Hospital Discharge Algorithm Based on Admission HbA1c for the Management of Patients With Type 2 Diabetes

Abstract

OBJECTIVEEffective treatment algorithms are needed to guide diabetes care at hospital discharge in general medicine and surgery patients with type 2 diabetes.RESEARCH DESIGN AND METHODSThis was a prospective, multicenter open-label study aimed to determine the safety and efficacy of a hospital discharge algorithm based on admission HbA1c. Patients with HbA1c <7% (53.0 mmol/mol) were discharged on their preadmission diabetes therapy, HbA1c between 7 and 9% (53.0–74.9 mmol/mol) were discharged on a preadmission regimen plus glargine at 50% of hospital daily dose, and HbA1c >9% were discharged on oral antidiabetes agents (OADs) plus glargine or basal bolus regimen at 80% of inpatient dose. The primary outcome was HbA1c concentration at 12 weeks after hospital discharge.RESULTSA total of 224 patients were discharged on OAD (36%), combination of OAD and glargine (27%), basal bolus (24%), glargine alone (9%), and diet (4%). The admission HbA1c was 8.7 ± 2.5% (71.6 mmol/mol) and decreased to 7.3 ± 1.5% (56 mmol/mol) at 12 weeks of follow-up (P < 0.001). The change of HbA1c from baseline at 12 weeks after discharge was −0.1 ± 0.6, −0.8 ± 1.0, and −3.2 ± 2.4 in patients with HbA1c <7%, 7–9%, and >9%, respectively (P < 0.001). Hypoglycemia (<70 mg/dL) was reported in 22% of patients discharged on OAD only, 30% on OAD plus glargine, 44% on basal bolus, and 25% on glargine alone and was similar in patients with admission HbA1c ≤7% (26%) compared with those with HbA1c >7% (31%, P = 0.54).CONCLUSIONSMeasurement of HbA1c on admission is beneficial in tailoring treatment regimens at discharge in general medicine and surgery patients with type 2 diabetes.

13. Diabetes Care in the Hospital

“…If glycemic medications are changed or glucose control is not optimal at discharge, continuing contact may be needed to avoid hyperglycemia and hypoglycemia. A recent discharge algorithm for glycemic medication adjustment based on admission A1C found that the average A1C in patients with diabetes decreased from 8.7% (72 mmol/mol) on admission to 7.3% (56 mmol/mol) 3 months after discharge (34). Therefore, if an A1C from the prior 3 months is unavailable, measuring the A1C in all patients with diabetes or hyperglycemia admitted to the hospital is recommended.…”

14. Diabetes Care in the Hospital: Standards of Medical Care in Diabetes—2018

“…Because inpatient insulin use (5) and discharge orders (6) can be more effective if based on an A1C level on admission (7), perform an A1C test on all patients with diabetes or hyperglycemia admitted to the hospital if the test has not been performed in the prior 3 months. In addition, diabetes self-management knowledge and behaviors should be assessed on admission and diabetes self-management education (DSME) should be provided, if appropriate.…”

Discharge pharmacotherapy for Type 2 diabetic inpatients at two hospitals of different tiers in Zhejiang Province, China

“…Medication compliance drops post-discharge almost inevitably, especially in insulin treatment [39]. Even with a standard discharge algorithm and close post-discharge follow-up, BBI therapy has the highest hypoglycemia risk [17]. It's prudent to be concerned that, with the more advanced age, lower level of literacy and poorer compliance with disease management, patients from SMH may have multiple barriers to safely implement BBI treatment post-discharge [38].…”

“…Yet one aspect the Chinese guideline neglects is the discharge management for T2DM patients [2], which is a critical part of successful hospitalization for T2DM [11,13]. Unlike the generally accepted in-hospital management of hyperglycemia [14,15], there is little consensus on algorithms for discharge transition [16,17]. It's conceivable that there would be greater discrepancies in discharge pharmacotherapy for T2DM.…”