Impact of inpatient diabetes management, education, and improved discharge transition on glycemic control 12 months after discharge

Deborah J Wexler, Catherine C Beauharnais, Susan Regan, David M Nathan, Enrico Cagliero, Mary E Larkin, Deborah J Wexler, Catherine C Beauharnais, Susan Regan, David M Nathan, Enrico Cagliero, Mary E Larkin

Abstract

Aim: To determine whether inpatient diabetes management and education with improved transition to outpatient care (IDMET) improves glycemic control after hospital discharge in patients with uncontrolled type 2 diabetes (T2DM).

Methods: Adult inpatients with T2DM and HbA1c > 7.5% (58 mmol/mol) admitted for reasons other than diabetes to an academic medical center were randomly assigned to either IDMET or usual care (UC). Linear mixed models estimated treatment-dependent differences in the change in HbA1c (measured at 3, 6, and 12 months) from baseline to 1-year follow-up.

Results: Thirty-one subjects had mean age 55 ± 12.6 years, with mean HbA1c of 9.7 ± 1.6% (82 ± 18 mmol/mol). Mean inpatient glucose was lower in the IDMET than in the UC group (176 ± 66 versus 195 ± 74 mg/dl [9.7 versus 10.8 mmol/l], P = 0.001). In the year after discharge, the average HbA1c reduction was greater in the IDMET group compared with the UC group by 0.6% (SE 0.5%, [7 (SE 5)mmol/mol], P = 0.3). Among patients newly discharged on insulin, the average HbA1c reduction was greater in the in the IDMET group than in the UC group by 2.4% (SE 1.0%, [25 (SE 11)mmol/mol], P = 0.04).

Conclusions: Inpatient diabetes management (IDMET) substantially improved glycemic control 1 year after discharge in patients newly discharged on insulin; patients previously treated with insulin did not benefit.

Trial registration: ClinicalTrials.gov NCT00869362.

Conflict of interest statement

Disclosure statement: The authors declare that they have no conflict of interest.

Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

Figures

Figure 1. Consort Diagram
Figure 1. Consort Diagram
Figure 2
Figure 2
a. HbA1c up to 12 months after hospital discharge in all subjects. Linear mixed model including fixed effects of treatment group, treatment times visit interaction, and random participant-specific intercepts and slopes over time; P value for overall difference between groups=0.3. b. HbA1c up to 12 months after hospital discharge in patients not treated with insulin prior to hospital admission (“insulin-naïve”). Linear mixed model including fixed effects of treatment group, treatment times visit interaction, and random participant-specific intercepts and slopes over time; P value for overall difference between groups=0.04.
Figure 2
Figure 2
a. HbA1c up to 12 months after hospital discharge in all subjects. Linear mixed model including fixed effects of treatment group, treatment times visit interaction, and random participant-specific intercepts and slopes over time; P value for overall difference between groups=0.3. b. HbA1c up to 12 months after hospital discharge in patients not treated with insulin prior to hospital admission (“insulin-naïve”). Linear mixed model including fixed effects of treatment group, treatment times visit interaction, and random participant-specific intercepts and slopes over time; P value for overall difference between groups=0.04.

References

    1. Menzin J, Korn JR, Cohen J, Lobo F, Zhang B, Friedman M, et al. Relationship between glycemic control and diabetes-related hospital costs in patients with type 1 or type 2 diabetes mellitus. J Manag Care Pharm. 2010;16:264–275.
    1. The NICE-SUGAR Study Investigators. Intensive versus conventional glucose control in critically ill patients. N Engl J Med. 2009;360:1283–1297.
    1. Clement S, Braithwaite SS, Magee MF, Ahmann A, Smith EP, Schafer RG, et al. Management of diabetes and hyperglycemia in hospitals. Diabetes Care. 2004;27:553–591.
    1. Umpierrez GE, Smiley D, Jacobs S, Peng L, Temponi A, Mulligan P, et al. Randomized study of basal-bolus insulin therapy in the inpatient management of patients with type 2 diabetes undergoing general surgery (RABBIT 2 Surgery) Diabetes Care. 2011;34:256–261.
    1. Umpierrez GE, Smiley D, Zisman A, Prieto LM, Palacio A, Ceron M, et al. RAndomized Study of Basal Bolus Insulin Therapy in the inpatient management of patients with type 2 diabetes (RABBIT 2 Trial) Diabetes Care; 2007;30:2181–2186.
    1. Gandra SR, Lawrence LW, Parasuraman BM, Darin RM, Sherman JJ, Wall JL. Total and component health care costs in a non-Medicare HMO population of patients with and without type 2 diabetes and with and without macrovascular disease. J Manag Care Pharm. 2006;12:546–554.
    1. Menzin J, Langley-Hawthorne C, Friedman M, Boulanger L, Cavanaugh R. Potential short-term economic benefits of improved glycemic control: A managed care perspective. Diabetes Care. 2001;24:51–55.
    1. Roman SH, Chassin MR. Windows of opportunity to improve diabetes care when patients with diabetes are hospitalized for other conditions. Diabetes Care. 2001;24:1371–1376.
    1. Braithwaite SS, Magee M, Sharretts JM, Schnipper JL, Amin A, Maynard G. The case for supporting inpatient glycemic control programs now: the evidence and beyond. J Hosp Med. 2008;3:6–16.
    1. Moghissi ES, Korytkowski MT, DiNardo M, Einhorn D, Hellman R, Hirsch IB, et al. American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control. Endocr Pract. 2009;15:353–369.
    1. Levetan CS, Passaro M, Jablonski K, Kass M, Ratner RE. Unrecognized diabetes among hospitalized patients. Diabetes Care. 1998;21:246–249.
    1. Koproski J, Pretto Z, Poretsky L. Effects of an intervention by a diabetes team in hospitalized patients with diabetes. Diabetes Care. 1997;20:1553–1555.
    1. Raccah D, Hanaire-Broutin H, Sert-Langeron C, Brin S, Chabrier G, Fontaine PM, et al. Insulin initiation in type 2 diabetic patients admitted in hospital in France and follow-up at 1 year. Diabetes Metab. 2006;32:244–250.
    1. Gobl CS, Dobes B, Luger A, Bischof MG, Krebs M. Long-term impact of a structured group-based inpatient-education program for intensive insulin therapy in patients with diabetes mellitus. Wien Klin Wochenschr. 2010;122:341–345.
    1. Wei NJ, Grant RW, Nathan DM, Wexler DJ. Effect of hospital admission on glycemic control one year after discharge. Endocr Pract. 2012:1–22.
    1. Wexler DJ, Beauharnais CC, Regan S, Nathan DM, Cagliero E, Larkin ME. Impact of inpatient diabetes management and education on glycemic control 12 months after discharge. Abstract presented at Endocrine Society; June 4, 2011; Boston, MA.
    1. Beauharnais CC, Larkin ME, Zai AH, Boykin EC, Luttrell J, Wexler DJ. Efficacy and cost-effectiveness of an automated screening algorithm in an inpatient clinical trial. Clin Trials. 2012
    1. Welch GW, Jacobson AM, Polonsky WH. The Problem Areas in Diabetes Scale. An evaluation of its clinical utility. Diabetes Care. 1997;20:760–766.
    1. Hayward RA, Manning WG, Kaplan SH, Wagner EH, Greenfield S. Starting insulin therapy in patients with type 2 diabetes: effectiveness, complications, and resource utilization. JAMA. 1997;278:1663–1669.
    1. Harris SB, Kapor J, Lank CN, Willan AR, Houston T. Clinical inertia in patients with T2DM requiring insulin in family practice. Can Fam Physician. 2010;56:e418–e424.
    1. Karter AJ, Subramanian U, Saha C, Crosson JC, Parker MM, Swain BE, et al. Barriers to insulin initiation: The translating research into action for diabetes insulin starts project. Diabetes Care. 2010;33:733–735.
    1. Hernandez AF, Greiner MA, Fonarow GC, Hammill BG, Heidenreich PA, Yancy CW, et al. Relationship between early physician follow-up and 30-day readmission among Medicare beneficiaries hospitalized for heart failure. JAMA. 2010;303:1716–1722.
    1. Phillips CO, Wright SM, Kern DE, Singa RM, Shepperd S, Rubin HR. Comprehensive discharge planning with postdischarge support for older patients with congestive heart failure: A meta-analysis. JAMA. 2004;291:1358–1367.
    1. Rigotti NA, Munafo MR, Stead LF. Smoking cessation interventions for hospitalized smokers: a systematic review. Arch Intern Med. 2008;168:1950–1960.
    1. Peikes D, Chen A, Schore J, Brown R. Effects of care coordination on hospitalization, quality of care, and health care expenditures among Medicare beneficiaries: 15 randomized trials. JAMA. 2009;301:603–618.
    1. Lipska KJ, Wang Y, Kosiborod M, Masoudi FA, Havranek EP, Krumholz HM, et al. Discontinuation of antihyperglycemic therapy and clinical outcomes after acute myocardial infarction in older patients with diabetes. Circ Cardiovasc Qual Outcomes. 2010;3:236–242.
    1. Griffith ML, Boord JB, Eden SK, Matheny ME. Clinical inertia of discharge planning among patients with poorly controlled diabetes mellitus. J Clin Endocrinol Metab. 2012
    1. Cook CB, Seifert KM, Hull BP, Hovan MJ, Charles JC, Miller-Cage V, et al. Inpatient to outpatient transfer of diabetes care: Planning for an effective hospital discharge. Endocr Pract. 2009;15:263–269.
    1. Roland M, Torgerson DJ. What are pragmatic trials? BMJ. 1998;316:285.
    1. Cohen HJ, Feussner JR, Weinberger M, Carnes M, Hamdy RC, Hsieh F, et al. A controlled trial of inpatient and outpatient geriatric evaluation and management. N Engl J Med. 2002;346:905–912.

Source: PubMed

Sponsorzy i współpracownicy

Warunki medyczne

Interwencje lekowe

3
Subskrybuj