The Association Between Insulin Initiation and Adverse Outcomes After Hospital Discharge in Older Adults: a Population-Based Cohort Study

Inpatient Metformin Utilization and Post-hospitalization Clinical Outcomes: An Observational Cohort Study

BACKGROUND

Metformin is the first-line treatment for diabetes, with multiple long-term benefits. However, there is limited evidence for its use in the inpatient setting, and clinical guidelines have historically recommended holding oral diabetes medications during acute hospitalization. While studies have not found evidence of harm from continuing metformin during hospitalization, withholding may lead to unnecessary insulin prescriptions, which in turn may lead to hypoglycemia events after discharge and other associated complications.

OBJECTIVE

To investigate the association between metformin use during hospitalization and post-hospitalization outcomes.

DESIGN

Observational cohort study from January 2016 to January 2022, emulating a target trial.

PARTICIPANTS

Adults with type 2 diabetes admitted to a Veterans Health Administration hospital for common medical conditions.

INTERVENTIONS

Continuation of an outpatient metformin prescription during hospitalization.

MAIN MEASURES

Hypoglycemia within 90 days of discharge. Secondary outcomes included insulin prescriptions at discharge, 90-day readmissions, and 90-day mortality.

KEY RESULTS

The propensity-matched cohort included 67,162 hospitalizations, equally split between those who did and did not have metformin continued during hospitalization. Within 90 days of hospital discharge, those that received metformin had lower risk of hypoglycemia (1.5% vs 1.8%; OR 0.83, 95% CI 0.73-0.93; p = 0.003), readmissions (29.4% vs 30.6%; OR 0.96, 95% CI 0.92-1.00; p= 0.03), and mortality (6.4% vs 7.4%; OR 0.86, 95% CI 0.80-0.92; p <0.001). Patients receiving metformin also had lower risk of insulin prescriptions at discharge (18.5% vs 20.3%; OR 0.89, 95% CI 0.84-0.95; p<0.001).

CONCLUSIONS

Continuation of metformin during hospitalization for patients with type 2 diabetes was associated with decreased risk of post-hospitalization insulin prescriptions and 90-day hypoglycemia, readmissions, and mortality. These findings question clinical guideline recommendations to hold metformin during hospitalization.

Developing a Diabetes Discharge Order Set for Patients With Diabetes on Insulin

BACKGROUND

Insulin, a high-risk medication, is prone to prescribing errors. Patients with diabetes experience higher hospitalization rates and extended hospital stays. Prescription errors, such as missing orders, inappropriate insulin type, missing instructions, and lack of appropriate intensification of insulin regimens are common issues. This project explored the use of system-based interventions and educational tools to minimize errors and improve the quality of insulin discharge regimens.

METHODS

A needs assessment and baseline chart review were conducted before adapting a diabetes order set obtained from the University of California, San Diego. Subsequent beta testing and broader implementation were followed by repeat chart reviews to assess the impact.

RESULTS

Providers strongly desired an insulin discharge order set, with 98% of those surveyed expressing this preference. Those who were high utilizers of the order set showed increased rates of ordering all supplies (55%), compared with pre-intervention rates (27%). However, no change was observed in the practice of intensifying insulin regimens in patients with uncontrolled diabetes upon discharge.

DISCUSSION

Insulin prescribing is prone to error. A diabetes discharge order set may improve the percentage of patients who receive necessary insulin supplies at discharge and provide educational resources to encourage appropriate insulin regimens at hospital discharge.

Associations Between Implementation of the Caregiver Advise Record Enable (CARE) Act and Health Service Utilization for Older Adults with Diabetes: Retrospective Observational Study

BACKGROUND

The Caregiver Advise Record Enable (CARE) Act is a state level law that requires hospitals to identify and educate caregivers ("family members or friends") upon discharge.

OBJECTIVE

This study examined the association between the implementation of the CARE Act in a Pennsylvania health system and health service utilization (ie, reducing hospital readmission, emergency department [ED] visits, and mortality) for older adults with diabetes.

METHODS

The key elements of the CARE Act were implemented and applied to the patients discharged to home. The data between May and October 2017 were pulled from inpatient electronic health records. Likelihood-ratio chi-square tests and multivariate logistic regression models were used for statistical analysis.

RESULTS

The sample consisted of 2591 older inpatients with diabetes with a mean age of 74.6 (SD 7.1) years. Of the 2591 patients, 46.1% (n=1194) were female, 86.9% (n=2251) were White, 97.4% (n=2523) had type 2 diabetes, and 69.5% (n=1801) identified a caregiver. Of the 1801 caregivers identified, 399 (22.2%) received discharge education and training. We compared the differences in health service utilization between pre- and postimplementation of the CARE Act; however, no significance was found. No significant differences were detected from the bivariate analyses in any outcomes between individuals who identified a caregiver and those who declined to identify a caregiver. After adjusting for risk factors (multivariate analysis), those who identified a caregiver (12.2%, 219/1801) was associated with higher rates of 30-day hospital readmission than those who declined to identify a caregiver (9.9%, 78/790; odds ratio [OR] 1.38, 95% CI 1.04-1.87; P=.02). Significantly lower rates were detected in 7-day readmission (P=.02), as well as 7-day (P=.03) and 30-day (P=.01) ED visits, among patients with diabetes whose identified caregiver received education and training than those whose identified caregiver did not receive education and training in the bivariate analyses. However, after adjusting for risk factors, no significance was found in 7-day readmission (OR 0.53, 95% CI 0.27-1.05; P=.07), 7-day ED visit (OR 0.63, 95% CI 0.38-1.03; P=.07), and 30-day ED visit (OR 0.73, 95% CI 0.52-1.02; P=.07). No significant associations were found for other outcomes (ie, 30-day readmission and 7-day and 30-day mortality) in both the bivariate and multivariate analyses.

CONCLUSIONS

Our study found that the implementation of the CARE Act was associated with certain health service utilization. The identification of caregivers was associated with higher rates of 30-day hospital readmission in the multivariate analysis, whereas having identified caregivers who received discharge education was associated with lower rates of readmission and ED visit in the bivariate analysis.

[Risk factors associated with emergency service re-visits in frailty diabetic patients who consult for hypoglycaemia]

INTRODUCTION AND OBJECTIVES

Emergency department (ED) visits due to hypoglycaemia are frequent in elderly patients. The main objective of the study is to evaluate the risk factors associated to ED re-visits at 90days in elderly patients who visited ED with an episode of hypoglycaemia.

MATERIAL AND METHODS

A retrospective observational study was designed, including elderly diabetic patients (>65years) attended in a fragility area of an ED for an episode of hypoglycaemia. To evaluate the risk factors associated to ED re-visits at 90days a multivariate analysis with logistic regression was performed, including those variables related to comorbidity and antidiabetic treatment with a P<0.2 in a previous univariate analysis.

RESULTS

106 patients were included. %HbA1c value was available in 87 (82.1%) patients. Ten (11.5%) patients presented a value of HbA1c ≤5.5%. Antidiabetic treatment was changed to 63 (59.4%) patients at discharge. Thirty-eight (36.1%) patients re-visited the ED at 90days, 9 for glycaemic alterations. The risk factors associated to 90days ED re-visit were: being man (OR: 3.62 [95%CI: 1.24-10.51)), treatment modified at discharge (OR: 0.31 [0.11-0.91]) and to present an HbA1c value ≤5.5% (OR: 5.33 [1.16-14.51]).

CONCLUSIONS

Fragile patients with diabetes who visit ED for hypoglycaemia present, in high frequency, HbA1c values lower than those recommended, being associated to an increase of ED re-visit risk at 90days.

Intensification of Diabetes Medications at Hospital Discharge and Clinical Outcomes in Older Adults in the Veterans Administration Health System

IMPORTANCE

Transient elevations of blood glucose levels are common in hospitalized older adults with diabetes and may lead clinicians to discharge patients with more intensive diabetes medications than they were using before hospitalization.

OBJECTIVE

To investigate outcomes associated with intensification of outpatient diabetes medications at discharge.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study assessed patients 65 years and older with diabetes not taking insulin who were hospitalized in the Veterans Health Administration Health System between January 1, 2011, and September 28, 2016, for common medical conditions. Data analysis was performed from January 1, 2020, to March 31, 2021.

EXPOSURE

Discharge with intensified diabetes medications, defined as filling a prescription at hospital discharge for a new or higher-dose medication than was being used before hospitalization. Propensity scores were used to construct a matched cohort of patients who did and did not receive diabetes medication intensifications.

MAIN OUTCOMES AND MEASURES

Coprimary outcomes of severe hypoglycemia and severe hyperglycemia were assessed at 30 and 365 days using competing risk regressions. Secondary outcomes included all-cause readmissions, mortality, change in hemoglobin A1c (HbA1c) level, and persistent use of intensified medications at 1 year after discharge.

RESULTS

The propensity-matched cohort included 5296 older adults with diabetes (mean [SD] age, 73.7 [7.7] years; 5212 [98.4%] male; and 867 [16.4%] Black, 47 [0.9%] Hispanic, 4138 [78.1%] White), equally split between those who did and did not receive diabetes medication intensifications at hospital discharge. Within 30 days, patients who received medication intensifications had a higher risk of severe hypoglycemia (hazard ratio [HR], 2.17; 95% CI, 1.10-4.28), no difference in risk of severe hyperglycemia (HR, 1.00; 95% CI, 0.33-3.08), and a lower risk of death (HR, 0.55; 95% CI, 0.33-0.92). At 1 year, no differences were found in the risk of severe hypoglycemia events, severe hyperglycemia events, or death and no difference in change in HbA1c level was found among those who did vs did not receive intensifications (mean postdischarge HbA1c, 7.72% vs 7.70%; difference-in-differences, 0.02%; 95% CI, -0.12% to 0.16%). At 1 year, 48.0% (591 of 1231) of new oral diabetes medications and 38.5% (548 of 1423) of new insulin prescriptions filled at discharge were no longer being filled.

CONCLUSIONS AND RELEVANCE

In this national cohort study, among older adults hospitalized for common medical conditions, discharge with intensified diabetes medications was associated with an increased short-term risk of severe hypoglycemia events but was not associated with reduced severe hyperglycemia events or improve HbA1c control. These findings indicate that short-term hospitalization may not be an effective time to intervene in long-term diabetes management.

Racial Disparities in Post-Acute Home Health Care Referral and Utilization among Older Adults with Diabetes

Racial and ethnic disparities exist in diabetes prevalence, health services utilization, and outcomes including disabling and life-threatening complications among patients with diabetes. Home health care may especially benefit older adults with diabetes through individualized education, advocacy, care coordination, and psychosocial support for patients and their caregivers. The purpose of this study was to examine the association between race/ethnicity and hospital discharge to home health care and subsequent utilization of home health care among a cohort of adults (age 50 and older) who experienced a diabetes-related hospitalization. The study was limited to patients who were continuously enrolled in Medicare for at least 12 months and in the United States. The cohort (n = 786,758) was followed for 14 days after their diabetes-related index hospitalization, using linked Medicare administrative, claims, and assessment data (2014–2016). Multivariate logistic regression models included patient demographics, comorbidities, hospital length of stay, geographic region, neighborhood deprivation, and rural/urban setting. In fully adjusted models, hospital discharge to home health care was significantly less likely among Hispanic (OR 0.8, 95% CI 0.8–0.8) and American Indian (OR 0.8, CI 0.8–0.8) patients compared to White patients. Among those discharged to home health care, all non-white racial/ethnic minority patients were less likely to receive services within 14-days. Future efforts to reduce racial/ethnic disparities in post-acute care outcomes among patients with a diabetes-related hospitalization should include policies and practice guidelines that address structural racism and systemic barriers to accessing home health care services.

A systematic review considering risk factors for mortality of patients discharged from hospital with a diagnosis of diabetes

AIM

To identify known risk factors for mortality for adult patients, discharged from hospital with diabetes.

METHOD

The systematic review was based on the PRISMA protocol. Studies were identified through EMBASE & MEDLINE databases. The inclusion criteria were papers that were published over the last 6 years, in English language, and focused on risk factors of mortality in adult patients with diabetes, after they were discharged from hospitals. This was followed by data extraction "with quality assessment and semi-quantitative synthesis according to PRISMA guidelines".

RESULTS

There were 35 studies identified, considering risk factors relating to mortality for patients, discharged from hospital with diabetes. These studies are distributed internationally. 48 distinct statistically significant risk factors for mortality can be identified. Risk factors can be grouped into the following categories; demographic, socioeconomic, lifestyle, patient medical, inpatient stay, medication related, laboratory results, and gylcaemic status. These risk factors can be further divided into risk factors identified in generalized populations of patients with diabetes, compared to specific sub-populations of people with diabetes.

CONCLUSION

A relatively small number of studies have considered risk factors relating to mortality for patients, discharged from hospital with a diagnosis of diabetes. Mortality is an important outcome, when considering discharge from hospital with diabetes. However, there has only been limited consideration within the research literature.

Predictors of 30-day unplanned hospital readmission among adult patients with diabetes mellitus: a systematic review with meta-analysis

Adult patients with diabetes mellitus (DM) represent one-fifth of all 30-day unplanned hospital readmissions but some may be preventable through continuity of care with better DM self-management. We aim to synthesize evidence concerning the association between 30-day unplanned hospital readmission and patient-related factors, insurance status, treatment and comorbidities in adult patients with DM. We searched full-text English language articles in three electronic databases (MEDLINE, Embase and CINAHL) without confining to a particular publication period or geographical area. Prospective and retrospective cohort and case-control studies which identified significant risk factors of 30-day unplanned hospital readmission were included, while interventional studies were excluded. The study participants were aged ≥18 years with either type 1 or 2 DM. The random effects model was used to quantify the overall effect of each factor. Twenty-three studies published between 1998 and 2018 met the selection criteria and 18 provided information for the meta-analysis. The data were collected within a period ranging from 1 to 15 years. Although patient-related factors such as age, gender and race were identified, comorbidities such as heart failure (OR=1.81, 95% CI 1.67 to 1.96) and renal disease (OR=1.69, 95% CI 1.34 to 2.12), as well as insulin therapy (OR=1.45, 95% CI 1.24 to 1.71) and insurance status (OR=1.41, 95% CI 1.22 to 1.63) were stronger predictors of 30-day unplanned hospital readmission. The findings may be used to target DM self-management education at vulnerable groups based on comorbidities, insurance type, and insulin therapy.

Patterns and predictors of antihyperglycemic intensification at hospital discharge for type 2 diabetic patients not on home insulin

BACKGROUND

Diabetes mellitus is a prevalent condition among hospitalized patients and the inpatient setting presents an opportunity for providers to review and adjust antihyperglycemic medications. We sought to describe practice patterns and predictors of antihyperglycemic intensification (AHI) at hospital discharge for type 2 diabetes mellitus (T2DM) patients not on home insulin.

METHODS

We conducted a retrospective study of adult patients with T2DM receiving either non-insulin antihyperglycemic (NIA) or no antihyperglycemic medications prior to admission who were hospitalized within two hospitals in the Johns Hopkins Health System from December 2015 to September 2016. Mean hospital glucose values and observed vs. individualized target hemoglobin A1C values (based on risk of mortality score) were used to define an indication for AHI. Multivariable logistic regression was used to identify predictors of AHI.

RESULTS

A total of 554 discharges of 475 unique patients were included. An indication for AHI was present in 104 (18.8%) of discharges, and AHI occurred in 30 (28.8%) of these discharges. Higher mean admission BG values and A1C, fewer pre-admission antihyperglycemic agents, involvement of the diabetes service, and admitting service were associated with AHI, while no association was observed with age, sex, race, risk of mortality and severity of illness scores, or length of stay. AHI was not associated with 30-day readmission.

CONCLUSION

An indication for AHI occurs relatively infrequently among hospitalized patients, but when present, AHI occurs in approximately 1 in 3 discharges. AHI appears to be related largely to the degree of hyperglycemia, and diabetes service involvement. Further studies are needed to understand the implications of AHI at hospital discharge on short and long-term outcomes in this population.

Discharge pharmacotherapy for Type 2 diabetic inpatients at two hospitals of different tiers in Zhejiang Province, China

Objects

To look into the discharge pharmacotherapy for type 2 diabetics admitted to two general hospitals of different ranks and inspect current real-world management of discharge pharmacology and its related factors.

Methods

Type 2 diabetics admitted to a tertiary general hospital (Ningbo Medical Treatment Centre Lihuili Hospital, LHLH) or a secondary general hospital (Simen Hospital, SMH) for intensification of their anti-diabetics were included for retrospective analysis. Patients’ demographics, clinical characteristics, admission diabetes therapy and discharge diabetes pharmacology were analyzed and compared among patients in each hospital as well as between two hospitals.

Results

391 patients from LHLH and 164 patients from SMH were included for analyzing. Compared with patients from LHLH, patients from SMH were older, more illiterate and had higher HbA1c concentrations. While there was a nearly equal split of oral anti-diabetes drugs (OADs)-only and Insulin treatment in LHLH’s discharge pharmacotherapy, insulin treatment dominated SMH’s. Basal-and-bolus insulin assumed the majority of SMH’s insulin regimens but only accounted for less than 20% of LHLH’s. The principal discrepancy in OADs-only treatment existed in the utilization of newer classes of OADs. Cost and body mass index (BMI) were the main differentiating factors among OADs-only treatments while duration, BMI and HbA1c differ among insulin treatments at LHLH. Clinical characteristics didn’t significantly differ among OADs-only treatments and HbA1c was the only differentiating factor among insulin treatments at SMH. Overall, hospital, duration, HbA1c, and vascular diseases were main factors that affect discharge pharmacology.

Conclusions

Great disparities exist in the discharge pharmacotherapy at two hospitals. Diabetes management is mostly glucose-oriented at SMH while multifactorial considerations were reflected in LHLH’s discharge pharmacotherapy. Besides differences in patients’ demographics, medication availability and diagnosis of early-stage vascular complications, lack of practical algorithm for discharge management in T2DM may be the underlying deficiency and a key part for future improvement.

Prevalence of Diabetes Medication Intensifications in Older Adults Discharged From US Veterans Health Administration Hospitals

Importance

Elevated blood glucose levels are common in hospitalized older adults and may lead clinicians to intensify outpatient diabetes medications at discharge, risking potential overtreatment when patients return home.

Objective

To assess how often hospitalized older adults are discharged with intensified diabetes medications and the likelihood of benefit associated with these intensifications.

Design, Setting, and Participants

This retrospective cohort study examined patients aged 65 years and older with diabetes not previously requiring insulin. The study included patients who were hospitalized in a Veterans Health Administration hospital for common medical conditions between 2011 and 2013.

Main Outcomes and Measures

Intensification of outpatient diabetes medications, defined as receiving a new or higher-dose medication at discharge than was being taken prior to hospitalization. Mixed-effect logistic regression models were used to control for patient and hospitalization characteristics.

Results

Of 16 178 patients (mean [SD] age, 73 [8] years; 15 895 [98%] men), 8535 (53%) had a preadmission hemoglobin A1c (HbA1c) level less than 7.0%, and 1044 (6%) had an HbA1c level greater than 9.0%. Overall, 1626 patients (10%) were discharged with intensified diabetes medications including 781 (5%) with new insulins and 557 (3%) with intensified sulfonylureas. Nearly half of patients receiving intensifications (49% [791 of 1626]) were classified as being unlikely to benefit owing to limited life expectancy or already being at goal HbA1c, while 20% (329 of 1626) were classified as having potential to benefit. Both preadmission HbA1c level and inpatient blood glucose recordings were associated with discharge with intensified diabetes medications. Among patients with a preadmission HbA1c level less than 7.0%, the predicted probability of receiving an intensification was 4% (95% CI, 3%-4%) for patients without elevated inpatient blood glucose levels and 21% (95% CI, 15%-26%) for patients with severely elevated inpatient blood glucose levels.

Conclusions and Relevance

In this study, 1 in 10 older adults with diabetes hospitalized for common medical conditions was discharged with intensified diabetes medications. Nearly half of these individuals were unlikely to benefit owing to limited life expectancy or already being at their HbA1c goal.