BACKGROUND Avoidable hospital readmission is a focus of quality improvement efforts. The effectiveness of individual elements of the standard discharge process in reducing rehospitalisation is unknown. METHODS The authors conducted a case-control study of 1039 patients experiencing rehospitalisation within 30 days of discharge and 981 non-rehospitalised patients matched on admission diagnosis, discharge disposition, and severity of illness. In separate models for each discharge process component, the authors measured the relationship between readmission and discharge summary completion, contents of discharge summary, completion of discharge instructions, contents of discharge instructions, presence of caregiver for discharge instruction, completion of medication reconciliation, and arrangement of ambulatory follow-up prior to discharge. RESULTS Adjusting for patient and hospital characteristics, including severity of illness and discharge disposition, the study failed to find an association between readmission and most components of the discharge process. There was no association between readmission and medication reconciliation, transmission of discharge summary to an outpatient physician, or documentation of any specific aspect of discharge instruction. Associations were found between readmission and discharge with followup arranged (adjusted odds ratio (OR) 1.21; 95% CI 1.05 to 1.37) and increasing number of medicines (adjusted OR 1.02; 95% CI 1.01 to 1.04). CONCLUSIONS Documentation of discharge process components in the medical record may not reflect actual discharge process activities. Alternatively, mandated discharge processes are ineffective in preventing readmission. The observed absence of an association between discharge documentation and readmission indicates that discharge quality improvement initiatives should target metrics of discharge process quality beyond improving rates of documentation.
We report a case of acute, painful polyneuropathy in a boy with newly diagnosed type 1 diabetes mellitus associated with a precipitous drop in hemoglobin A1c. After initiation of insulin, the patient's hemoglobin A1c dropped from 14.1 to 7.6%, and he developed severe pain in his feet, which prevented him from walking. Nerve conduction studies were consistent with mild to moderate sensorimotor peripheral neuropathy. Initially, he required opiate analgesics for pain control. Three months after presentation, the patient showed dramatic improvement and regained his ability to walk. Although not well described in the pediatric literature, this case represents insulin neuritis, one of the few diabetic neuropathies that has a favorable outcome.
To evaluate the contemporary prevalence of diabetic peripheral neuropathy (DPN) in participants with type 1 diabetes in the T1D Exchange Clinic Registry throughout the U.S. RESEARCH DESIGN AND METHODSDPN was assessed with the Michigan Neuropathy Screening Instrument Questionnaire (MNSIQ) in adults with ‡5 years of type 1 diabetes duration. A score of ‡4 defined DPN. Associations of demographic, clinical, and laboratory factors with DPN were assessed. RESULTSAmong 5,936 T1D Exchange participants (mean 6 SD age 39 6 18 years, median type 1 diabetes duration 18 years [interquartile range 11, 31], 55% female, 88% non-Hispanic white, mean glycated hemoglobin [HbA 1c ] 8.1 6 1.6% [65.3 6 17.5 mmol/mol]), DPN prevalence was 11%. Compared with those without DPN, DPN participants were older, had higher HbA 1c , had longer duration of diabetes, were more likely to be female, and were less likely to have a college education and private insurance (all P < 0.001). DPN participants also were more likely to have cardiovascular disease (CVD) (P < 0.001), worse CVD risk factors of smoking (P 5 0.008), hypertriglyceridemia (P 5 0.002), higher BMI (P 5 0.009), retinopathy (P 5 0.004), reduced estimated glomerular filtration rate (P 5 0.02), and Charcot neuroarthropathy (P 5 0.002). There were no differences in insulin pump or continuous glucose monitor use, although DPN participants were more likely to have had severe hypoglycemia (P 5 0.04) and/or diabetic ketoacidosis (P < 0.001) in the past 3 months. CONCLUSIONSThe prevalence of DPN in this national cohort with type 1 diabetes is lower than in prior published reports but is reflective of current clinical care practices. These data also highlight that nonglycemic risk factors, such as CVD risk factors, severe hypoglycemia, diabetic ketoacidosis, and lower socioeconomic status, may also play a role in DPN development.Diabetic neuropathy is a prevalent complication in patients with diabetes and a major cause of morbidity and mortality (1). Among the various forms of diabetic neuropathy, distal symmetric polyneuropathy (DPN) and diabetic autonomic neuropathies are by far the most studied (1).
Older people form a growing proportion and volume of those accessing urgent care. Non-specific presentations, multiple comorbidities and functional decline make assessment and management of this cohort challenging. Comprehensive Geriatric Assessment offers an evidence based framework to assess and mange older people, especially those with frailty. In this article we describe the CGA approach, underpinned by specific examples illustrating some of the key competencies required, and describe the role of the Acute Frailty Network (AFN). The AFN is a national improvement collaborative designed to support hospitals in delivering evidence based care for older people with frailty and urgent care needs. We describe the principles underlying the approach of the AFN, derived from working with over 20 hospitals, and some of the early successes.
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