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1.
J Med Internet Res ; 26: e50508, 2024 Sep 24.
Artículo en Inglés | MEDLINE | ID: mdl-39316431

RESUMEN

BACKGROUND: There are numerous mobile health (mHealth) interventions for treatment adherence and self-management; yet, little is known about user engagement or interaction with these technologies. OBJECTIVE: This systematic review aimed to answer the following questions: (1) How is user engagement defined and measured in studies of mHealth interventions to promote adherence to prescribed medical or health regimens or self-management among people living with a health condition? (2) To what degree are patients engaging with these mHealth interventions? (3) What is the association between user engagement with mHealth interventions and adherence or self-management outcomes? (4) How often is user engagement a research end point? METHODS: Scientific database (Ovid MEDLINE, Embase, Web of Science, PsycINFO, and CINAHL) search results (2016-2021) were screened for inclusion and exclusion criteria. Data were extracted in a standardized electronic form. No risk-of-bias assessment was conducted because this review aimed to characterize user engagement measurement rather than certainty in primary study results. The results were synthesized descriptively and thematically. RESULTS: A total of 292 studies were included for data extraction. The median number of participants per study was 77 (IQR 34-164). Most of the mHealth interventions were evaluated in nonrandomized studies (157/292, 53.8%), involved people with diabetes (51/292, 17.5%), targeted medication adherence (98/292, 33.6%), and comprised apps (220/292, 75.3%). The principal findings were as follows: (1) >60 unique terms were used to define user engagement; "use" (102/292, 34.9%) and "engagement" (94/292, 32.2%) were the most common; (2) a total of 11 distinct user engagement measurement approaches were identified; the use of objective user log-in data from an app or web portal (160/292, 54.8%) was the most common; (3) although engagement was inconsistently evaluated, most of the studies (99/195, 50.8%) reported >1 level of engagement due to the use of multiple measurement methods or analyses, decreased engagement across time (76/99, 77%), and results and conclusions suggesting that higher engagement was associated with positive adherence or self-management (60/103, 58.3%); and (4) user engagement was a research end point in only 19.2% (56/292) of the studies. CONCLUSIONS: The results revealed major limitations in the literature reviewed, including significant variability in how user engagement is defined, a tendency to rely on user log-in data over other measurements, and critical gaps in how user engagement is evaluated (infrequently evaluated over time or in relation to adherence or self-management outcomes and rarely considered a research end point). Recommendations are outlined in response to our findings with the goal of improving research rigor in this area. TRIAL REGISTRATION: PROSPERO International Prospective Register of Systematic Reviews CRD42022289693; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022289693.


Asunto(s)
Automanejo , Telemedicina , Humanos , Telemedicina/estadística & datos numéricos , Enfermedad Crónica/terapia , Automanejo/métodos , Cumplimiento y Adherencia al Tratamiento/estadística & datos numéricos , Cumplimiento y Adherencia al Tratamiento/psicología , Femenino , Masculino
2.
Clin Diabetes ; 42(1): 17-26, 2024.
Artículo en Inglés | MEDLINE | ID: mdl-38230325

RESUMEN

Screening for autoantibodies associated with type 1 diabetes can identify people most at risk for progressing to clinical type 1 diabetes and provide an opportunity for early intervention. Drawbacks and barriers to screening exist, and concerns arise, as methods for disease prevention are limited and no cure exists today. The availability of novel treatment options such as teplizumab to delay progression to clinical type 1 diabetes in high-risk individuals has led to the reassessment of screening programs. This study explored awareness, readiness, and attitudes of endocrinology providers toward type 1 diabetes autoantibody screening.

3.
J Gen Intern Med ; 2023 Nov 08.
Artículo en Inglés | MEDLINE | ID: mdl-37940754

RESUMEN

BACKGROUND: Guidelines recommend deintensifying hypoglycemia-causing medications for older adults with diabetes whose hemoglobin A1c is below their individualized target, but this rarely occurs in practice. OBJECTIVE: To understand physicians' decision-making around deintensifying diabetes treatment. DESIGN: National physician survey. PARTICIPANTS: US physicians in general medicine, geriatrics, or endocrinology providing outpatient diabetes care. MAIN MEASURES: Physicians rated the importance of deintensifying diabetes medications for older adults with type 2 diabetes, and of switching medication classes, on 5-point Likert scales. They reported the frequency of these actions for their patients, and listed important barriers and facilitators. We evaluated the independent association between physicians' professional and practice characteristics and the importance of deintensifying and switching diabetes medications using multivariable ordered logistic regression models. KEY RESULTS: There were 445 eligible respondents (response rate 37.5%). The majority of physicians viewed deintensifying (80%) and switching (92%) diabetes medications as important or very important to the care of older adults. Despite this, one-third of physicians reported deintensifying diabetes medications rarely or never. While most physicians recognized multiple reasons to deintensify, two-thirds of physicians reported barriers of short-term hyperglycemia and patient reluctance to change medications or allow higher glucose levels. In multivariable models, geriatricians rated deintensification as more important compared to other specialties (p=0.027), and endocrinologists rated switching as more important compared to other specialties (p<0.006). Physicians with fewer years in practice rated higher importance of deintensification (p<0.001) and switching (p=0.003). CONCLUSIONS: While most US physicians viewed deintensifying and switching diabetes medications as important for the care of older adults, they deintensified infrequently. Physicians had ambivalence about the relative benefits and harms of deintensification and viewed it as a potential source of conflict with their patients. These factors likely contribute to clinical inertia, and studies focused on improving shared decision-making around deintensifying diabetes medications are needed.

4.
Clin Diabetes ; 41(2): 208-219, 2023.
Artículo en Inglés | MEDLINE | ID: mdl-37092143

RESUMEN

In this retrospective analysis, we explored the correlation between measured average glucose (mAG) and A1C-estimated average glucose (eAG) in hospitalized patients with diabetes and identified factors associated with discordant mAG and eAG at the transition from home to hospital. Having mAG lower than eAG was associated with Black race, other race, increasing length of stay, community hospital setting, surgery, fever, metformin use, certain inpatient diets, home antihyperglycemic treatment, and coded type 1 or type 2 diabetes. Having mAG higher than eAG was associated with certain discharge services (e.g., intensive care unit), higher BMI, hypertension, tachycardia, higher albumin, higher potassium, anemia, inpatient glucocorticoid use, and treatment with home insulin, secretagogues, and glucocorticoids. These factors should be considered when using patients' A1C as an indicator of outpatient glycemic control to determine the inpatient antihyperglycemic regimens.

5.
Curr Diab Rep ; 22(8): 353-364, 2022 08.
Artículo en Inglés | MEDLINE | ID: mdl-35759171

RESUMEN

PURPOSE OF REVIEW: Glucose management in the hospital is difficult due to non-static factors such as antihyperglycemic and steroid doses, renal function, infection, surgical status, and diet. Given these complex and dynamic factors, machine learning approaches can be leveraged for prediction of glucose trends in the hospital to mitigate and prevent suboptimal hypoglycemic and hyperglycemic outcomes. Our aim was to review the clinical evidence for the role of machine learning-based models in predicting hospitalized patients' glucose trajectory. RECENT FINDINGS: The published literature on machine learning algorithms has varied in terms of population studied, outcomes of interest, and validation methods. There have been tools developed that utilize data from both continuous glucose monitors and large electronic health records (EHRs). With increasing sample sizes, inclusion of a greater number of predictor variables, and use of more advanced machine learning algorithms, there has been a trend in recent years towards increasing predictive accuracy for glycemic outcomes in the hospital setting. While current models predicting glucose trajectory offer promising results, they have not been tested prospectively in the clinical setting. Accurate machine learning algorithms have been developed and validated for prediction of hypoglycemia and hyperglycemia in the hospital. Further work is needed in implementation/integration of machine learning models into EHR systems, with prospective studies to evaluate effectiveness and safety of such clinical decision support on glycemic and other clinical outcomes.


Asunto(s)
Glucosa , Pacientes Internos , Glucemia , Humanos , Hipoglucemiantes , Aprendizaje Automático , Estudios Prospectivos
6.
Endocr Pract ; 28(5): 458-464, 2022 May.
Artículo en Inglés | MEDLINE | ID: mdl-35131439

RESUMEN

OBJECTIVE: Some studies have shown that there is an undercoding of diabetes mellitus among hospitalized patients, which can have adverse clinical and financial implications for health systems. We aimed to validate the discharge diagnostic coding of diabetes mellitus in hospitalized patients using clinical and laboratory-based diagnostic indicators as the reference. METHODS: This was a retrospective cohort study of 83 690 discharges of 48 615 unique adult patients who were hospitalized in an academic medical center over 4.5 years and had at least 4 blood glucose measurements during admission. A missing diabetes code (MDC) was defined using 2 criteria. MDC1 was defined as the presence of any of the following: blood glucose ≥200 (x2), A1C ≥6.5%, home antihyperglycemic medication, or preadmission code for diabetes, whereas MDC2 was defined as preadmission diabetes or at least 2 other criteria in MDC1. Multivariable logistic regression was used to identify factors associated with MDC compared to the present diabetes code. RESULTS: MDC1 and MDC2 were present in 12 186 (14.6%) and 3542 (4.7%) discharges, respectively. Factors associated with both MDC1 and MDC2 were medium-dose steroid use [adjusted odds ratio (aOR) 2.11, 2.01], high-dose steroid use (aOR 4.70, 2.50), intermediate medical care service (aOR 1.65, 1.55), infection (aOR 1.21, 1.34), and hepatic disease (aOR 1.93, 1.92). CONCLUSION: In this retrospective study, MDC ranged from 5% to 15% and was associated with various clinical factors. Further prospective studies are needed to validate these findings, explore the mechanisms behind these associations, and understand the clinical and financial implications.


Asunto(s)
Glucemia , Diabetes Mellitus , Adulto , Codificación Clínica , Diabetes Mellitus/diagnóstico , Diabetes Mellitus/epidemiología , Hemoglobina Glucada/análisis , Humanos , Estudios Retrospectivos , Esteroides
7.
Endocr Pract ; 28(12): 1232-1236, 2022 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-36183992

RESUMEN

OBJECTIVE: Managing hospitalized patients on ambulatory U-500 insulin is challenging because of limited guidance on how to safely adjust insulin doses during admission. We sought to evaluate glycemic outcomes in relation to inpatient insulin doses in patients receiving U-500 prior to hospitalization. METHODS: Retrospective study of hospitalized patients on ambulatory U-500 seen consecutively from January 2015 to December 2019. Primary outcomes were inpatient hypoglycemia, hyperglycemia, and normoglycemia at different insulin dosages expressed as weight-based (unit/kg/d) inpatient total daily dose (TDD) and ratio of inpatient to outpatient TDD. RESULTS: We identified 66 admissions of 46 unique patients. The median (interquartile range) body mass index was 41.0 kg/m2 (35.1, 46.8), home TDD 212 units (120, 300), and home insulin dose 1.6 units/kg/d (1.1, 2.2). The median (interquartile range) inpatient insulin dose was 0.7 unit/kg/d (0.3, 1.0) and the ratio of inpatient to outpatient TDD was 0.4 (0.2, 0.8). Hyperglycemia persisted throughout the hospitalization. For the outcomes of hyperglycemia and normoglycemia, we found no association between increased levels of insulin dosages. For the outcome of hypoglycemia, significantly higher odds were observed when non-fasting patients received an inpatient TDD that was either > 40% of their home TDD or > 0.6 unit/kg/d of insulin. CONCLUSION: Patients on ambulatory U-500 have significant hyperglycemia during admission. Inpatient insulin doses of 40% of home TDD or ≤ 0.6 unit/kg were not associated with increased hypoglycemia risk. Further prospective studies are needed to determine effective doses in these high-risk patients.


Asunto(s)
Insulina , Humanos , Estudios Retrospectivos , Insulina/uso terapéutico
8.
Endocr Pract ; 28(8): 774-779, 2022 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-35550182

RESUMEN

OBJECTIVE: To determine the optimal insulin-to-steroid dose ratio for the attainment of glycemic control in hospitalized patients. METHODS: We retrospectively studied data collected from the electronic health records within an academic medical center from 18 599 patient-days where patients were treated concurrently with insulin and steroids. Multivariate logistic regression analyses, which included demographic and clinical variables, were performed to assess the relationships between the exposures of total and basal insulin-to-steroid ratios and the outcomes of glycemic control (all blood glucose readings on the following patient-day were >70 and ≤180 mg/dL) and hypoglycemia within 3 subgroups of steroid dosing: low (≤10-mg prednisone equivalent dose [PED]), medium (from >10-mg to ≤40-mg PED), and high (>40-mg PED). RESULTS: Increased insulin-to-steroid ratio was associated with increased odds of both glycemic control and hypoglycemia. The optimal total insulin-to-steroid ratio for attaining glycemic control was 0.294 U/kg/10-mg PED in the low-dose subgroup, 0.257 U/kg/10-mg PED in the medium-dose subgroup, and 0.085 U/kg/10-mg PED in the high-dose subgroup. The optimal basal insulin-to-steroid ratio was 0.215 U/kg/10-mg PED in the low-dose subgroup, 0.126 U/kg/10-mg PED in the medium-dose subgroup, and 0.036 U/kg/10-mg PED in the high-dose subgroup. CONCLUSION: Increasing insulin-to-steroid ratios are positively associated with glycemic control and hypoglycemia. Our study suggests that approximately 0.3 U/kg/10-mg PED is an optimal dose for low- and medium-dose steroids, whereas approximately 0.1 U/kg/10-mg PED is an optimal dose for high-dose steroids. Further prospective studies are needed to identify insulin regimens that will optimize glycemic control in steroid-treated patients while minimizing the risk of hypoglycemia.


Asunto(s)
Hiperglucemia , Hipoglucemia , Glucemia , Humanos , Hiperglucemia/tratamiento farmacológico , Hiperglucemia/prevención & control , Hipoglucemia/inducido químicamente , Hipoglucemia/epidemiología , Hipoglucemiantes , Pacientes Internos , Insulina , Insulina Regular Humana/uso terapéutico , Estudios Retrospectivos , Esteroides/uso terapéutico
9.
J Gen Intern Med ; 36(5): 1244-1249, 2021 05.
Artículo en Inglés | MEDLINE | ID: mdl-32935316

RESUMEN

BACKGROUND: The blood glucose level triggering a critical action value (CAV) for hypoglycemia is not standardized, and associated outcomes are unknown. OBJECTIVE: To evaluate the clinical consequences of, and provider responses to, CAVs for hypoglycemia. DESIGN: Retrospective cohort study at Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center between April 1, 2013, and January 31, 2017. PARTICIPANTS: Patients with an ambulatory serum glucose < 50 mg/dL. Point-of-care capillary glucose and whole blood glucose samples were excluded. MAIN MEASURES: Electronic medical record (EMR) review for providers' documented response to CAV, associated patient symptoms, and serious adverse events. KEY RESULTS: We analyzed 209 CAVs for hypoglycemia from 154 patients. The median age (IQR) was 59 years (46, 69), 89 (57.8%) were male, and 96 (62.3%) were black. Provider-to-patient contact occurred in 128 of 209 (61.2%) episodes, among which no documented etiology was observed for 81 of 128 (63.3%), no recommendations were provided in 32 of 128 (25.0%), and no patient-reported hypoglycemic symptoms were documented in 103 of 128 (80.5%). Serious adverse events were documented in 4 of 128 episodes (3.1%), two required glucagon administration, and three required an ED visit. Provider-to-patient contact was associated with the patient having malignant neoplasm (adjusted OR 3.63, p = 0.045) or a hypoglycemic disorder (adjusted OR 7.70, p = 0.018) and inversely associated with a longer time from specimen collection to EMR result (adjusted OR 0.90 per hour, p = 0.016). CONCLUSIONS: There is inconsistent provider-to-patient contact following CAVs for hypoglycemia, and the etiology and symptoms of hypoglycemia were infrequently documented. There were few serious documented adverse events associated with hypoglycemia, although undocumented events may have occurred, and the incidence of serious adverse events in non-contacted patients remains unknown. These findings demonstrate a need to standardize provider response to CAVs for hypoglycemia. Decreasing the lag time between sample collection and laboratory result reporting may increase provider-to-patient contact.


Asunto(s)
Glucemia , Hipoglucemia , Instituciones de Atención Ambulatoria , Humanos , Hipoglucemia/inducido químicamente , Hipoglucemia/diagnóstico , Hipoglucemia/epidemiología , Hipoglucemiantes , Masculino , Persona de Mediana Edad , Estudios Retrospectivos
10.
J Gen Intern Med ; 36(6): 1533-1542, 2021 06.
Artículo en Inglés | MEDLINE | ID: mdl-33479925

RESUMEN

BACKGROUND: Hypoglycemia is a common and serious adverse effect of diabetes treatment, especially for patients using insulin or insulin secretagogues. Guidelines recommend that these patients be assessed for interval hypoglycemic events at each clinical encounter and be provided anticipatory guidance for hypoglycemia prevention. OBJECTIVE: To determine the frequency and content of hypoglycemia communication in primary care visits. DESIGN: Qualitative study PARTICIPANTS: We examined 83 primary care visits from one urban health practice representing 8 clinicians and 33 patients using insulin or insulin secretagogues. APPROACH: Using a directed content analysis approach, we analyzed audio-recorded primary care visits collected as part of the Achieving Blood Pressure Control Together study, a randomized trial of behavioral interventions for hypertension. The coding framework included communication about interval hypoglycemia, defined as discussion of hypoglycemic events or symptoms; the components of hypoglycemia anticipatory guidance in diabetes guidelines; and hypoglycemia unawareness. Hypoglycemia documentation in visit notes was compared to visit transcripts. KEY RESULTS: Communication about interval hypoglycemia occurred in 24% of visits, and hypoglycemic events were reported in 16%. Despite patients voicing fear of hypoglycemia, clinicians rarely assessed hypoglycemia frequency, severity, or its impact on quality of life. Hypoglycemia anticipatory guidance was provided in 21% of visits which focused on diet and behavior change; clinicians rarely counseled on hypoglycemia treatment or avoidance of driving. Limited discussions of hypoglycemia unawareness occurred in 8% of visits. Documentation in visit notes had low sensitivity but high specificity for ascertaining interval hypoglycemia communication or hypoglycemic events, compared to visit transcripts. CONCLUSIONS: In this high hypoglycemia risk population, communication about interval hypoglycemia and counseling for hypoglycemia prevention occurred in a minority of visits. There is a need to support clinicians to more regularly assess their patients' hypoglycemia burden and enhance counseling practices in order to optimize hypoglycemia prevention in primary care.


Asunto(s)
Diabetes Mellitus Tipo 2 , Diabetes Mellitus , Hipoglucemia , Comunicación , Diabetes Mellitus Tipo 2/tratamiento farmacológico , Humanos , Hipoglucemia/inducido químicamente , Hipoglucemia/epidemiología , Hipoglucemia/terapia , Hipoglucemiantes/efectos adversos , Insulina , Atención Primaria de Salud , Calidad de Vida
11.
J Surg Res ; 246: 243-250, 2020 02.
Artículo en Inglés | MEDLINE | ID: mdl-31610352

RESUMEN

BACKGROUND: Recent studies demonstrate favorable diabetic foot ulcer (DFU) healing outcomes with the implementation of a multidisciplinary team. We aimed to describe the incidence of and risk factors associated with ulcer recurrence after initial complete healing among a cohort of patients with DFU treated in a multidisciplinary setting. METHODS: All patients presenting to our multidisciplinary diabetic limb preservation service from 6/2012-04/2018 were enrolled in a prospective database. The incidence of ulcer recurrence after complete wound healing was assessed per limb using the Kaplan-Meier method, and a stepwise multivariable Cox proportional hazards model was created to identify independent predictors of ulcer recurrence. RESULTS: A total of 244 patients with 304 affected limbs were included. Ulcer recurrence rates at one and 3 y after healing were 30.6 ± 3.0% and 64.4 ± 5.2%, respectively. Recurrent ulcers were smaller (4.4 ± 1.1 cm2versus 8.2 ± 1.2 cm2; P = 0.04) and had a lower Wound, Ischemia, and foot Infection stage (stage 4: 7.7% versus 22.4%; P < 0.001) than initial ulcers, and wound healing time was significantly reduced (95.0 ± 9.8 versus 131.8 ± 7.0 d; P = 0.004). Independent predictors of ulcer recurrence included abnormal proprioception (HR, 1.57 [95% CI 1.02-4.43]) and younger age (HR 1.02 per year [95% CI 1.01-1.04]). CONCLUSIONS: In this prospective cohort of patients with DFU, time to diagnosis and healing was significantly lower for recurrent ulcers, and downstaging was common. These data suggest that engaging patients with DFU in a multidisciplinary care model with frequent follow-up and focused patient education may serve to decrease DFU morbidity.


Asunto(s)
Pie Diabético/epidemiología , Recuperación del Miembro , Grupo de Atención al Paciente , Prevención Secundaria/métodos , Cicatrización de Heridas , Cuidados Posteriores/métodos , Pie Diabético/diagnóstico , Pie Diabético/terapia , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Educación del Paciente como Asunto , Estudios Prospectivos , Recurrencia , Estudios Retrospectivos , Factores de Riesgo , Índice de Severidad de la Enfermedad , Factores de Tiempo , Resultado del Tratamiento
12.
J Vasc Surg ; 70(4): 1263-1270, 2019 10.
Artículo en Inglés | MEDLINE | ID: mdl-30850287

RESUMEN

OBJECTIVE: The inpatient cost of care for diabetic foot ulcers (DFUs) has been estimated to be $1.4 billion annually in the United States. We have previously demonstrated that the risk of 30-day unplanned readmission for patients with DFU is nearly 22%. Our aim was to quantify the cost of readmissions for patients admitted with DFU. METHODS: All patients presenting to our multidisciplinary diabetic limb preservation service from June 2012 to June 2016 were enrolled in a prospective database. Inpatient costs and net margins were calculated overall and for index admissions vs 30-day unplanned readmissions. RESULTS: A total of 249 admissions for 150 patients were included. Of these, 206 admissions were index admissions and 43 were 30-day readmissions. The most common reason for readmission was the foot wound (49%), followed by a bypass wound (14%), renal complications (9%), and other systemic complications. Surgical interventions during readmission were common (47%) and included both podiatric (37%) and vascular (23%). The wound healing outcomes were favorable, with 78% of all wounds achieving healing by 1 year. Limb salvage was 91% overall. The median hospital cost per admission was $20,111 (interquartile range, $12,589-$33,254) and did not differ between the index and readmissions ($22,165 vs $19,408; P = .46). However, the hospital net margins were lower after readmission ($3908 vs $1975; P = .02). The overall cost of care for patients requiring readmission was significantly greater than that for patients not readmitted ($79,315 vs $28,977; P < .001). During the study period, DFU care at our institution cost $7.9 million, of which $1.2 million (16%) was attributable to readmission costs. CONCLUSIONS: Readmissions for patients with DFU are common and associated with a substantial cost burden. The cost of readmission for patients with DFU was as high as the cost of the index admission but with lower hospital net margins. When extrapolated to national data, the 15% readmission cost burden we have reported would be equivalent to $210 million hospital costs annually. Focused efforts at preventing readmissions in this high-risk patient population are essential to reducing the overall costs of care associated with DFUs.


Asunto(s)
Pie Diabético/economía , Pie Diabético/terapia , Costos de Hospital , Pacientes Internos , Admisión del Paciente/economía , Readmisión del Paciente/economía , Análisis Costo-Beneficio , Bases de Datos Factuales , Pie Diabético/diagnóstico , Femenino , Humanos , Recuperación del Miembro/economía , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Tiempo , Resultado del Tratamiento , Cicatrización de Heridas
13.
J Vasc Surg ; 70(1): 233-240, 2019 07.
Artículo en Inglés | MEDLINE | ID: mdl-30606663

RESUMEN

OBJECTIVE: Increasing Wound, Ischemia, and foot Infection (WIfI) stage has previously been shown to be associated with prolonged wound healing time, higher number of surgical procedures, and increased cost of care in patients with diabetic foot ulcers (DFUs) treated in a multidisciplinary setting. However, the profitability of this care model is unknown. We aimed to quantify the hospital costs and net margins associated with multidisciplinary DFU care. METHODS: All patients presenting to our multidisciplinary diabetic limb preservation service (January 2012-June 2016) were enrolled in a prospective database. Inpatient and outpatient costs and net margin (U.S. dollars) were calculated for each wound episode (initial visit until complete wound healing) overall and per day of care according to WIfI classification. RESULTS: A total of 319 wound episodes in 248 patients were captured. Patients required an average of 2.6 ± 0.2 inpatient admissions and 0.9 ± 0.1 outpatient procedures to achieve complete healing. Limb salvage at 1 year was 95.0% ± 2.4%. The overall mean cost of care per wound episode was $24,226 ± $2176, including $41,420 ± $3318 for inpatient admissions and $11,265 ± $1038 for outpatient procedures. The mean net margin was $2412 ± $375 per wound episode, including $5128 ± $622 for inpatient admissions and a net loss ($-3730 ± $596) for outpatient procedures. Mean time to wound healing was 136.3 ± 7.9 days, ranging from 106.5 ± 13.1 days for WIfI stage 1 wounds to 229.5 ± 20.0 days for WIfI stage 4 wounds (P < .001). When adjusted for days of care, the net margin ranged from $2.6 ± $1.3 per day (WIfI stage 1) to $23.6 ± $18.8 (WIfI stage 4). CONCLUSIONS: The costs associated with multidisciplinary DFU care are substantial, especially with advanced-stage wounds. Whereas hospitals can operate at a profit overall, the net margins associated with outpatient procedures performed in a hospital-based facility are prohibitive, and the overall net margins are relatively low, given the labor required to achieve good outcomes. Thus, reimbursement for the multidisciplinary care of DFUs should be re-examined.


Asunto(s)
Comercio , Pie Diabético/economía , Pie Diabético/terapia , Costos de Hospital , Grupo de Atención al Paciente/economía , Atención Ambulatoria/economía , Análisis Costo-Beneficio , Bases de Datos Factuales , Pie Diabético/diagnóstico , Femenino , Humanos , Recuperación del Miembro/economía , Masculino , Persona de Mediana Edad , Admisión del Paciente/economía , Estudios Retrospectivos , Factores de Tiempo , Resultado del Tratamiento , Cicatrización de Heridas
14.
J Vasc Surg ; 68(4): 1096-1103, 2018 10.
Artículo en Inglés | MEDLINE | ID: mdl-29622357

RESUMEN

OBJECTIVE: Previous studies have reported correlation between the Wound, Ischemia, and foot Infection (WIfI) classification system and wound healing time on unadjusted analyses. However, in the only multivariable analysis to date, WIfI stage was not predictive of wound healing. Our aim was to examine the association between WIfI classification and wound healing after risk adjustment in patients with diabetic foot ulcers (DFUs) treated in a multidisciplinary setting. METHODS: All patients presenting to our multidisciplinary DFU clinic from June 2012 to July 2017 were enrolled in a prospective database. A Cox proportional hazards model accounting for patients' sociodemographics, comorbidities, medication profiles, and wound characteristics was used to assess the association between WIfI classification and likelihood of wound healing at 1 year. RESULTS: There were 310 DFU patients enrolled (mean age, 59.0 ± 0.7 years; 60.3% male; 60.0% black) with 709 wounds, including 32.4% WIfI stage 1, 19.9% stage 2, 25.2% stage 3, and 22.4% stage 4. Mean wound healing time increased with increasing WIfI stage (stage 1, 96.9 ± 8.3 days; stage 4, 195.1 ± 10.6 days; P < .001). Likelihood of wound healing at 1 year was 94.1% ± 2.0% for stage 1 wounds vs 67.4% ± 4.4% for stage 4 (P < .001). After risk adjustment, increasing WIfI stage was independently associated with poor wound healing (stage 4 vs stage 1: hazard ratio, [HR] 0.44; 95% confidence interval, 0.33-0.59). Peripheral artery disease (HR, 0.73), increasing wound area (HR, 0.99 per square centimeter), and longer time from wound onset to first assessment (HR, 0.97 per month) also decreased the likelihood of wound healing, whereas use of clopidogrel was protective (HR, 1.39; all, P ≤ .04). The top three predictors of poor wound healing were WIfI stage 4 (z score, -5.40), increasing wound area (z score, -3.14), and WIfI stage 3 (z score, -3.11), respectively. CONCLUSIONS: Among patients with DFU, the WIfI classification system predicts wound healing at 1 year in both crude and risk-adjusted analyses. This is the first study to validate the WIfI score as an independent predictor of wound healing using multivariable analysis.


Asunto(s)
Técnicas de Apoyo para la Decisión , Pie Diabético/diagnóstico , Pie Diabético/terapia , Cicatrización de Heridas , Terapia Combinada , Bases de Datos Factuales , Pie Diabético/clasificación , Pie Diabético/patología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Valor Predictivo de las Pruebas , Modelos de Riesgos Proporcionales , Estudios Retrospectivos , Factores de Riesgo , Índice de Severidad de la Enfermedad , Factores de Tiempo , Resultado del Tratamiento
15.
J Vasc Surg ; 67(5): 1455-1462, 2018 05.
Artículo en Inglés | MEDLINE | ID: mdl-29248237

RESUMEN

OBJECTIVE: We have previously demonstrated that the Society for Vascular Surgery Wound, Ischemia, and foot Infection (WIfI) classification correlates with wound healing time in patients with diabetic foot ulcers (DFUs) treated in a multidisciplinary setting. Our aim was to assess whether the charges and costs associated with DFU care increase with higher WIfI stages. METHODS: All patients presenting to our multidisciplinary diabetic limb preservation service from June 2012 to June 2016 were enrolled in a prospective database. Inpatient and outpatient charges, costs, and total revenue from initial visit until complete wound healing were compared for wounds stratified by WIfI classification. RESULTS: A total of 319 wound episodes in 248 patients were captured, including 31% WIfI stage 1, 16% stage 2, 30% stage 3, and 24% stage 4 wounds. Limb salvage at 1 year was 95% ± 2%, and wound healing was achieved in 85% ± 2%. The mean number of overall inpatient admissions (stage 1, 2.07 ± 0.48 vs stage 4, 3.40 ± 0.27; P < .001), procedure-related admissions (stage 1, 1.86 ± 0.45 vs stage 4, 2.28 ± 0.24; P < .001), and inpatient vascular interventions (stage 1, 0.14 ± 0.10 vs stage 4, 0.80 ± 0.12; P < .001) increased significantly with increasing WIfI stage. There were no significant differences in mean number of inpatient podiatric interventions or outpatient procedures between groups (P ≥ .10). The total cost of care per wound episode increased progressively from stage 1 ($3995 ± $1047) to stage 4 ($50,546 ± $4887) wounds (P < .001). Inpatient costs were significantly higher for advanced stage wounds (stage 1, $21,296 ± $4445 vs stage 4, $54,513 ± $5001; P < .001), whereas outpatient procedure costs were not significantly different between groups (P = .72). Overall, hospital total revenue increased with increasing WIfI stage (stage 1, $4182 ± $1185 vs stage 4, $55,790 ± $5540; P < .002). CONCLUSIONS: Increasing WIfI stage is associated with a prolonged wound healing time, a higher number of surgical procedures, and an increased cost of care. While limb salvage outcomes are excellent, the overall cost of DFU care from presentation to healing is substantial, especially for patients with advanced (WIfI stage 3/4) disease treated in a multidisciplinary setting.


Asunto(s)
Pie Diabético/economía , Pie Diabético/terapia , Precios de Hospital , Costos de Hospital , Grupo de Atención al Paciente/economía , Evaluación de Procesos, Atención de Salud/economía , Cicatrización de Heridas , Infección de Heridas/economía , Infección de Heridas/terapia , Atención Ambulatoria/economía , Amputación Quirúrgica/economía , Baltimore , Terapia Combinada , Bases de Datos Factuales , Pie Diabético/clasificación , Pie Diabético/diagnóstico , Femenino , Humanos , Recuperación del Miembro , Masculino , Persona de Mediana Edad , Admisión del Paciente/economía , Estudios Retrospectivos , Índice de Severidad de la Enfermedad , Factores de Tiempo , Resultado del Tratamiento , Infección de Heridas/clasificación , Infección de Heridas/diagnóstico
16.
J Vasc Surg ; 68(5): 1473-1481, 2018 11.
Artículo en Inglés | MEDLINE | ID: mdl-29803684

RESUMEN

OBJECTIVE: Previous studies show conflicting results in wound healing outcomes based on angiosome direct perfusion (DP), but few have adjusted for wound characteristics in their analyses. We have previously shown that the Society for Vascular Surgery Wound, Ischemia, and foot Infection (WIfI) classification correlates with wound healing in diabetic foot ulcers (DFUs) treated by a multidisciplinary team. The aim of this study was to compare WIfI classification vs DP and pedal arch patency as predictors of wound healing in patients presenting with DFU and peripheral arterial disease. METHODS: We performed a retrospective review of a prospectively maintained database of all patients with peripheral arterial disease presenting to our multidisciplinary DFU clinic who underwent angiography. An angiosome was considered directly perfused if the artery feeding the angiosome was revascularized or was completely patent. Wound healing time at 1 year was compared on the basis of DP vs indirect perfusion, Rutherford pedal arch grade, and WIfI classification using univariable statistics and Cox proportional hazards models. RESULTS: Angiography was performed on 225 wounds in 99 patients (mean age, 63.3 ± 1.2 years; 62.6% male; 53.5% black) during the entire study period. There were 33 WIfI stage 1, 33 stage 2, 51 stage 3, and 108 stage 4 wounds. DP was achieved in 154 wounds (68.4%) and indirect perfusion in 71 wounds (31.6%). On univariable analysis, WIfI classification was significantly associated with improved wound healing (57.2% for WIfI 3/4 vs 77.3% for WIfI 1/2; P = .02), whereas DP and pedal arch patency were not (both, P ≥ .08). After adjusting for baseline patient and wound characteristics, WIfI stage remained independently predictive of wound healing (WIfI 3/4: hazard ratio [HR], 0.77; 95% confidence interval [CI], 0.67-0.88), whereas DP (HR, 0.82; 95% CI, 0.55-1.21) and pedal arch grade (HR, 0.85; 95% CI, 0.70-1.03) were not. CONCLUSIONS: In our population of patients treated by a multidisciplinary diabetic foot service, the Society for Vascular Surgery WIfI classification system was a stronger predictor of diabetic foot wound healing than DP or pedal arch patency. Our results suggest that a measure of wound severity should be included in all future studies assessing wound healing as an outcome, as differences in patients' wound characteristics may be a strong contributor to the variation of angiosome-directed perfusion results previously observed.


Asunto(s)
Angiografía , Pie Diabético/diagnóstico por imagen , Pie/irrigación sanguínea , Enfermedad Arterial Periférica/diagnóstico por imagen , Cicatrización de Heridas , Anciano , Bases de Datos Factuales , Pie Diabético/clasificación , Pie Diabético/fisiopatología , Pie Diabético/terapia , Femenino , Humanos , Masculino , Persona de Mediana Edad , Modelos Cardiovasculares , Enfermedad Arterial Periférica/clasificación , Enfermedad Arterial Periférica/fisiopatología , Enfermedad Arterial Periférica/terapia , Valor Predictivo de las Pruebas , Pronóstico , Flujo Sanguíneo Regional , Estudios Retrospectivos , Índice de Severidad de la Enfermedad , Factores de Tiempo , Grado de Desobstrucción Vascular
17.
J Vasc Surg ; 67(3): 876-886, 2018 03.
Artículo en Inglés | MEDLINE | ID: mdl-29017807

RESUMEN

OBJECTIVE: Readmission rates are known to be high for vascular surgery patients in general, but there are limited data describing the risk of surgical and nonsurgical readmission among patients with diabetic foot ulcers (DFUs). Our aim was to identify factors associated with unplanned readmission in DFU patients treated in a multidisciplinary setting. METHODS: We studied a single-center cohort of patients enrolled in a multidisciplinary diabetic foot service (July 2012-June 2017). Readmissions were stratified by planned vs unplanned and related vs unrelated to the wound and vascular status. Predictors of unplanned 30-day readmission were examined with univariable and multivariable logistic regression models including all covariates with P ≤ .10. RESULTS: There were 460 admissions in 206 patients during the study period, including 99 total readmissions (21.5%). Readmissions were categorized as planned (n = 18 [18.2%]) or unplanned (n = 81 [81.8%]) and as related (n = 67 [67.7%]) or unrelated (n = 32 [32.3%]) to the wound and vascular status. The most frequent reasons for unplanned 30-day readmission were deterioration of the foot wound (41%), vascular complications (15%), gastrointestinal complications (10%), cardiac complications (8%), and acute kidney injury (8%). The average length of stay for the initial admission was 9.0 ± 7.1 days, whereas the average unplanned readmission length of stay was 8.6 ± 9.1 days (P = .38). On univariable analysis, hypertension (odds ratio [OR], 2.80; 95% confidence interval [CI], 1.19-6.59), peripheral arterial disease (OR, 1.80; 95% CI, 1.09-2.99), and exposure to an open vascular operation (OR, 2.64; 95% CI, 1.34-5.17) were associated with a higher risk of 30-day unplanned readmission (P ≤ .02). Private, military, or self-pay insurance was protective (OR, 0.52; 95% CI, 0.28-0.97). Wound duration, location, and Wound, Ischemia, and foot Infection (WIfI) classification were not associated with readmission (P ≥ .22). After risk adjustment, only hypertension (OR, 2.80; 95% CI, 1.19-6.59) and current smoking (OR, 1.95; 95% CI, 1.02-3.73) were independently associated with 30-day unplanned readmission, but the predictive accuracy of the model was weak (C statistic = 0.69). CONCLUSIONS: We found a 17% unplanned 30-day readmission rate in this prospective cohort of DFU patients enrolled in a multidisciplinary diabetic foot service. Only current smoking and hypertension were independent predictors of readmission after risk adjustment. These findings suggest that implementation of a smoking cessation program may be beneficial to reduce unplanned readmissions in DFU patients. They also highlight the complexity involved in achieving comprehensive DFU care and the unpredictability of readmissions in this unique population of patients.


Asunto(s)
Pie Diabético/cirugía , Grupo de Atención al Paciente , Readmisión del Paciente , Complicaciones Posoperatorias/etiología , Técnicas de Cierre de Heridas/efectos adversos , Cicatrización de Heridas , Anciano , Baltimore , Terapia Combinada , Bases de Datos Factuales , Pie Diabético/complicaciones , Pie Diabético/diagnóstico , Pie Diabético/patología , Femenino , Humanos , Hipertensión/complicaciones , Tiempo de Internación , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Oportunidad Relativa , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/terapia , Estudios Retrospectivos , Factores de Riesgo , Fumar/efectos adversos , Factores de Tiempo , Resultado del Tratamiento
18.
Curr Diab Rep ; 18(8): 49, 2018 06 16.
Artículo en Inglés | MEDLINE | ID: mdl-29907898

RESUMEN

PURPOSE OF REVIEW: Hyperglycemia occurs frequently in hospitalized patients with stroke and peripheral vascular disease (PVD). Guidelines for inpatient glycemic management are not well established for this patient population. We will review the clinical impact of hyperglycemia in this acute setting and review the evidence for glycemic control. RECENT FINDINGS: Hyperglycemia in acute stroke is associated with poor short and long-term outcomes, and perioperative hyperglycemia in those undergoing revascularization for PVD is linked to increased post-surgical complications. Studies evaluating tight glucose control do not demonstrate improvement in clinical outcomes, although the risk for hypoglycemia increases substantially. Additional studies are needed to evaluate tight glucose goals relative to our current standard of care and the role of permissive hyperglycemia. Given the limited data to guide glycemic management in these patient populations, it is recommended that general guidelines for inpatient glycemic control be followed. Special considerations should be made to address factors that may impact glucose management, including neurological deficits and clinical changes that occur in the postoperative state.


Asunto(s)
Enfermedades Cardiovasculares/complicaciones , Hiperglucemia/complicaciones , Pacientes Internos , Humanos , Hiperglucemia/tratamiento farmacológico , Hipoglucemiantes/uso terapéutico , Insulina/uso terapéutico , Enfermedades Vasculares Periféricas/complicaciones , Enfermedades Vasculares Periféricas/cirugía , Accidente Cerebrovascular/complicaciones
19.
J Surg Res ; 224: 102-111, 2018 04.
Artículo en Inglés | MEDLINE | ID: mdl-29506825

RESUMEN

BACKGROUND: Socioeconomic deprivation is associated with poor glycemic control and higher hospital admission rates in patients with diabetes. We sought to quantify the effects of neighborhood socioeconomic deprivation on wound healing among a cohort of patients with diabetic foot ulceration (DFU) treated in a multidisciplinary setting. METHODS: Socioeconomic disadvantage was calculated for all patients using the area deprivation index (ADI) stratified by quartile (from ADI-0: least through ADI-3: most). Predictors of wound healing were assessed using Cox proportional hazards models accounting for patient demographics, wound characteristics, and ADI category. RESULTS: Six hundred twenty-one wounds were evaluated, including 59% ADI-0, 7% ADI-1, 12% ADI-2, and 22% ADI-3. After accounting for patient demographics and wound characteristics, the likelihood of wound healing was similar between groups (ADI-3 versus ADI-0: hazards ratio [HR] 1.03 [95% confidence interval 0.76-1.41]). Independent predictors of poor wound healing included peripheral arterial disease (HR 0.75), worse wound stage (stage 4: HR 0.48), larger wound area (HR 0.99), and partially dependent functional status (HR 0.45) (all, P < 0.05). CONCLUSIONS: In a multidisciplinary setting, wound healing was largely dependent on wound characteristics and vascular status rather than patient demographics or neighborhood socioeconomic disadvantage. Use of a multidisciplinary approach to the management of DFU may overcome the negative effects of socioeconomic disadvantage frequently described in the diabetic population.


Asunto(s)
Pie Diabético/fisiopatología , Cicatrización de Heridas , Adolescente , Adulto , Anciano , Niño , Preescolar , Pie Diabético/terapia , Femenino , Humanos , Renta , Lactante , Recién Nacido , Seguro de Salud , Masculino , Persona de Mediana Edad , Modelos de Riesgos Proporcionales , Características de la Residencia , Estudios Retrospectivos , Clase Social , Adulto Joven
20.
J Med Internet Res ; 20(2): e72, 2018 02 27.
Artículo en Inglés | MEDLINE | ID: mdl-29487046

RESUMEN

BACKGROUND: Prediabetes is a high-risk state for the future development of type 2 diabetes, which may be prevented through physical activity (PA), adherence to a healthy diet, and weight loss. Mobile health (mHealth) technology is a practical and cost-effective method of delivering diabetes prevention programs in a real-world setting. Sweetch (Sweetch Health, Ltd) is a fully automated, personalized mHealth platform designed to promote adherence to PA and weight reduction in people with prediabetes. OBJECTIVE: The objective of this pilot study was to calibrate the Sweetch app and determine the feasibility, acceptability, safety, and effectiveness of the Sweetch app in combination with a digital body weight scale (DBWS) in adults with prediabetes. METHODS: This was a 3-month prospective, single-arm, observational study of adults with a diagnosis of prediabetes and body mass index (BMI) between 24 kg/m2 and 40 kg/m2. Feasibility was assessed by study retention. Acceptability of the mobile platform and DBWS were evaluated using validated questionnaires. Effectiveness measures included change in PA, weight, BMI, glycated hemoglobin (HbA1c), and fasting blood glucose from baseline to 3-month visit. The significance of changes in outcome measures was evaluated using paired t test or Wilcoxon matched pairs test. RESULTS: The study retention rate was 47 out of 55 (86%) participants. There was a high degree of acceptability of the Sweetch app, with a median (interquartile range [IQR]) score of 78% (73%-80%) out of 100% on the validated System Usability Scale. Satisfaction regarding the DBWS was also high, with median (IQR) score of 93% (83%-100%). PA increased by 2.8 metabolic equivalent of task (MET)-hours per week (SD 6.8; P=.02), with mean weight loss of 1.6 kg (SD 2.5; P<.001) from baseline. The median change in A1c was -0.1% (IQR -0.2% to 0.1%; P=.04), with no significant change in fasting blood glucose (-1 mg/dL; P=.59). There were no adverse events reported. CONCLUSIONS: The Sweetch mobile intervention program is a safe and effective method of increasing PA and reducing weight and HbA1c in adults with prediabetes. If sustained over a longer period, this intervention would be expected to reduce diabetes risk in this population. TRIAL REGISTRATION: ClincialTrials.gov NCT02896010; https://clinicaltrials.gov/ct2/show/NCT02896010 (Archived by WebCite at http://www.webcitation.org/6xJYxrgse).


Asunto(s)
Aplicaciones Móviles/normas , Estado Prediabético/terapia , Telemedicina/métodos , Adulto , Femenino , Humanos , Masculino , Proyectos Piloto , Estado Prediabético/patología , Estudios Prospectivos , Encuestas y Cuestionarios , Pérdida de Peso
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