151-LB: A Pilot Randomized Controlled Trial to Reduce Hospital Readmission Risk of Patients with Diabetes: 90-Day Outcomes

Abstract

Unplanned hospital readmission is a high-priority quality measure and target for cost reduction. Patients with diabetes are at higher risk of readmission than patients without diabetes. We previously presented results of a pilot randomized controlled trial (RCT) of an intervention designed to reduce readmission risk (the Diabetes Transition of Hospital Care [DiaTOHC] program) with outcomes assessed 30 days after hospital discharge. Here we present secondary outcomes assessed 90 days after discharge. Patients predicted to be high risk (>=27%) for readmission based on a validated readmission risk tool (DERRITM) were randomized 1:1 to the intervention (INT) or usual care (UC). The intervention consisted of inpatient diabetes education, coordination of care, post-discharge support by a nurse practitioner, adjustment of diabetes therapy, and weekly phone calls for 30 days after discharge. There were 45 INT and 46 UC patients randomized and analyzed by intention-to-treat. Twenty-one INT and 23 UC patients had a readmission (46.7% vs. 50%) while 25 INT and 27 UC patients had a readmission or Emergency Department (ED) visit (55.6% vs. 58.7%). The ratio of the mean estimated cost of readmissions, ED visits, and the intervention in the INT group was 0.51 (0.25-1.02)95%CL the cost of readmissions and ED visits in the UC group. Among the 69 patients with an admission A1C >7%, 14 INT and 17 UC patients had a readmission (41.2% vs. 48.6%), and 18 INT and 21 UC patients had a readmission or ED visit (52.9% vs. 60.0%), yielding relative risk reductions of 15.2% and 11.8%. The INT:UC group ratio of the mean estimated cost was 0.50 (0.22-1.12)95%CL. No differences were statistically significant in this pilot study. The DiaTOHC intervention may modestly reduce readmission risk and cut costs by half within 90 days after discharge among patients with an admission A1C >7%. This merits further investigation in a larger RCT. Disclosure D.J. Rubin: None. S. Watts: None. A. Deak: None. C. Vaz: None. S. Tanner: None. D. Recco: None. M. Tivon: None. F.R. Dillard: None. E. Brzana: None. K.E. Joyce: None. A. Karunakaran: None. A. Iwamaye: None. E. Miller: None. C. Mathai: None. N. Kondamuri: None. B.S. Albury: None. S. Allen: None. M.D. Naylor: None. S. Golden: None. J. Wu: None. Funding National Institute of Diabetes and Digestive and Kidney Diseases (K23DK102963)

Predicting and Preventing Acute Care Re-Utilization by Patients with Diabetes

“…: 88 Control: 92 usual care 30-day : 14.1% 30-day ED : 9.1% k 30-day : 20.5%, RRI 46.1% 30-day ED : 9.8% ( P =0.87) Inpatient pharmacist counseling, visiting nurse home evaluations, symptom screening phone calls and after-hospital care planning by NP, follow-up in post-discharge clinic within 3 days, telemonitoring of glucose, follow-up with PCP or endocrinologist within 1 week of discharge Pharmacy coordination, Wright, 2019 [ 64 ] Adults with discharge diagnosis for heart failure, acute myocardial infarction, chronic obstructive pulmonary disease, pneumonia, or diabetes (75% had DM) Prospective pragmatic interventional study with 5:1 matched controls Int. : 187 Control: 935 30-day : 15% 30-day ED : 22% 30-day : 9% ( P = 0.02), RRR 40%* 30-day ED : 20% ( P = 0.48) Coordination between inpatient and outpatient pharmacist Diabetes Transition of Hospital Care (DiaTOHC), Rubin [ 65 ], 2020 [ 66 ] Diabetes and high risk of 30-day readmission (≥27%) based on DERRI Pilot RCT N = 91 Int. : 46 Control: 45 Subgroup with A1c>7% N = 69 30-day readmission or ED : 39.1% 90-day : 50% 90-day readmission or ED : 60.0% A1c>7% Subgroup 30-day readmission or ED visit: 40% 30-day readmission or ED : 31.8% 90-day : 46.7% 90-day readmission or ED : 52.9% A1c>7% Subgroup 30-day readmission or ED: 26.5% ( P = 0.23) Focused inpatient diabetes education, coordination of care, physician titration of diabetes therapy upon discharge based on A1c algorithm, and post-discharge phone calls by NP until 30 days after discharge Multidisciplinary diabetes clinic, Bhalodkar, 2020 [ 27 ] Adults admitted to medicine service with diagnosis of diabetes RCT N = 192 Int.…”

“…Components of these programs include discharge care coordination, diabetes education, medication adjustment by a diabetes specialist upon discharge, outpatient follow-up in a diabetes clinic, follow-up by telephone for care coordination and diabetes assessment, and home care by a visiting nurse. Of the four RCTs, three reported reductions in acute care re-utilization at 30 days, 90 days, and 1 year [ 60 , 65 , 66 , 68 ], and one found no statistically significant difference in readmissions or ED visits at 30 days [ 63 ]. Three non-randomized studies reported a 31–40% RRR in 30-day readmission rates associated with their interventions [ 61 , 62 , 64 ].…”

Interventions incorporating a multi‐disciplinary team approach and a dedicated care team can help reduce preventable hospital readmissions of people with type 2 diabetes mellitus: A scoping review of current literature

“…Brumm et al 25 did not find a significant association between the use of a diabetes transition programme conducted solely by a nurse practitioner who was also a nurse educator and significant reductions in hospital readmissions. RCT's conducted by Rubin et al 26 , 27 found that the use of the Diabetes Transition of Hospital Care intervention involving only a nurse practitioner did not significantly reduce hospital readmissions. Marusic et al 28 found that the provision of additional pre‐discharge pharmacotherapeutic education by an endocrinologist was not associated with significant reductions in hospital readmissions.…”

Linee guida per la gestione del paziente adulto con diabete o con iperglicemia ricoverato in setting clinico non critico

“…Una modalità di dimissione ospedaliera comprendente un piano strutturato di dimissione si associa a livelli glicemici medi post-dimissione significativamente più bassi rispetto a quelli misurati nel caso di dimissione senza un piano strutturato di dimissione. Inoltre, adottare un piano strutturato di dimissione offre vantaggi in termini di re-ospedalizzazioni con conseguenti riduzione anche dei costi (38)(39)(40)(41).…”