The relationship between diabetes mellitus and 30-day readmission rates

15. Diabetes Care in the Hospital: Standards of Medical Care in Diabetes-2020

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc20-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc20-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Diabetes and higher HbA1c levels are independently associated with adverse renal outcomes in inpatients following multiple hospital admissions

OBJECTIVE

To assess the association between glycaemic status prior to the first hospital presentation with developing adverse renal outcomes overtime in patients with multiple hospital re-admissions.

DESIGN

A prospective observational cohort study.

PARTICIPANTS

All inpatients aged ≥54 years admitted between 2013 and 16 to a tertiary hospital.

MAIN OUTCOMES

We prospectively measured HbA1c levels in all inpatients aged ≥54 years admitted between 2013 and 16. Diabetes was defined as prior documented diagnosis of diabetes and/or HbA1c ≥6.5% (47·5 mmol/L). Included patients had ≥ two admissions (at least 90 days apart), baseline estimated glomerular filtration rate (eGFR) >30 ml/min/1·73m² and no history of renal replacement therapy. We assessed several renal outcomes: (a) 50% decline in eGFR; (b) rapid decline in renal function (eGFR decline >5 mL/min/1·73m²/year) and (c) final eGFR<30 ml/min/1·73m².

RESULTS

Of 4126 inpatients with a median follow-up of 465 days (254, 740), 26% had diabetes. The presence of diabetes was associated with higher odds of (a) 50% decline in eGFR (OR = 1·42;95% CI:1·18-1·70;p < 0·001); (b) rapid decline in renal function (OR = 1·40;95%CI:1·20-1·63;p < 0·001), and (c) reaching eGFR<30 ml/min/1.73m² (OR = 1·25;95%CI:1·03-1·53;p < 0·05). Every 1% (11 mmol/L) increase in baseline HbA1c was associated with significantly greater odds of (a) >50% decline in eGFR (OR = 1·07;95% CI:1·01-1·4;p < 0·05) and (b) rapid decline in renal function (OR = 1·11;95% CI:1·05-1·18;p < 0·001).

CONCLUSIONS

In patients with ≥two admissions, the presence of diabetes and higher HbA1c levels were strongly and independently associated with adverse renal outcomes at follow up. Such patients are at high risk of relatively rapid deterioration in renal function and a logical target for structured preventive interventions.

Implementation of machine learning algorithms to create diabetic patient re-admission profiles

BACKGROUND

Machine learning is a branch of Artificial Intelligence that is concerned with the design and development of algorithms, and it enables today's computers to have the property of learning. Machine learning is gradually growing and becoming a critical approach in many domains such as health, education, and business.

METHODS

In this paper, we applied machine learning to the diabetes dataset with the aim of recognizing patterns and combinations of factors that characterizes or explain re-admission among diabetes patients. The classifiers used include Linear Discriminant Analysis, Random Forest, k-Nearest Neighbor, Naïve Bayes, J48 and Support vector machine.

RESULTS

Of the 100,000 cases, 78,363 were diabetic and over 47% were readmitted.Based on the classes that models produced, diabetic patients who are more likely to be readmitted are either women, or Caucasians, or outpatients, or those who undergo less rigorous lab procedures, treatment procedures, or those who receive less medication, and are thus discharged without proper improvements or administration of insulin despite having been tested positive for HbA1c.

CONCLUSION

Diabetic patients who do not undergo vigorous lab assessments, diagnosis, medications are more likely to be readmitted when discharged without improvements and without receiving insulin administration, especially if they are women, Caucasians, or both.

A Restrictive Hemoglobin Transfusion Threshold of Less Than 7 g/dL Decreases Blood Utilization Without Compromising Outcomes in Patients With Hip Fractures

INTRODUCTION

In patients with hip fracture, a transfusion threshold of hemoglobin (Hb) <8 g/dL is associated with similar or better outcomes than more liberal thresholds. Whether a more restrictive threshold of <7 g/dL Hb produces equivalent outcomes in such patients is unknown. The aim of the study was to examine whether a restrictive threshold of <7 g/dL Hb is safe in this population.

METHODS

In January 2015, a blood management program was implemented that uses a restrictive transfusion threshold of <7 g/dL Hb in hemodynamically stable patients and <8 g/dL in patients with symptomatic anemia or a history of coronary artery disease. We identified 498 patients treated for hip fractures from January 2013 through May 2017. We compared perioperative outcomes of 207 patients treated before with those of 291 patients treated after restrictive threshold implementation.

RESULTS

After restrictive threshold implementation, the proportion of patients receiving packed red blood cell (PRBC) transfusions decreased from 51% to 33% (P < 0.001); the mean number of PRBC units transfused per patient decreased by 40% (from 1.1 to 0.7; P < 0.001); inpatient cardiac morbidity decreased from 22.2% to 12.4% (P = 0.004); 30-day readmissions decreased from 14% to 8.6% (P = 0.04); and length of stay was unchanged (P = 0.06). Compared with the prerestrictive threshold cohort, the postrestrictive threshold group had lower odds of transfusion (odds ratio [OR] = 0.42; 95% confidence interval [CI], 0.29 to 0.62); transfusion of >1 unit of PRBCs (OR = 0.34; 95% CI, 0.22 to 0.52); and inpatient cardiac morbidity (OR = 0.45; 95% CI, 0.27 to 0.75). No significant differences were observed in inpatient morbidity, mortality, 30-day readmission, or 90-day survival.

DISCUSSION

A restrictive threshold of <7 g/dL Hb in hemodynamically stable patients with hip fractures is associated with noninferior perioperative outcomes and less blood utilization compared with a threshold of <8 g/dL.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Association of Glucose Concentrations at Hospital Discharge With Readmissions and Mortality: A Nationwide Cohort Study

CONTEXT

Low blood glucose concentrations during the discharge day may affect 30-day readmission and posthospital discharge mortality rates.

OBJECTIVE

To investigate whether patients with diabetes and low glucose values during the last day of hospitalization are at increased risk of readmission or mortality.

DESIGN AND OUTCOMES

Minimum point of care glucose values were collected during the last 24 hours of hospitalization. We used adjusted rates of 30-day readmission rate, 30-, 90-, and 180-day mortality rates, and combined 30-day readmission/mortality rate to identify minimum glucose thresholds above which patients can be safely discharged.

PATIENTS AND SETTING

Nationwide cohort study including 843,978 admissions of patients with diabetes at the Veteran Affairs hospitals 14 years.

RESULTS

The rate ratios (RRs) increased progressively for all five outcomes as the minimum glucose concentrations progressively decreased below the 90 to 99 mg/dL category, compared with the 100 to 109 mg/dL category: 30-day readmission RR, 1.01 to 1.45; 30-day readmission/mortality RR, 1.01 to 1.71; 30-day mortality RR, 0.99 to 5.82; 90-day mortality RR, 1.01 to 2.40; 180-day mortality RR, 1.03 to 1.91. Patients with diabetes experienced greater 30-day readmission rates, 30-, 90- and 180-day postdischarge mortality rates, and higher combined 30-day readmission/mortality rates, with glucose levels <92.9 mg/dL, <45.2 mg/dL, 65.8 mg/dL, 67.3 mg/dL, and <87.2 mg/dL, respectively.

CONCLUSION

Patients with diabetes who had hypoglycemia or near-normal glucose values during the last day of hospitalization had higher rates of 30-day readmission and postdischarge mortality.

VALIDATION AND COMPARISON OF TWO 30-DAY RE-ADMISSION PREDICTION MODELS IN PATIENTS WITH DIABETES

Objective: The objective was to evaluate the 30-day re-admission predictive performance of the HOSPITAL score and Diabetes Early Re-admission Risk Indicator (DERRI^™) in hospitalized diabetes patients. Methods: This was a case-control study in an academic, tertiary center in the United States. Adult hospitalized diabetes patients were randomly identified between January 1, 2014, and September 30, 2017. Patients were categorized into two groups: (1) re-admitted within 30 days, and (2) not re-admitted within 30 days. Predictive performance of the HOSPITAL and DERRI^™ scores was evaluated by calculating receiver operating characteristics curves (c-statistic), Hosmer-Lemeshow goodness-of-fit tests, and Brier scores. Results: A total of 200 patients were included (100 re-admitted, 100 non-re-admitted). The HOSPITAL score had a c-statistic of 0.731 (95% confidence interval [CI], 0.661 to 0.800), Hosmer-Lemeshow test P = .211, and Brier score 0.212. The DERRI^™ score had a c-statistic of 0.796 (95% CI, 0.734 to 0.857), Hosmer-Lemeshow test P = .114, and Brier score 0.212. The difference in receiver operating characteristic curves was not statistically significant between the two scores but showed a higher c-statistic with the DERRI^™ score (P = .055). Conclusion: Both HOSPITAL and DERRI^™ scores showed good predictive performance in 30-day re-admission of adult hospitalized diabetes patients. There was no significant difference in discrimination and calibration between the scores. Abbreviations: CI = confidence interval; DERRI^™ = Diabetes Early Re-admission Risk Indicator; IQR = interquartile range.

Risk factors for readmission of inpatients with diabetes: A systematic review

AIM

We have limited understanding of which risk factors contribute to increased readmission rates amongst people discharged from hospital with diabetes. We aim to complete the first review of its kind, to identify, in a systematic way, known risk factors for hospital readmission amongst people with diabetes, in order to better understand this costly complication.

METHOD

The review was prospectively registered in the PROSPERO database. Risk factors were identified through systematic review of literature in PubMed, EMBASE & SCOPUS databases, performed independently by two authors prior to data extraction, with quality assessment and semi-quantitative synthesis according to PRISMA guidelines.

RESULTS

Eighty-three studies were selected for inclusion, predominantly from the United States, and utilising retrospective analysis of local or regional data sets. 76 distinct statistically significant risk factors were identified across 48 studies. The most commonly identified risk factors were; co-morbidity burden, age, race and insurance type. Few studies conducted power calculations; unstandardized effect sizes were calculated for the majority of statistically significant risk factors.

CONCLUSION

This review is important in assessing the current state of the literature and in supporting development of interventions to reduce readmission risk. Furthermore, it provides an important foundation for development of rigorous, pre-specified risk prediction models.

Retrospective study of inpatient diabetes management service, length of stay and 30-day readmission rate of patients with diabetes at a community hospital

Background: Hospitalized patients with diabetes are at risk of complications and longer length of stay (LOS). Inpatient Diabetes Management Services (IDMS) are known to be beneficial; however, their impact on patient care measures in community, non-teaching hospitals, is unknown.

Objectives: To evaluate whether co-managing patients with diabetes by the IDMS team reduces LOS and 30-day readmission rate (30DR).

Methods: This retrospective quality improvement cohort study analyzed LOS and 30DR among patients with diabetes admitted to a community hospital. The IDMS medical team consisted of an endocrinologist, nurse practitioner, and diabetes educator. The comparison group consisted of hospitalized patients with diabetes under standard care of attending physicians (mostly internal medicine-trained hospitalists). The relationship between study groups and outcome variables was assessed using Generalized Estimating Equation models.

Results: 4,654 patients with diabetes (70.8 ± 0.2 years old) were admitted between January 2016 and May 2017. The IDMS team co-managed 18.3% of patients, mostly with higher severity of illness scores (p < 0.0001). Mean LOS in patients co-managed by the IDMS team decreased by 27%. Median LOS decreased over time in the IDMS group (p = 0.046), while no significant decrease was seen in the comparison group. Mean 30DR in patients co-managed by the IDMS decreased by 10.71%. Median 30DR decreased among patients co-managed by the IDMS (p = 0.048).

Conclusions: In a community hospital setting, LOS and 30DR significantly decreased in patients co-managed by a specialized diabetes team. These changes may be translated into considerable cost savings.

Impact of pharmacotherapeutic education on medication adherence and adverse outcomes in patients with type 2 diabetes mellitus: a prospective, randomized study

AIM

To evaluate the impact of pharmacotherapeutic education on 30-day post-discharge medication adherence and adverse outcomes in patients with type 2 diabetes mellitus (T2DM).

METHODS

The prospective, randomized, single-center study was conducted at the Medical Department of University Hospital Dubrava, Zagreb, between April and June 2018. One hundred and thirty adult patients with T2DM who were discharged to the community were randomly assigned to either the intervention or the control group. Both groups during the hospital stay received the usual diabetes education. The intervention group received additional individual pre-discharge pharmacotherapeutic education about the discharge prescriptions. Medication adherence and occurrence of adverse outcomes (adverse drug reactions, readmission, emergency department visits, and death) were assessed at the follow-up visit, 30 days after discharge.

RESULTS

The number of adherent patients was significantly higher in the intervention group (57/64 [89.9%] vs 41/61 [67.2%]; χ2 test, P=0.003]. There was no significant difference between the groups in the number of patients who experienced adverse outcomes (31/64 [48.4%] vs 36/61 [59.0%]; χ2 test, P=0.236). However, higher frequencies of all adverse outcomes were consistently observed in the control group.

CONCLUSION

Pharmacotherapeutic education of patients with T2DM can significantly improve 30-day post-discharge medication adherence, without a significant reduction in adverse clinical outcomes. ClinicalTrial.gov identification number: NCT03438162.

15. Diabetes Care in the Hospital: Standards of Medical Care in Diabetes-2019

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Risk of hospitalization of elderly rural workers in the state of Rio Grande do Sul

Abstract Objective : To analyze the risk of hospitalization of elderly rural workers in the state of Rio Grande do Sul, Brazil. Method : A cross-sectional, population-based study was carried out of retired rural workers (N=604), over 60 years of age, of both genders, selected by clusters. In order to evaluate the risk of hospitalization, the Probability of Repeated Hospitalization (or PIR) instrument validated and evaluated for Brazil was used. Risk of hospitalization was calculated through logistic regression analysis, and was classified into the following strata: low (<0.300); medium (0.300-0.399); medium-high (0.400-0.499) and high (≥0.500). Results : The rural elderly persons surveyed had a low risk of hospitalization (n=553; 91.6%). There was a predominance of men among the medium to high risk categories (n=42; 82.3%), distributed mainly in the Santa Maria, Sul and Camaquã regions. Conclusion: The results of the present study suggest a low risk of hospitalization among this population, however, there is a need for improved, more profound and robust research into the identification of factors associated with the health specificities of this population.

Predischarge and Postdischarge Risk Factors for Hospital Readmission Among Patients With Diabetes

BACKGROUND

Hospital readmission within 30 days of discharge (30-d readmission) is an undesirable outcome. Readmission of patients with diabetes is common and costly. Most of the studies that have examined readmission risk factors among diabetes patients did not include potentially important clinical data.

OBJECTIVES

To provide a more comprehensive understanding of 30-day readmission risk factors among patients with diabetes based on predischarge and postdischarge data.

RESEARCH DESIGN

In this retrospective cohort study, 48 variables were evaluated for association with readmission by multivariable logistic regression.

SUBJECTS

In total, 17,284 adult diabetes patients with 44,203 hospital discharges from an urban academic medical center between January 1, 2004 and December 1, 2012.

MEASURES

The outcome was all-cause 30-day readmission. Model performance was assessed by c-statistic.

RESULTS

The 30-day readmission rate was 20.4%, and the median time to readmission was 11 days. A total of 27 factors were statistically significant and independently associated with 30-day readmission (P<0.05). The c-statistic was 0.82. The strongest risk factors were lack of a postdischarge outpatient visit within 30 days, hospital length-of-stay, prior discharge within 90 days, discharge against medical advice, sociodemographics, comorbidities, and admission laboratory values. A diagnosis of hypertension, preadmission sulfonylurea use, admission to an intensive care unit, sex, and age were not associated with readmission in univariate analysis.

CONCLUSIONS

There are numerous risk factors for 30-day readmission among patients with diabetes. Postdischarge factors add to the predictive accuracy achieved by predischarge factors. A better understanding of readmission risk may ultimately lead to lowering that risk.

Strategies to Prevent Readmission in High-Risk Patients with Diabetes: the Importance of an Interdisciplinary Approach

PURPOSE OF REVIEW

Patients with diabetes are known to have higher 30-day readmission rates compared to the general inpatient population. A number of strategies have been shown to be effective in lowering readmission rates.

RECENT FINDINGS

A review of the current literature revealed several strategies that have been associated with a decreased risk of readmission in high-risk patients with diabetes. These strategies include inpatient diabetes survival skills education and medication reconciliation prior to discharge to send the patient home with the "right" medications. Other key strategies include scheduling a follow-up phone call soon after discharge and an office visit to adjust the diabetes regimen. The authors identified the most successful strategies to reduce readmissions as well as some institutional barriers to following a transitional care program. Recent studies have identified risk factors in the diabetes population that are associated with an increased risk of readmission as well as interventions to lower this risk. A standardized transitional care program that focuses on providing interventions while reducing barriers to implementation can contribute to a decreased risk of readmission.

EXTERNAL VALIDATION OF THE DIABETES EARLY RE-ADMISSION RISK INDICATOR (DERRI™)

OBJECTIVE

The Diabetes Early Re-admission Risk Indicator (DERRI^™) was previously developed and internally validated as a tool to predict the risk of all-cause re-admission within 30 days of discharge (30-day re-admission) of hospitalized patients with diabetes. In this study, the predictive performance of the DERRI^™ with and without additional predictors was assessed in an external sample.

METHODS

We conducted a retrospective cohort study of adult patients with diabetes discharged from two academic medical centers between January 1, 2000 and December 31, 2014. We applied the previously developed DERRI^™, which includes admission laboratory results, sociodemographics, a diagnosis of certain comorbidities, and recent discharge information, and evaluated the effect of adding metabolic indicators on predictive performance using multivariable logistic regression. Total cholesterol and hemoglobin A1c (A1c) were selected based on clinical relevance and univariate association with 30-day re-admission.

RESULTS

Among 105,974 discharges, 19,032 (18.0%) were followed by 30-day re-admission for any cause. The DERRI^™ had a C-statistic of 0.634 for 30-day re-admission. Total cholesterol was the lipid parameter most strongly associated with 30-day re-admission. The DERRI^™ predictors A1c and total cholesterol were significantly associated with 30-day re-admission; however, their addition to the DERRI^™ did not significantly change model performance (C-statistic, 0.643 [95% confidence interval, 0.638 to 0.647]; P = .92).

CONCLUSION

Performance of the DERRI^™ in this external cohort was modest but comparable to other re-admission prediction models. Addition of A1c and total cholesterol to the DERRI^™ did not significantly improve performance. Although the DERRI^™ may be useful to direct resources toward diabetes patients at higher risk, better prediction is needed.

ABBREVIATIONS

A1c = hemoglobin A1c; CI = confidence interval; DERRI^™ = Diabetes Early Re-admission Risk Indicator; GEE = generalized estimating equation; HDL-C = high-density-lipoprotein cholesterol; ICD-9-CM = International Classification of Diseases, Ninth Revision, Clinical Modification; LDL-C = low-density-lipoprotein cholesterol.

Inpatient diabetes management by specialized diabetes team versus primary service team in non-critical care units: impact on 30-day readmission rate and hospital cost

OBJECTIVE

We compared the cost-effectiveness of two inpatient diabetes care models: one offered by a specialized diabetes team (SDT) versus a primary service team (PST).

RESEARCH DESIGN AND METHODS

We retrospectively evaluated 756 hospital admissions of patients with diabetes to non-critical care units over 6 months. Out of 392 patients who met the eligibility criteria, 262 were matched 1:1 based on the mean of the initial four blood glucose (BG) values after admission. Primary outcomes were 30-day readmission rate and frequency, hospital length of stay (LOS) and estimated hospital cost. Secondary outcomes included glycemic control and BG variability.

RESULTS

Diabetes complexity and in-hospital complications were significantly higher among patients treated by SDT versus PST. Thirty-day readmission rate to medical services was lower by 30.5% in the SDT group versus the PST group (P<0.001), while 30-day readmission rate to surgical services was 5% higher in the SDT group versus the PST group (P<0.05), but frequency of 30-day readmissions was lower (1.1 vs 1.6 times, P<0.05). LOS in medical services was not different between the two groups, but it was significantly longer in surgical services in SDT (P<0.05). However, LOS was significantly lower in patients who were seen by SDT during the first 24 hours of admission compared with those who were seen after that (4.7 vs 6.1 days, P<0.001). Compliance to follow-up was higher in the SDT group. These changes were translated into considerable cost saving.

CONCLUSIONS

Inpatient diabetes management by an SDT significantly reduces 30-day readmission rate to medical services, reduces inpatient diabetes cost, and improves transition of care and adherence to follow-up. SDT consultation during the first 24 hours of admission was associated with a significantly shorter hospital LOS.

Diabetes and the hospitalized patient : A cluster analytic framework for characterizing the role of sex, race and comorbidity from 2006 to 2011

In the US, one in four adults has two or more chronic conditions; this population accounts for two thirds of healthcare spending. Comorbidity, the presence of multiple simultaneous health conditions in an individual, is increasing in prevalence and has been shown to impact patient outcomes negatively. Comorbidities associated with diabetes are correlated with increased incidence of preventable hospitalizations, longer lengths of stay (LOS), and higher costs. This study focuses on sex and race disparities in outcomes for hospitalized adult patients with and without diabetes. The objective is to characterize the impact of comorbidity burden, measured as the Charlson Weighted Index of Comorbidities (WIC), on outcomes including LOS, total charges, and disposition (specifically, probability of routine discharge home). Data from the National Inpatient Sample (2006-2011) were used to build a cluster-analytic framework which integrates cluster analysis with multivariate and logistic regression methods, for several goals: (i) to evaluate impact of these covariates on outcomes; (ii) to identify the most important comorbidities in the hospitalized population; and (iii) to create a simplified WIC score. Results showed that, although hospitalized women had better outcomes than men, the impact of diabetes was worse for women. Also, non-White patients had longer lengths of stay and higher total charges. Furthermore, the simplified WIC performed equivalently in the generalized linear models predicting standardized total charges and LOS, suggesting that this new score can sufficiently capture the important variability in the data. Our findings underscore the need to evaluate the differential impact of diabetes on physiology and treatment in women and in minorities.