysis (EK, Y-SY, S-CL, Y-RL, J-YC, C-NH); provision of patients or study materials (Y-RL, J-YC); obtaining funding (EK, Y-SY, S-CL, Y-RL, J-YC, C-NH); administrative, technical, or logistic support (EK, Y-SY, S-CL, Y-RL, J-YC, C-NH); and supervision (J-YC, C-NH). 

Address Correspondence to: Chien-Ning Huang, MD, PhD, or Jeng-Yuan Chiou, PhD, Chung Shan Medical University Hospital, 110th, 1st Section, Jianguo North Rd, South District, Taichung, Taiwan. Email:

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