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

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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.

Introduction

Up to one third of patients with diabetes are hospitalized annually, usually for reasons other than uncontrolled diabetes [1]. Much of the research in this area has focused on appropriate inpatient glycemic management. It has now been established that, notwithstanding the controversy over intensive glycemic control in ICU patients [2], good glycemic control remains an important goal among all hospitalized patients [3] and can be achieved safely in general medical and surgical settings [4], [5].

From a health systems perspective, hospitalization may also offer an opportunity to impact long-term glycemic control. Hospital admission identifies diabetes patients at highest risk for uncontrolled diabetes, complications, and costs [1]. As a group, hospitalized diabetes patients generate 40–50% of the total national inpatient and outpatient costs associated with diabetes in the United States [6]. Better glycemic control is associated with lower hospital admission rates and decreased inpatient costs [7]. The hospital setting, with its concentration of resources, may thus present an opportunity to improve long-term glycemic control and diabetes care as well as lowering post-discharge healthcare costs [8], [9], [10], [11]. The one randomized trial in this field showed improvement in post-discharge glycemic control after inpatient diabetes management, but followed patients for 3 months only [12]. In observational trials with longer follow-up times, hospital admission to address uncontrolled diabetes has been associated with improved post-discharge glycemic control measured by HbA1c [13], [14]. However, these results must be interpreted cautiously as there is a tendency for HbA1c levels to decline in the year following a hospital admission even in the absence of intervention [15]. While these studies support the proposal that that hospital admission may serve as a “window of opportunity” to improve long-term diabetes care [8], [9], there may be drawbacks to this approach, such as the potential risk that intensification of diabetes medication regimens may increase the rate of hypoglycemia after discharge. In addition, the marginal benefit of diabetes teaching in the inpatient setting, when patients are coping with acute illness, is not clear.

The effect of inpatient diabetes management and education aimed at improving long-term glycemic control when patients with uncontrolled diabetes are admitted for non-metabolic reasons has not been studied in a randomized trial. We performed a randomized trial to test the hypothesis that focused inpatient diabetes management, education, and discharge planning would improve glycemic control in patients with type 2 diabetes and hemoglobin A1c (HbA1c) > 7.5% (58 mmol/mol) in the year following discharge.

Section snippets

Study design

The study was a 12-month non-blinded randomized trial conducted on general medical and surgical wards of a tertiary care hospital (Massachusetts General Hospital, Boston, MA). The objective was to determine whether an inpatient diabetes management, education, and discharge transition (IDMET) program, including medication titration and augmented diabetes self-management education while subjects were hospitalized, followed by facilitated transition to outpatient care, could improve long term

Results

Of the 1420 initially screened patients who met HbA1c eligibility criteria, the majority (n = 745) were too ill to participate in the trial, while others (n = 300) were excluded if they could not speak English, had an endocrinology consult prior to screening, or resided out-of-state. Overall, 73 patients were eligible for the trial, and 31 (42%) consented to enroll (see CONSORT diagram, Fig. 1). Enrollment was closed after 13 months of recruitment.

All 15 subjects assigned to the IDMET group

Discussion

This is the first randomized trial to study the impact of inpatient diabetes management, education, and discharge transition planning on glycemic control up to 1 year after hospital discharge. While the intervention had little impact in patients treated with insulin prior to hospital admission, it was beneficial in insulin-naïve patients. Most of these patients initiated insulin, learned to administer and manage it, and had the dose titrated while they were in the hospital; their transition

Conflict of interest

The authors declare that they have no conflict of interest.

Author's contributions

DW conceived of the project and designed the study with assistance from DN and ML. DW, CB, EC, and ML executed the study. SR managed the data and assisted with some statistical analyses. DW performed the remainder of the data analysis. DW drafted the manuscript. All authors reviewed and edited the manuscript. DW had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Acknowledgements

We are grateful to Emily Boykin APRN CDE, formerly of the MGH Diabetes Center, Tiffany Soper APRN CDE of the MGH Diabetes Center, and Richard Pompei RN of MGH for help with initiation and conduct of the trial and to Hui Zheng PhD of MGH for statistical consultation.

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  • Cited by (0)

    Preliminary results of this trial were published in abstract form at the Endocrine Society conference, ENDO 2011, in Boston, MA on June 4, 2011 and presented orally as part of a presentation titled “Effect of inpatient diabetes management on outpatient control: Implications for inpatient staff” at the American Diabetes Association Scientific Sessions in Philadelphia, PA on June 12, 2012.

    ☆☆

    This study was funded by and DJW is supported by an NIDDK Career Development Award (K23 DK 080 228). DMN is funded by the Charlton Fund for Innovative Diabetes Research.

    ClinicalTrials.gov: NCT00869362.

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