Home Telemonitoring to Reduce Readmission of High-Risk Patients: a Modified Intention-to-Treat Randomized Clinical Trial.

BACKGROUND: Home telemonitoring has been used with discharged patients in an attempt to reduce 30-day readmissions with mixed results. OBJECTIVE: To assess whether home 30-day telemonitoring after discharge for patients at high risk of readmission would reduce readmissions or mortality. DESIGN: Prospective, randomized controlled trial. PATIENTS: We compared 30-day readmission rates and mortality for patients at high risk for readmission who received home telemonitoring versus standard care between November 1, 2014, and November 30, 2018, in 2 tertiary care hospitals. INTERVENTIONS: The intervention group received home-installed equipment to measure blood pressure, heart rate, pulse oximetry, weight if heart failure was present, and glucose if diabetes was present. Results were transmitted daily and reviewed by a nurse. Both groups received standard care. MAIN MEASURES: The primary outcome was a composite end point of hospital readmission or death within 30 days after discharge. The secondary outcome was an emergency department visit within 30 days after discharge. KEY RESULTS: A total of 1380 participants (mean [SD] age, 66 [14] years; 722 [52.3%] men and 658 [47.7%] women) participated in this study. Using a modified intention-to-treat analysis, the risk of readmission or death within 30 days among patients at high readmission risk was 23.7% (137/578) in the control group and 18.2% (87/477) in the telemonitoring group (absolute risk difference, - 5.5% [95% CI, - 10.4 to - 0.6%]; relative risk, 0.77 [95% CI, 0.61 to 0.98]; P = .03). Emergency department visits occurred within 30 days after discharge in 14.2% (81/570) of patients in the control group and 8.6% (40/464) of patients in the telemonitoring group (absolute risk difference, - 5.6% [95% CI, - 9.4 to - 1.8%]; relative risk, 0.61 [95% CI, 0.42 to 0.87]; P = .005). CONCLUSIONS: Thirty days of postdischarge telemonitoring may reduce readmissions of high-risk patients. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT02136186.

Inpatient to outpatient transfer of diabetes care: planing for an effective hospital discharge.

OBJECTIVE: To review data on diabetes discharge planning, provide a definition of an effective diabetes discharge, and summarize one institution's diabetes discharge planning processes in a teaching hospital. METHODS: We performed a MEDLINE search of the English-language literature published between January 1998 and December 2007 for articles related to the inpatient to outpatient transition of diabetes care. Regulatory guidelines about discharge planning were reviewed. We also analyzed our institution's procedures regarding hospital discharge. RESULTS: We define an effective diabetes discharge as one where the patient has received the necessary skills training and been provided with a clear and understandable postdischarge plan for diabetes care that has been clearly documented and is accessible by the patient's outpatient health care team. Diabetes is one of the most common conditions managed in the hospital, yet how to transition a patient with diabetes to the outpatient setting is understudied, and the outcome of patients with diabetes after discharge is unknown. Strategies that can be used to ensure an effective diabetes discharge are early identification of patients in need of education, implementation of a clinical pathway, and clear instructions about medications and follow-up appointments at the time of discharge. CONCLUSIONS: Effective transfer of care from the inpatient to the outpatient setting remains a priority in the United States. Studies are needed to better define how best to ensure that patients with diabetes are successfully transitioned to ambulatory care.

Temporal and geographic patterns of hypoglycemia among hospitalized patients with diabetes mellitus.

BACKGROUND: Hypoglycemia is often cited as a barrier to achieving inpatient glycemic targets. We sought to characterize hypoglycemic events in our institution by work-shift cycle and by specific treatment area. METHODS: Capillary (bedside) and blood (laboratory) glucose values of <70 mg/dl for patients with either a known diagnosis of diabetes or with evidence of hyperglycemia were abstracted from our laboratory database for hospitalizations between October 1, 2007, and February 3, 2008. Hypoglycemic events were analyzed by 12 h nursing work-shift cycles (day shift, 07:00 to 18:59; night shift, 19:00 to 06:59) and by the six medical, surgical, and intensive care areas in the hospital (designated areas 1 to 6). RESULTS: We identified 206 individual patients with either diabetes or hyperglycemia (mean age, 67 years; 56% men; 83% white) who had 423 hypoglycemic events. There were 78% more hypoglycemic events during the night shift (n = 271 events in 128 individual patients) than during the day shift (n = 152 events in 96 individual patients). Most of the night-shift hypoglycemic measurements were detected between 04:00 and 04:59 or 06:00 and 06:59. The mean hypoglycemic level was comparable between shifts (p = .79) and across the six inpatient areas. The number of hypoglycemic events per person increased with lengths of hospital stay >5 days. The prevalence of hypoglycemia varied across patient care areas within the hospital, with most (28%) detected in one area of the hospital. CONCLUSION: There are temporal and geographic patterns in the occurrence of hypoglycemia among patients with diabetes or hyperglycemia in our hospital. Further study should focus on the reasons underlying these variations so that specific interventions can address the risk of hypoglycemia during peak times and places.

Development of computer-based training to enhance resident physician management of inpatient diabetes.

BACKGROUND: Treating hyperglycemia promotes better outcomes among inpatients. Knowledge deficits about management of inpatient diabetes are prevalent among resident physicians, which may affect the care of a substantial number of these patients. METHODS: A computer-based training (CBT) curriculum on inpatient diabetes and hyperglycemia was developed and implemented for use by resident physicians and focuses on several aspects of the management of inpatient diabetes and hyperglycemia: (1) review of importance of inpatient glucose control, (2) overview of institution-specific data, (3) triaging and initial admission actions for diabetes or hyperglycemia, (4) overview of pharmacologic management, (5) insulin-dosing calculations and ordering simulations, (6) review of existing policies and procedures, and (7) discharge planning. The curriculum was first provided as a series of lectures, then formatted and placed on the institutional intranet as a CBT program. RESULTS: Residents began using the inpatient CBT in September 2008. By August 2009, a total of 29 residents had participated in CBT: 8 in family medicine, 12 in internal medicine, and 9 in general surgery. Most of the 29 residents confirmed that module content met stated objectives, considered the information valuable to their inpatient practices, and believed that the quality of the online modules met expectations. The majority reported that the modules took just the right amount of time to complete (typically 30 min each). CONCLUSIONS: Improvement in inpatient diabetes care requires continuous educational efforts. The CBT format and curriculum content were well accepted by the resident physicians. Ongoing assessment must determine whether resident practice patterns are influenced by such training.

Diabetes care in hospitalized noncritically ill patients: More evidence for clinical inertia and negative therapeutic momentum.

BACKGROUND: Little is known about management of hyperglycemia in inpatients. OBJECTIVE: To gain insight into caring for hospitalized patients with hyperglycemia. DESIGN: Retrospective analysis. SETTING: Teaching hospital. PATIENTS: Data on all patients discharged between January 1, 2001, and December 31, 2004 with a diagnosis of diabetes or hyperglycemia were extracted and linked to laboratory and pharmacy databases. Only the data on patients who did not require intensive care and who were hospitalized for at least 3 days were analyzed. MEASUREMENTS: Average bedside glucose during the first and last 24 hours of hospital stay and for the entire length of stay; assessment of changes in insulin regimen and dose. RESULTS: The average age of patients included in the study (n = 2916) was 69 years. Fifty-seven percent of the patients were men, 90% were white, and average length of stay was 5.7 days. More than 20% of the patients had evidence of sustained hyperglycemia. Forty-two percent of the patients who showed poor control of glycemia (glucose > 200 mg/dL) during the first 24 hours were discharged in poor control. The frequency of hypoglycemia was low (only 2.2 of 100 measurements per person) compared with hyperglycemia (25.5 of 100 measurements per person). Most patients (72%) received insulin during hospitalization, but there was high use of short-acting insulin and less than optimal intensification of therapy (clinical inertia); many patients had insulin therapy decreased despite persistent hyperglycemia (negative therapeutic momentum). CONCLUSIONS: Glycemic control in the hospital was frequently poor, and there was suboptimal use of insulin, even among patients with sustained hyperglycemia. Educational programs directed at practitioners should focus on the importance of inpatient glucose control and provide guidelines on how and when to change therapy.

Management of inpatient hyperglycemia: assessing perceptions and barriers to care among resident physicians.

OBJECTIVE: To develop insight into resident physician attitudes about inpatient hyperglycemia and determine perceived barriers to optimal management. METHODS: As part of a planned educational program, a questionnaire was designed and administered to determine the opinions of residents about the importance of inpatient glucose control, their perceptions about what glucose ranges were desirable, and the problems they encountered when trying to manage hyperglycemia in hospitalized patients. RESULTS: Of 70 resident physicians from various services, 52 completed the survey (mean age, 31 years; 48% men; 37% in first year of residency training). Most respondents indicated that glucose control was "very important" in critically ill and perioperative patients but only "somewhat important" in non-critically ill patients. Most residents indicated that they would target a therapeutic glucose range within the recommended levels in published guidelines. Most residents also said they felt "somewhat comfortable" managing hyperglycemia and hypoglycemia and using subcutaneous insulin therapy, whereas most residents (48%) were "not at all comfortable" with use of intravenous administration of insulin. In general, respondents were not very familiar with existing institutional policies and preprinted order sets relating to glucose management. The most commonly reported barrier to management of inpatient hyperglycemia was lack of knowledge about appropriate insulin regimens and how to use them. Anxiety about hypoglycemia was only the third most frequent concern. CONCLUSION: Most residents acknowledged the importance of good glucose control in hospitalized patients and chose target glucose ranges consistent with existing guidelines. Lack of knowledge about insulin treatment options was the most commonly cited barrier to ideal management. Educational programs should emphasize inpatient treatment strategies for glycemic control.