Hospital Readmissions among Commercially Insured and Medicare Advantage Beneficiaries with Diabetes and the Impact of Severe Hypoglycemic and Hyperglycemic Events

BACKGROUND

Hospital readmission is common among patients with diabetes. Some readmissions, particularly for hypoglycemia and hyperglycemia, may be avoidable with better care transitions and post-discharge management.

OBJECTIVE

To ascertain the most common reasons and risk factors for readmission among adults with diabetes, with specific consideration of severe dysglycemia.

DESIGN

Retrospective analysis of data from the OptumLabs Data Warehouse, an administrative data set of commercially insured and Medicare Advantage beneficiaries across the U.S.

PARTICIPANTS

Adults ≥18 years of age with diabetes, discharged from a hospital between January 1, 2009, and December 31, 2014 (N = 342,186).

MAIN MEASURES

Principal diagnoses and risk factors for 30-day unplanned readmissions, subset as being for severe dysglycemia vs. all other causes.

KEY RESULTS

We analyzed 594,146 index hospitalizations among adults with diabetes: mean age 68.2 years (SD, 13.0), 52.9% female, and 67.8% white. The all-cause 30-day readmission rate was 10.8%. Heart failure was the most common cause for index hospitalization (5.5%) and readmission (8.9%). Severe dysglycemia accounted for 2.6% of index hospitalizations (48.1% hyperglycemia, 50.4% hypoglycemia, 1.5% unspecified) and 2.5% of readmissions (38.3% hyperglycemia, 61.0% hypoglycemia, 0.7% unspecified). Younger patient age, severe dysglycemia at index or prior hospitalization, and the Diabetes Complications Severity Index (DCSI) were the strongest risk factors predisposing patients to severe dysglycemia vs. other readmissions. Prior episodes of severe dysglycemia and the DCSI were also independent risk factors for other-cause readmissions, irrespective of the cause of the index hospitalization.

CONCLUSIONS

Adults with diabetes are hospitalized and readmitted for a wide range of health conditions, and hospitalizations for severe hypoglycemia and hyperglycemia remain common, with high rates of recurrence. Severe dysglycemia is most likely to occur among younger patients with multiple diabetes complications and prior history of such events.

Trends in Omalizumab Utilization for Asthma: Evidence of Suboptimal Patient Selection

BACKGROUND

Utilization trends of omalizumab, a first-in-its-class asthma biologic approved in 2003 for individuals not controlled by inhaled corticosteroids (ICSs), may reveal lessons in patient selection.

OBJECTIVE

To describe utilization patterns for omalizumab since its introduction in 2003, with a focus on patient-level characteristics of patients for whom omalizumab was initiated.

METHODS

Using a large US database of administrative claims, we identified privately insured and Medicare Advantage beneficiaries with asthma between 2003 and 2015. Characteristics of incident (no omalizumab use in the previous 12 months) and prevalent users of omalizumab for asthma were described and omalizumab use trends graphed. A comparison cohort (1:5 matching proportion) of nonomalizumab users was compared with incident omalizumab users on demographic characteristics, medication adherence (medication possession ratio [MPR]) for ICSs and/or ICS/long-acting β-agonist (ICS-LABA), exacerbation frequency, and asthma control in the 6 months before omalizumab initiation.

RESULTS

We identified 7,658 prevalent and 3,399 incident omalizumab users. Omalizumab incidence peaked in the second quarter of 2004 at 0.65 per 1,000 individuals with asthma, whereas prevalence peaked in the fourth quarter of 2006 at 3.22; as of fourth quarter 2015, rates were 0.14 and 1.96, respectively. In the 12 months before omalizumab initiation, 72.5% had low adherence (MPR ≤ 0.75) and 48.6% had very low adherence (MPR ≤ 0.5) to ICSs and/or ICS-LABA. In the period 2003 to 2015, the mean number of exacerbations in the 12 months before incident use ranged from 1.50 to 2.11 and the proportion that had poor asthma control (≥3 rescue inhalers dispensed) ranged from 54% to 67%. Incident omalizumab users were less likely to have good asthma control than the matched cohort of nonusers (adjusted odds ratio, 0.53 [0.48-0.59]).

CONCLUSIONS

Omalizumab use for asthma has been gradually decreasing following a peak shortly after its market availability. Many omalizumab users have low or very low adherence rates for ICSs and/or ICS-LABA in the 12 months before omalizumab initiation.

Increased Computed Tomography Utilization in the Emergency Department and Its Association with Hospital Admission

Introduction

Our goal was to investigate trends in computed tomography (CT) utilization in emergency departments (EDs) and its association with hospitalization.

Methods

We conducted an analysis of an administrative claims database of U.S. privately insured and Medicare Advantage enrollees. We identified ED visits from 2005 through 2013 and assessed for CT use, associated factors, and hospitalization after CT, along with patient demographics. We used both descriptive methods and regression models adjusted for year, age, sex, race, geographic region, and Hwang comorbidity score to explore associations among CT use, year, demographic characteristics, and hospitalization.

Results

We identified 33,144,233 ED visits; 5,901,603 (17.8%) involved CT. Over time, CT use during ED visits increased 59.9%. CT use increased in all age groups but decreased in children since 2010. In propensity-matching analysis, odds of hospitalization increased with age, comorbidities, male sex, and CT use (odds ratio, 2.38). Odds of hospitalization over time decreased more quickly for patients with CT.

Conclusion

CT utilization in the ED has increased significantly from 2005 through 2013. For children, CT use after 2010 decreased, indicating caution about CT use. Male sex, older age, and higher number of comorbidities were predictors of CT in the ED. Over time, odds of hospitalization decreased more quickly for patients with CT.