Inpatient Diabetes Education Seems to Reduce Readmissions

Miriam E. Tucker

July 05, 2013

CHICAGO — Formal inpatient diabetes education was associated with a reduction in the rate of hospital readmission for patients with poorly controlled diabetes, a new study has found.

Another study, of Medicare beneficiaries with type 2 diabetes, found that major risk factors for readmission are patient complexity, older age, and longer duration of initial hospital stay.

Both studies were presented here at the American Diabetes Association (ADA) 2013 Scientific Sessions, the first by Sara J. Healy, MD, a soon-to-be endocrinology fellow at the Ohio State University Medical Center in Columbus, and the second by Sandipan Bhattacharjee, a graduate student in pharmaceutical systems and policy at the Robert C. Byrd Health Sciences Center in Morgantown, West Virginia.

Hospital readmission is a major target of healthcare quality-improvement efforts. Since October 2012, hospitals have had their Medicare reimbursement cut if their 30-day readmission rates for pneumonia, heart failure, and heart attacks exceed a certain threshold. It is expected that other conditions will be added, Dr. Healy noted in her presentation.

"There is unlikely to be a magic bullet to reduce readmissions; this seems to be true among patients with diabetes as well," said Kasia Lipska, MD, an endocrinologist from the Yale University School of Medicine in New Haven, Connecticut, who has conducted research into hospital-related issues in Medicare beneficiaries with diabetes. "Patients who are particularly vulnerable to begin with, such as those who are older and have multiple comorbidities, appear to be most likely to be readmitted," she told Medscape Medical News.

"Complex patients with diabetes may be vulnerable to multiple complications following admission, and there is no one-size-fits-all cure for that," added Dr. Lipska.

Did Diabetes Education Reduce Hospital Readmission?

Dr. Healy presented retrospective data on patients hospitalized at her institution from 2008 to 2010 with a discharge diagnosis of diabetes (type 1 or type 2) and glycated hemoglobin levels (HbA1c) greater than 9%.

The researchers conducted a 30-day analysis of 2265 patients and a 180-day analysis of 2069 patients.

Inpatient diabetes education was delivered to 43% of the patients by dedicated nurse-educators. It comprised individualized teaching and basic survival skills, and insulin-using patients were taught insulin-pump management and carbohydrate counting. Participants received materials to take home and some received supplies; when needed, educators also assisted with medication reconciliation and ensured that patients had appropriate prescriptions.

Readmission rates were lower for those who received the education than for those who did not (11% vs 16%; P = .0001), Dr. Healy reported.

At 30 days, 33% of those who were readmitted had received an education consult, compared with 44% of those not readmitted. At 180 days, 37% of those readmitted had received education, compared with 45% of those not readmitted.

After adjustment for a variety of factors — including socioeconomic status, HbA1c, length of initial stay, type of insurance, and top 3 discharge diagnoses — the education was independently associated with a 34% reduction in readmission risk at 30 days (P = .001). At 180 days, the education was associated with a 20% reduction in readmission (P = .04).

Higher HbA1c was associated with a lower readmission rate only for patients who had received the education. Patients of all races who received the education had a lower risk for readmission at 30 days; at 180 days, that benefit was seen only for black patients.

"These data support a role of the diabetes educator beyond the management of diabetes emergencies. One explanation for this broad effect could be through modifying comorbidities with improved glycemic control. In addition, diabetes education may have a more indirect effect, by promoting compliance to diet, medications, and better self-care behaviors in general," Dr. Healy concluded in her presentation.

However, Dr. Lipska urged caution in interpreting the findings. "Diabetes education may be associated with other 'high-quality' features of hospital admission and discharge planning, which may have not been measured but that influence the risk for readmission. It's important to note that they found an association, but this association is not necessarily causal... Prospective studies are needed," she told Medscape Medical News.

Readmission Risk Factors

Meanwhile, Mr. Bhattacharjee presented retrospective data on 202,496 Medicare Advantage Plan enrollees with type 2 diabetes who had been hospitalized between July 1, 2007 and August 30, 2011. A total of 24% were readmitted for any cause — 13% within 30 days and 11% from 31 to 120 days.

Baseline characteristics that increased the risk for readmission included being older than 75 years (15.0%) and having severe diabetes complications at baseline (15.7% for those with a Diabetes Complications Severity Index score in the highest quartile).

On multivariate analysis, 30-day readmission was associated with complications specific to the elderly, including urinary incontinence (adjusted odds ratio [OR], 1.12), cognitive impairment (adjusted OR, 1.22), and falls (adjusted OR, 1.2). A diagnosis of cancer also increased the risk (adjusted OR, 1.18).

"The message from our study is that certain patient characteristics, such as complexity and older age, should be carefully considered when treating elderly individuals with diabetes. The intervention programs should be tailored to the specific needs of individual patients," Mr. Bhattacharjee told Medscape Medical News.

Dr. Healy, Mr. Bhattacharjee, and Dr. Lipska have disclosed no relevant financial relationships. Dr. Lipska blogs for Medscape Medical News about diabetes meetings.

American Diabetes Association (ADA) 2013 Scientific Sessions. Abstracts 262-OR and 311-OR, presented June 24, 2013.


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