[Prognostic factors in patients admitted with type 2 diabetes in Internal Medicine Services: hospital mortality and readmission in one year (DICAMI study)]

Hospital Outcomes of Adult Diabetic Patients by Glycated Hemoglobin Level in Nonsurgical Pathology in a High-Complexity Institution

Recent evidence supports the relationship between in-hospital hyperglycemia and inpatient complications. Besides, glycated hemoglobin (HbA1c) can predict the clinical course of patients with type 2 diabetes mellitus (DM2) during hospital stays. This study aimed to assess the relationship between HbA1c levels and inpatient outcomes. Type 2 diabetes mellitus patients with age greater than 18 years, hospital length of stay greater than 24 hours, and one HbA1c report during their in-hospital management were included. All the electronic care records of patients admitted at the Clinical Versalles, a high-volume institution, in Manizales-Colombia were revised. The following variables were considered: hospital length of stay, diagnoses at the arrival, complications, capillary glucose levels, and treatment at discharge. Variables were categorized by HbA1c levels: group 1 = ⩽ 7%, group 2 = 7.01% to 8.5%, group 3 = 8.51% to ⩽10% and group 4 = >10%. There were a total of 232 patients. Average age was 69.7 years, mean HbA1c was 7.19 ± 2.03, average body mass index (BMI) was 28.8 ± 5.6. About HbA1c, 146 (62.9%) had ⩽7.5%. The most frequent admission diagnosis was by cardiovascular diseases. Average hospitalization was 7.5 ± 5.7 days. There was no relationship between the levels of HbA1c with hospital stays, inpatient complications, or readmissions. Infections and respiratory diseases were more common conditions related to higher HbA1c levels, especially when these were 8.5%. In diabetic patients with nonsurgical diseases and high HbA1c levels, there was no association with clinical complications, length of stay, readmissions, or in-hospital mortality, but changes in treatment at discharge were observed.

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.

Derivation and validation of a predictive model for the readmission of patients with diabetes mellitus treated in internal medicine departments

OBJECTIVES

We developed a predictive model for the hospital readmission of patients with diabetes. The objective was to identify the frail population that requires additional strategies to prevent readmissions at 90 days.

METHODS

Using data collected from 1977 patients in 3 studies on the national prevalence of diabetes (2015-2017), we developed and validated a predictive model of readmission at 90 days for patients with diabetes.

RESULTS

A total of 704 (36%) readmissions were recorded. There were no differences in the readmission rates over the course of the 3 studies. The hospitals with more than 500 beds showed significantly (p=.02) higher readmission rates than those with fewer beds. The main reasons for readmission were infectious diseases (29%), cardiovascular diseases (24) and respiratory diseases (14%). Readmissions directly related to diabetic decompensations accounted for only 2% of all readmissions. The independent variables associated with hospital readmission were patient's age, degree of comorbidity, estimated glomerular filtration rate, degree of disability, presence of previous episodes of hypoglycaemia, use of insulin in treating diabetes and the use of systemic glucocorticoids. The predictive model showed an area under the ROC curve (AUC) of 0.676 (95% confidence interval [95% CI] 0.642-0.709; p=.001) in the referral cohort. In the validation cohort, the model showed an AUC of 0.661 (95% CI 0.612-0.710; p=.001).

CONCLUSION

The model we developed for predicting readmissions for hospitalised patients with type 2 diabetes helps identify a subgroup of frail patients with a high risk of readmission.

Efficacy and feasibility of basal-bolus insulin regimens and a discharge-strategy in hospitalised patients with type 2 diabetes--the HOSMIDIA study

AIMS

Guidelines recommend use of basal-bolus insulin in hospitalised patients with hyperglycaemia, but information about implementation and medication reconciliation at discharge is scarce. The HOSMIDIA study evaluated a management program involving basal-bolus insulin and an algorithm for medication reconciliation at discharge in non-critically ill hospitalised patients with type 2 diabetes in clinical practice.

METHODS

HOSMIDIA was a prospective, observational study performed during routine clinical practice at 15 Spanish hospitals during hospitalisation, with follow-up 3 months postdischarge. Study patients (n = 134) received a basal-bolus regimen with insulin glargine during hospitalisation and treatment at discharge was adjusted according to a simple algorithm. The control group (n = 62) included patients with similar characteristics hospitalised during the month before study initiation and had no follow-up after discharge.

RESULTS

Compared with control subjects, patients in the prospective study achieved lower mean total (167.7 ± 41.1 vs. 190.5 ± 53.3 mg/dl) preprandial (164.2 ± 42.4 vs. 189.6 ± 52.6 mg/dl; p < 0.001) and fasting (137.0 ± 42.2 vs. 165.8 ± 56.5 mg/dl) blood glucose levels while hospitalised, without increased hypoglycaemic episodes (17.7% vs. 19.3% patients). In the prospective study, glycaemic control improved from admission to discharge, with control maintained 3 months after discharge. The main treatment modification at discharge compared with admission was addition of basal insulin, and treatment at discharge was maintained at 3 months in 89% of patients.

CONCLUSION

The HOSMIDIA study confirmed that management of hyperglycaemia with basal-bolus insulin is feasible and effective in routine clinical practice, and that a simple strategy facilitating the reconciliation of medication on discharge can improve glycaemic control postdischarge.

Predictors of rehospitalization in patients admitted with heart failure in Abeokuta, Nigeria: data from the Abeokuta heart failure registry

OBJECTIVE

We sought, for the first time, to examine the rate and predictors of hospital readmission in patients discharged after an episode of heart failure (HF) in Nigeria.

METHODS

This was a hospital-based, prospective, observational study that used the data from the Abeokuta HF Registry.

RESULTS

Overall, 1.53% (95% confidence interval [CI] 0.58-4.02) and 12.2% (95% CI 8.88-16.8) of patients were re-hospitalized at least once within 30 days and 6 months, respectively (5.3% had multiple readmissions); the latter comprised 21/138 men (15.2%) and 11/124 (8.9%) women. A total of 11 (4.2%) died (all of whom had been rehospitalized). Worsening HF (24 cases, 75%) was the commonest reason for readmission. Among others, factors associated with rehospitalization included presence of mitral regurgitation (odds ratio [OR] 2.37, 95% CI 1.26-4.46), age ≥ 60 years (OR 2.04, 95% CI 0.96-3.29), presence of tricuspid regurgitation (OR 1.77, 95% CI 0.86-3.61), and presence of atrial fibrillation (OR 1.34, 95% CI 0.59-3.03). However, on an adjusted basis, only female sex (adjusted OR 0.33, 95% CI 0.14-0.79; P = .014 vs male) and body mass index <19 kg/m² (adjusted OR 3.74, 95% CI 1.15-12.16; P = .028 vs ≥ 19 kg/m²) were independent correlates of readmission during 6 months' follow-up.

CONCLUSIONS

HF rehospitalization within 6 months' follow-up occurred in ∼12% of our cohort living an environment where HF etiology is predominately nonischemic and the HF population is relatively younger. Higher rates of readmission were noted in those with older age, lower body mass index, low literacy, lower serum sodium level, and presence of atrial fibrillation, renal dysfunction, and valvular dysfunction.

The effect of diabetes on hospital readmissions

Hospital readmission is an important contributor to total medical expenditures and is an emerging indicator of quality of care. Diabetes, similar to other chronic medical conditions, is associated with increased risk of hospital readmission. Risk factors include previous hospitalization, extremes in age, and socioeconomic barriers. Preliminary studies suggest that acute and/or chronic glycemic control may be of importance when diabetes is the primary diagnosis or when it is a comorbidity. Very limited evidence from prospective randomized controlled trials aimed at improving glycemic control is available. However, whether one concludes that inpatient or outpatient glycemic control is partly responsible for reduced hospitalizations, attention to glycemic control in the hospital may facilitate sustained glycemic control post-discharge. Limited prospective and retrospective evidence suggest that the involvement of a diabetes specialist team may improve readmission rates, but attention to more generalized comprehensive approaches may also be worthwhile. Prospective interventional studies targeting interventions for improving glycemic control are needed to determine whether glycemic control impacts readmission rates.

[Consensus document on the management after hospital discharge of patient with hyperglycaemia]

The present document intends to adapt the general recommendations set up in a consensus to elaborate the hospital discharge report in medical specialties to the specific needs of the hospitalized diabetic population. Diabetes is an illness with a very high health cost, being the global risk of death in people with diabetes almost double than in non-diabetes people, justifying the fact that diabetes constitutes one of the most frequent diagnoses in hospitalized patients and the growing interest upon hyperglycaemia management during hospitalization and at discharge. To set up an adequate treatment plan at discharge suitable for each patient, the most important elements to take into account are the etiology and prior hyperglycaemia treatment, the patient's clinical situation and the degree of glycaemia control. Due to instability of glycaemia control, it is also needed to anticipate the educational needs for each patient, as well as to set up the monitoring schedule and follow-up at discharge, and an adequate treatment plan at discharge.

Relationship between glycemic control and readmission rates in patients hospitalized with congestive heart failure during implementation of hospital-wide initiatives

OBJECTIVE

To determine the relationship between inpatient glycemic control and hospital readmission in patients with congestive heart failure (CHF).

METHODS

We used an electronic data collection tool to identify patients with a discharge diagnosis of CHF who underwent point-of-care glucose assessments. Timeweighted mean glucose (TWMG), hemoglobin A1c, and glycemic lability index (GLI) served as glycemic indicators, and readmission for CHF was determined at 30 days and between 30 and 90 days.

RESULTS

The analysis included 748 patients. After adjustment for significant covariates, log-transformed increasing TWMG (odds ratio 3.3; P = .03) and log-transformed hemoglobin A1c (odds ratio 5.5; P = .04) were independently associated with higher readmission for CHF between 30 and 90 days, but not by 30 days. Renal disease, African American race, and year of hospital admission were also significantly associated with readmission, but GLI was not. There was no significant difference in TWMG when analyzed on the basis of race or renal status. We noted a decrease in TWMG (P = .004) and a trend for reduction in readmission rates between 30 and 90 days (P = .06) after hospital-wide interventions were implemented to improve glycemic control, but no significant difference was detected in GLI or hypoglycemia.

CONCLUSION

Increasing glucose exposure, but not glycemic variability, was associated with higher risk of readmission between 30 and 90 days in patients with CHF. Prospective studies are needed to confirm or refute these results.