Hospitalizations and readmissions due to dysglycemia among people with diabetes are common yet often preventable, new US research suggests.
The findings, from more than a half million index hospitalizations for over 300,000 patients with diabetes in a nationwide database, were published online July 6 in the Journal of General Internal Medicine by Rozalina G McCoy, MD, of the division of primary care internal medicine at Mayo Clinic, Rochester, Minnesota, and colleagues.
Overall, more than one in 10 patients had unplanned readmissions within 30 days of discharge. A history of severe hyper- or hypoglycemia (“dysglycemia”) and the presence of diabetes complications independently predicted all-cause readmission, while younger patients and those with diabetes complications had the highest risk for readmission due to dysglycemia.
“I cannot stress enough the importance of posthospital visits with a [healthcare] provider as soon as possible after hospital discharge,” Dr McCoy told Medscape Medical News.
“Patients with diabetes have a high risk of readmission after any hospitalization, so it is important to see these patients early, make sure they are doing well and understand hospital-discharge instructions — and that you, as their physician, agree with those instructions — and that there are no unresolved or active issues that need to be dealt with and that the patients are taking their medications as intended,” she noted.
In addition, she said, “the best way to prevent severe hypoglycemia and severe hyperglycemia is to help patients recognize them when they happen. Ask patients about them at each encounter — especially if they are at risk for these events — work with patients to understand why they happen, adjust medications as much as possible to prevent them, and develop a plan on how to manage these events early at home and thus prevent them from becoming so severe that they require hospitalization.”
Over 10% of Patients With Diabetes Are Readmitted Within 30 Days
The study was a retrospective analysis of data from the Optum-Labs DataWarehouse, an administrative data set of commercially insured and Medicare Advantage beneficiaries across the United States. Subjects were 342,186 adults aged ≥18 years with diabetes who were discharged from a hospital between January 1, 2009 and December 31, 2014.
Of the total 594,146 index hospitalizations, 2.6% were for severe dysglycemia. And of those 15,644, 48.1% were for hypoglycemia, 50.4% for hyperglycemia, and the rest unspecified. Heart failure was the most common cause for the index hospitalization, in 5.5%, while severe dysglycemia was the 11th most common.
Overall, 10.8% had unplanned readmissions. Of those, heart failure was also the most common reason for readmission (8.9% of readmissions), while severe dysglycemic events accounted for 2.5% of readmissions. Of those, nearly two-thirds were for hypoglycemia and over a third for hyperglycemia.
“We were somewhat surprised that the rate of hospitalization and especially readmission for severe dysglycemic events was as high as it was….This is despite the fact that such events may be avoidable with optimal outpatient management or at the very least frequently successfully managed at home,” Dr McCoy commented.
Readmission for severe dysglycemia occurred in 28.9% of those in whom dysglycemia was the reason for the index hospitalization, compared with just 1.8% of readmissions among patients who had been initially hospitalized for other causes.
This finding was actually counter to the investigators’ initial hypothesis that patients hospitalized for causes other than severe dysglycemia may be at increased risk for readmission for severe hypoglycemia or hyperglycemia because their diabetes management may be relatively deprioritized in the hospital as their acute health needs are being addressed, Dr McCoy noted.
Younger Age, Complications Up Dysglycemia Readmission Risk
Factors that increased the risk for all readmissions — for severe dysglycemia or any other reason — included longer length of stay during index hospitalization, unplanned rather than planned index hospitalization, lower income, and black race.
Patients whose index hospitalization was for severe dysglycemia were nearly nine times as likely to be readmitted for recurrent severe dysglycemia as for other reasons.
The risk for severe dysglycemia readmission was nearly twice as high among those aged less than 45 years compared with those 45 and older.
Score on the Diabetes Complications Severity Index (DCSI) also significantly predicted dysglycemia readmission: compared with patients with no diabetes complications, the risk of readmission for severe dysglycemia was 2.33-fold higher among patients with DCSI of 3 to 6 and 3.20-fold higher with DCSI ≥7.
In addition, patients using insulin were 80% more likely to be readmitted for severe dysglycemia and 6% more likely to be readmitted for other causes than those not using insulin.
Prevention Is Possible
Dr McCoy told Medscape Medical News that these findings can help clinicians in devising better tailored care and discharge planning.
“Inpatient diabetes education has been shown to reduce risk of readmission and may benefit high-risk patients. Similarly, medication review and reconciliation, care transitions programs, and follow-up telephone calls or appointments that specifically address diabetes management may reduce the risk of severe dysglycemia readmissions.”
Younger patients and those with a history of severe dysglycemia and/or multiple diabetes complications may benefit from diabetes-specific discharge planning and posthospital follow-up, she said.
And, she noted, “It is also very important to teach patients how to recognize severe dysglycemia and how to treat it at home before an episode becomes so severe that it requires hospitalization,” including “sick-day” instructions, how to manage urine ketones, and how to adjust insulin doses in response to hyperglycemia.
For severe hypoglycemia, guidance should include instructing family members, friends, and coworkers how to recognize hypoglycemia and how to use glucagon.
Overall, “We need to actively manage their diabetes treatment regimens, intensifying and deintensifying therapy proactively as needed to avoid hypoglycemic and hyperglycemic events,” she concluded.
This study was supported by the National Center for Advancing Translational Sciences, a component of the National Institutes of Health. Dr McCoy also receives support from the Mayo Clinic Robert D and Patricia E Kern Center for the Science of Health Care Delivery. Disclosures for the coauthors are listed in the paper.
J Gen Intern Med. Published online July 6, 2017. Abstract
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