- Email: [email protected]
Impact of inpatient diabetes transitions of care consult on glycemic control
G Model PEC 6498 No. of Pages 3
Patient Education and Counseling xxx (2019) xxx–xxx
Contents lists available at ScienceDirect
Patient Education and Counseling journal homepage: www.elsevier.com/locate/pateducou
Short Communication
Impact of inpatient diabetes transitions of care consult on glycemic control Ashleigh Powers, Marquita Winder* , MaryAnne Maurer, Kevin Brittain Columbia VA Medical Center, 6439 Garners Ferry Road, Columbia, SC 29209, United States
A R T I C L E I N F O
A B S T R A C T
Article history: Received 2 July 2019 Received in revised form 15 January 2020 Accepted 17 January 2020
Objective(s): An evaluation of a diabetes consult service for hospitalized patients was completed to determine effect on glycemic control. Methods: This medical record review was conducted to determine impact of a short-term program on patients with diabetes. The electronic medical record was used to identify patients diagnosed with diabetes mellitus and hospitalized from September 2016 to September 2017. A case-control design was utilized to compare patients with an inpatient order for the diabetes transitions of care service to those receiving usual care. The consultation service consisted of inpatient diabetes education and follow-up post discharge. The HbA1c reduction of adult inpatients those who completed a consult (n = 67) and those who received usual care (n = 67) were compared. Statistical analyses were conducted. Results: For the primary outcome of HbA1c reduction at 3 months, absolute difference from baseline to 3 months in the intervention was -2.9 % compared to 0.9 % in the control group (p < 0.001). Conclusions: Participation in the service reduced HbA1c at 3 months and 6 months post-discharge, reduced 30-day all-cause readmissions, and increased percentage of patients with HbA1c <9.0 % at 6 months post-discharge. Practical implications: A consult-based diabetes transitions of care service decreased HbA1c versus usual care. Published by Elsevier B.V.
Keywords: Transitions of care Diabetes Inpatient diabetes management Discharge Readmissions Inpatient diabetes education Hospitalization
1. Introduction The United States was deemed one of the top 10 countries for number of adults with diabetes and healthcare expenditure for 2017 [1]. It has been previously demonstrated that people with diabetes have hospital admission rates up to 6 times higher than people without diabetes [2–7]. Evidence is increasing regarding the challenges of inpatient diabetes management [8–10]. Provided that, there is much debate surrounding if inpatient diabetes education is a value-added service for the patient [11]. Diabetes self-management education is the process of facilitating skill, knowledge and ability necessary for diabetes self-care [12]. Engagement in diabetes self-management education and inpatient diabetes management has been shown to significantly decrease hemoglobin A1c (HbA1c) levels post-discharge [13,14]. Some perceived barriers to education include acuity of patients, limited amount of diabetes educators in an inpatient setting and abundant resources for outpatient education [11].
* Corresponding author at: 6439 Garners Ferry Road, Columbia, SC 29209, United States. E-mail address: [email protected] (M. Winder).
Approximately 15 % of certified diabetes educators reported practicing in an inpatient setting. According to the American Association of Diabetes Educators, the role of diabetes educators includes evaluating outcomes of facilitating transitions and care coordination efforts [15]. We conducted a retrospective, case cohort study to determine the effect of a diabetes transitions of care service on glycemic control using hemoglobin A1c (HbA1c) at 3 months after discharge. 2. Methods 2.1. Recruitment and enrollment The electronic medical record was used to identify patients with variables of interest for this single-center, retrospective, casecohort study conducted at a 216-bed teaching hospital in the U.S. Department of Veterans Affairs Health Care System. American Veterans aged 18 years or older with a diagnosis of type 1 or type 2 diabetes mellitus were randomized if they were admitted to the medical facility from September 2016 to September 2017. Patients were categorized in the control group or intervention group. Patients were included in the interventional cohort if an inpatient consult order was entered and completed by the clinical
https://doi.org/10.1016/j.pec.2020.01.010 0738-3991/Published by Elsevier B.V.
Please cite this article in press as: A. Powers, et al., Impact of inpatient diabetes transitions of care consult on glycemic control, Patient Educ Couns (2020), https://doi.org/10.1016/j.pec.2020.01.010
G Model PEC 6498 No. of Pages 3
2
A. Powers et al. / Patient Education and Counseling xxx (2019) xxx–xxx
pharmacist who was also a certified diabetes care and education specialist. These patients were matched using a 1:1 ratio to a control cohort consisting of patients diagnosed with type 1 or type 2 diabetes admitted to the facility receiving usual care which consisted of text orders to nursing staff or other house staff to provide education. Patients were excluded if they were deceased during admission or within 6 months post-intervention, were pregnant, had a debilitating condition during index admission prohibiting inpatient education (e.g. mechanical ventilation), were discharged to a skilled nursing facility or long-term care facility following index admission, or were enrolled in hospice care within 6 months post-discharge. Between September 2016 to September 2017, consults were completed for 79 patients. Of these, 12 were excluded in total; 9 patients were deceased and 3 were discharged to a skilled nursing facility. 2.2. Inpatient education A consult-based service to assist hospitalized veterans with diabetes self-management and education was marketed to hospitalists, physician residents and clinical pharmacists. Hospitalized patients were eligible for consult service referral if they were identified by the medicine service as either high risk or newly diagnosed patients with diabetes. The diabetes transitions of care clinical pharmacist, who is also a certified diabetes care and education specialist, completed all consults at bedside during admission. The hours of operation for the consult service were 8 a.m. to 4:30 pm Monday through Friday. Inpatient education consisted of delivering a Diabetes Basic Survival Skills booklet, which briefly reviewed diabetes pathophysiology, role of diet on blood glucose levels, medications, importance of self-monitoring blood glucose levels, treatment goals, and appropriate management of hypoglycemia. Patients were also given additional education documents depending on identified needs or barriers (i.e. review of proper insulin administration, sick day management, carbohydrate counting). All educational materials were facility approved and were designed on a fifth- to seventh-grade reading level. Additional inpatient services rendered included distributing glucometers as clinically indicated, providing patients with resources to refill medications, dispensing pill boxes, and delivering education on medication administration (i.e. insulin vials, insulin pens, and glucagon-like peptide 1 receptor agonist pens). All education was confirmed using teach-back method. 2.3. Transitions of care and outpatient follow-up Patients were followed by the clinical pharmacist throughout duration of their inpatient stay. Following discharge, the clinical pharmacist would coordinate with outpatient providers to ensure post-hospitalization follow-up. Potential transitions included enrolling patients into a primary care pharmacist clinic for intensive diabetes management, ensuring follow-up with a specialist (i.e. endocrinologist or nephrologist), or providing telephone follow-up with the diabetes transitions of care pharmacist until the patient was seen by the primary care provider. Importance of presenting to appointments was emphasized with all patients during admission, and all patients received a contact phone number for the transitional care provider for questions. 2.4. Definitions of care Patients in the intervention group received the aforementioned inpatient education and discharge coordination. Patients included in the control cohort received usual care, defined as routine diabetes education completed by floor nurses, discharge
pharmacists, or inpatient clinical pharmacists during daily rounds. Contrary to previous studies, patients admitted to the psychiatric unit were also included in this study. HbA1c was analyzed at baseline, 3 months and 6 months. 2.5. Data collected Data collected from patients in both interventional and control cohorts included: demographics (age in years, race, gender), BMI, baseline HbA1c, diabetes therapy prior to admission, length of stay, number of unscheduled readmissions within 30 days following index admission, emergency department visit rates for hypoglycemia and hyperglycemia, and number of face-to-face and telephone appointments with the transitions of care service within 6 months post-discharge. 2.6. Statistical analysis Statistical analyses were conducted using R statistical software, version 3.4.2. Patient demographic information was described using measures of central tendency and spread for continuous data and frequencies and percentages for categorical data; t-tests were used to compare group differences in patient demographics. Fisher’s Exact Tests and Chi-squared were used to compare dichotomous variables. Chi-squared tests were used for categorical variables. Mann-Whitney tests were used for continuously distributed nonparametric data. 3. Results 3.1. Baseline characteristics A total of 67 patients met criteria for inclusion in the intervention group; those patients were each matched using a 1:1 ratio to patients in a control group. At baseline (Table 1), average age was 63 years of age, with 89.6 % of patients being male in both groups. Average baseline HbA1c in the control group was 9.3 % vs. 11.2 % in the intervention group. 3.2. Outcomes For the primary outcome of HbA1c reduction at 3 months, absolute difference from baseline to 3 months in the intervention was -2.9 % compared to 0.8% in the control group (p < 0.001) Table 1 Baseline characteristics. Characteristic Gender, %a Male Female Age in years, mean SDb Classification of Diabetesa Type 1 Diabetes, % Type 2 Diabetes, % Subcategorization on Admissiona Newly Diagnosed Diabetes, % Uncontrolled Diabetes, % HbA1c, %c Charlson Comorbidity Indexc Insulin Oral agents Insulin + oral agents No medications a b c
Control, N=67 Intervention, N=67 P value 1 89.6 10.4 62 9.5
89.6 10.4 63 8.4
1.5 98.5
1.5 98.5
1.5 98.5 9.31 4.3 34.3 31.3 26.9 7.5
14.9 85.1 11.27 4.3 34.3 29.9 11.9 23.9
0.95 1
< 0.01
< 0.01 1 1 0.85 0.08 <0.01
Pearson chi-square (categorical variables). Two-sample t tests (normal distribution). Mann-Whitney test (nonparametric).
Please cite this article in press as: A. Powers, et al., Impact of inpatient diabetes transitions of care consult on glycemic control, Patient Educ Couns (2020), https://doi.org/10.1016/j.pec.2020.01.010
G Model PEC 6498 No. of Pages 3
A. Powers et al. / Patient Education and Counseling xxx (2019) xxx–xxx Table 2 HbA1c at 3 months.
Mean Variance Observations Pooled Variance Hypothsized Mean Difference df t Stat P(T<=t) one-tail t Critical one-tail P(T<=) two-tail t Critical two-tail
3
Declaration of Competing Interest Control
Intervention
0.88 3.34 35 6.29 0 73 3.63 <0.01 1.67 <0.01 1.99
2.99 8.87 40
The authors of this manuscript have nothing to disclose. Acknowledgements This material is the result of work supported with resources and the use of the facilities at the Columbia VA Health Care System. The contents and views expressed in this article are those of the authors and do not represent the views of the U.S. Department of Veterans Affairs or the United States Government. References
(Table 2). HbA1c at 6 months post-discharge was reduced on average by 2.5 % in the intervention group, compared to 0.9 % in the control group (p = 0.031). Seventy-seven percent of patients in the intervention group had a HbA1c value of <9.0 % (75 mmol/mol) at 6 months post-discharge, compared to 72 % of patients in the control group (p = 0.427). There was no statistically significant difference in unscheduled 30-day readmissions or average length of stay. Rates of emergency department visits for hypoglycemia and hyperglycemia were also similar between groups. 4. Discussion Our study suggests that participation in a pharmacist led transitions-of-care program can improve glycemic control via reduction in HbA1c at 3 months and 6 months post-discharge. Our observations are similar to those of Brumm et al. [16] who reported average A1c reduction of 2.2 % measured 2–8 months after enrollment in a diabetes transitions of care program. Our findings also bolster earlier findings from Dungan et al. that individualized inpatient diabetes education and transition programs are associated with a significant reduction in HbA1c dependent on baseline HbA1c, older age and initiation of insulin [17]. Our study has several limitations. As HbA1c is based on normal hemoglobin, increased red blood cell hemolysis with some hemoglobin variants or decreased number of white blood cells (i.e. anemia) may cause falsely low HbA1c values [18]. We did not exclude patients with hemoglobin variants (i.e. sickle cell trait) or anemia, thus the effect may not have been as large. Our study also has potentially limited generalizability due to the small sample size, single center study design and retrospective study design. 5. Conclusion A consult-based diabetes transitions of care service decreased HbA1c versus usual care. 6. Practical implications Our findings indicate that inpatient diabetes education and short-term follow-up post discharge is a value-added service. Funding
[1] International Diabetes Federation, IDF Diabetes Atlas, 8th edn, International Diabetes Federation, Brussels, Belgium, 2017. http://www.diabetesatlas.org. [2] S. Aro, T. Kangas, A. Reunanen, M. Salinto, V. Koivisto, Hospital use among diabetic patients and the general population, Diabetes Care 17 (11) (1994) 1320–1329. [3] S. Bo, G. Ciccone, G. Grassi, R. Gancia, R. Rosato, F. Merletti, et al., Patients with type 2 diabetes had higher rates of hospitalization than the general population, J. Clin. Epidemiol. 57 (11) (2004) 1196–1201. [4] M.J. Rosenthal, M. Fajardo, S. Gilmore, J.E. Morley, B.D. Naliboff, Hospitalization and mortality of diabetes in older adults. A 3-year prospective study, Diabetes Care 21 (2) (1998) 231–235. [5] P.T. Donnan, G.P. Leese, A.D. Morris, et al., Hospitalizations for people with type 1 and type 2 diabetes compared with the nondiabetic population of Tayside, Scotland: a retrospective cohort study of resource use, Diabetes Care 23 (12) (2000) 1774–1779. [6] G. De Berardis, A. D’Ettorre, G. Graziano, G. Lucisano, F. Pellegrini, S. Cammarota, et al., The burden of hospitalization related to diabetes mellitus: a population-based study, Nutr. Metab. Cardiovasc. Dis. 22 (7) (2012) 605–612. [7] F. Carral, G. Olveira, J. Salas, L. Garcia, A. Sillero, M. Aguilar, Care resource utilization and direct costs incurred by people with diabetes in a Spanish hospital, Diabetes Res. Clin. Pract. 56 (1) (2002) 27–34. [8] G.E. Umpierrez, Inpatient management of diabetes: an increasing challenge to the hospitalist physician, J. Hosp. Med. 2 (Suppl. 1) (2007) 33–35. [9] L.A. Knecht, S.M. Gauthier, J.C. Castro, R.E. Schmidt, M.D. Whitaker, R. Zimmerman, et al., Diabetes care in the hospital: Is there clinical inertia? J. Hosp. Med. 1 (3) (2006) 151–160. [10] C.B. Cook, K.M. Seifert, B.P. Hull, et al., Inpatient to outpatient transfer of diabetes care: planning for an effective hospital discharge, Endocr. Pract. 15 (3) (2009) 263–269. [11] A.T. Nettles, Patient education in the hospital, Diabetes Spectr. 18 (1) (2005) 44–48. [12] M.A. Powers, J. Bardsley, M. Cypress, P. Duker, M.M. Funnell, A. Hess Fischl, et al., Diabetes self-management education and support in type 2 diabetes: a joint position statement of the american diabetes association, the american association of diabetes educators, and the academy of nutrition and dietetics, Diabetes Care 38 (7) (2015) 1372–1382. [13] C.A. Chrvala, D. Sherr, R.D. Lipman, Diabetes self-management education for adults with type 2 diabetes mellitus: a systematic review of the effect on glycemic control, Patient Educ. Couns. 99 (6) (2016) 926–943. [14] D.J. Wexler, C.C. Beauharnais, S. Regan, D.M. Nathan, E. Cagliero, M.E. Larkin, Impact of inpatient diabetes management, education, and improved discharge transition on glycemic control 12 months after discharge, Diabetes Res. Clin. Pract. 98 (2) (2012) 249–256. [15] American Association of Diabetes Educators, Role of the diabetes educator in inpatient diabetes management, Diabetes Educ. 44 (1) (2018) 57–62. [16] S. Brumm, K. Theisen, M. Falciglia, Diabetes transition care from an inpatient to outpatient setting in a veteran population, Diabetes Educ. 42 (1) (2016) 346– 353. [17] K. Dungan, S. Lyons, K. Manu, M. Kulkarni, K. Ebrahim, C. Grantier, et al., An individualized inpatient diabetes education and hospital transition program for poorly controlled hospitalized patients with diabetes, Endocr. Pract. 20 (12) (2014) 1265–1273. [18] A. Smaldone, Glycemic Control and Hemoglobinopathy: When A1c May Not Be Reliable, Diabetes Spectr. 21 (1) (2008) 46–49.
None.
Please cite this article in press as: A. Powers, et al., Impact of inpatient diabetes transitions of care consult on glycemic control, Patient Educ Couns (2020), https://doi.org/10.1016/j.pec.2020.01.010
Patient Education and Counseling xxx (2019) xxx–xxx
Contents lists available at ScienceDirect
Patient Education and Counseling journal homepage: www.elsevier.com/locate/pateducou
Short Communication
Impact of inpatient diabetes transitions of care consult on glycemic control Ashleigh Powers, Marquita Winder* , MaryAnne Maurer, Kevin Brittain Columbia VA Medical Center, 6439 Garners Ferry Road, Columbia, SC 29209, United States
A R T I C L E I N F O
A B S T R A C T
Article history: Received 2 July 2019 Received in revised form 15 January 2020 Accepted 17 January 2020
Objective(s): An evaluation of a diabetes consult service for hospitalized patients was completed to determine effect on glycemic control. Methods: This medical record review was conducted to determine impact of a short-term program on patients with diabetes. The electronic medical record was used to identify patients diagnosed with diabetes mellitus and hospitalized from September 2016 to September 2017. A case-control design was utilized to compare patients with an inpatient order for the diabetes transitions of care service to those receiving usual care. The consultation service consisted of inpatient diabetes education and follow-up post discharge. The HbA1c reduction of adult inpatients those who completed a consult (n = 67) and those who received usual care (n = 67) were compared. Statistical analyses were conducted. Results: For the primary outcome of HbA1c reduction at 3 months, absolute difference from baseline to 3 months in the intervention was -2.9 % compared to 0.9 % in the control group (p < 0.001). Conclusions: Participation in the service reduced HbA1c at 3 months and 6 months post-discharge, reduced 30-day all-cause readmissions, and increased percentage of patients with HbA1c <9.0 % at 6 months post-discharge. Practical implications: A consult-based diabetes transitions of care service decreased HbA1c versus usual care. Published by Elsevier B.V.
Keywords: Transitions of care Diabetes Inpatient diabetes management Discharge Readmissions Inpatient diabetes education Hospitalization
1. Introduction The United States was deemed one of the top 10 countries for number of adults with diabetes and healthcare expenditure for 2017 [1]. It has been previously demonstrated that people with diabetes have hospital admission rates up to 6 times higher than people without diabetes [2–7]. Evidence is increasing regarding the challenges of inpatient diabetes management [8–10]. Provided that, there is much debate surrounding if inpatient diabetes education is a value-added service for the patient [11]. Diabetes self-management education is the process of facilitating skill, knowledge and ability necessary for diabetes self-care [12]. Engagement in diabetes self-management education and inpatient diabetes management has been shown to significantly decrease hemoglobin A1c (HbA1c) levels post-discharge [13,14]. Some perceived barriers to education include acuity of patients, limited amount of diabetes educators in an inpatient setting and abundant resources for outpatient education [11].
* Corresponding author at: 6439 Garners Ferry Road, Columbia, SC 29209, United States. E-mail address: [email protected] (M. Winder).
Approximately 15 % of certified diabetes educators reported practicing in an inpatient setting. According to the American Association of Diabetes Educators, the role of diabetes educators includes evaluating outcomes of facilitating transitions and care coordination efforts [15]. We conducted a retrospective, case cohort study to determine the effect of a diabetes transitions of care service on glycemic control using hemoglobin A1c (HbA1c) at 3 months after discharge. 2. Methods 2.1. Recruitment and enrollment The electronic medical record was used to identify patients with variables of interest for this single-center, retrospective, casecohort study conducted at a 216-bed teaching hospital in the U.S. Department of Veterans Affairs Health Care System. American Veterans aged 18 years or older with a diagnosis of type 1 or type 2 diabetes mellitus were randomized if they were admitted to the medical facility from September 2016 to September 2017. Patients were categorized in the control group or intervention group. Patients were included in the interventional cohort if an inpatient consult order was entered and completed by the clinical
https://doi.org/10.1016/j.pec.2020.01.010 0738-3991/Published by Elsevier B.V.
Please cite this article in press as: A. Powers, et al., Impact of inpatient diabetes transitions of care consult on glycemic control, Patient Educ Couns (2020), https://doi.org/10.1016/j.pec.2020.01.010
G Model PEC 6498 No. of Pages 3
2
A. Powers et al. / Patient Education and Counseling xxx (2019) xxx–xxx
pharmacist who was also a certified diabetes care and education specialist. These patients were matched using a 1:1 ratio to a control cohort consisting of patients diagnosed with type 1 or type 2 diabetes admitted to the facility receiving usual care which consisted of text orders to nursing staff or other house staff to provide education. Patients were excluded if they were deceased during admission or within 6 months post-intervention, were pregnant, had a debilitating condition during index admission prohibiting inpatient education (e.g. mechanical ventilation), were discharged to a skilled nursing facility or long-term care facility following index admission, or were enrolled in hospice care within 6 months post-discharge. Between September 2016 to September 2017, consults were completed for 79 patients. Of these, 12 were excluded in total; 9 patients were deceased and 3 were discharged to a skilled nursing facility. 2.2. Inpatient education A consult-based service to assist hospitalized veterans with diabetes self-management and education was marketed to hospitalists, physician residents and clinical pharmacists. Hospitalized patients were eligible for consult service referral if they were identified by the medicine service as either high risk or newly diagnosed patients with diabetes. The diabetes transitions of care clinical pharmacist, who is also a certified diabetes care and education specialist, completed all consults at bedside during admission. The hours of operation for the consult service were 8 a.m. to 4:30 pm Monday through Friday. Inpatient education consisted of delivering a Diabetes Basic Survival Skills booklet, which briefly reviewed diabetes pathophysiology, role of diet on blood glucose levels, medications, importance of self-monitoring blood glucose levels, treatment goals, and appropriate management of hypoglycemia. Patients were also given additional education documents depending on identified needs or barriers (i.e. review of proper insulin administration, sick day management, carbohydrate counting). All educational materials were facility approved and were designed on a fifth- to seventh-grade reading level. Additional inpatient services rendered included distributing glucometers as clinically indicated, providing patients with resources to refill medications, dispensing pill boxes, and delivering education on medication administration (i.e. insulin vials, insulin pens, and glucagon-like peptide 1 receptor agonist pens). All education was confirmed using teach-back method. 2.3. Transitions of care and outpatient follow-up Patients were followed by the clinical pharmacist throughout duration of their inpatient stay. Following discharge, the clinical pharmacist would coordinate with outpatient providers to ensure post-hospitalization follow-up. Potential transitions included enrolling patients into a primary care pharmacist clinic for intensive diabetes management, ensuring follow-up with a specialist (i.e. endocrinologist or nephrologist), or providing telephone follow-up with the diabetes transitions of care pharmacist until the patient was seen by the primary care provider. Importance of presenting to appointments was emphasized with all patients during admission, and all patients received a contact phone number for the transitional care provider for questions. 2.4. Definitions of care Patients in the intervention group received the aforementioned inpatient education and discharge coordination. Patients included in the control cohort received usual care, defined as routine diabetes education completed by floor nurses, discharge
pharmacists, or inpatient clinical pharmacists during daily rounds. Contrary to previous studies, patients admitted to the psychiatric unit were also included in this study. HbA1c was analyzed at baseline, 3 months and 6 months. 2.5. Data collected Data collected from patients in both interventional and control cohorts included: demographics (age in years, race, gender), BMI, baseline HbA1c, diabetes therapy prior to admission, length of stay, number of unscheduled readmissions within 30 days following index admission, emergency department visit rates for hypoglycemia and hyperglycemia, and number of face-to-face and telephone appointments with the transitions of care service within 6 months post-discharge. 2.6. Statistical analysis Statistical analyses were conducted using R statistical software, version 3.4.2. Patient demographic information was described using measures of central tendency and spread for continuous data and frequencies and percentages for categorical data; t-tests were used to compare group differences in patient demographics. Fisher’s Exact Tests and Chi-squared were used to compare dichotomous variables. Chi-squared tests were used for categorical variables. Mann-Whitney tests were used for continuously distributed nonparametric data. 3. Results 3.1. Baseline characteristics A total of 67 patients met criteria for inclusion in the intervention group; those patients were each matched using a 1:1 ratio to patients in a control group. At baseline (Table 1), average age was 63 years of age, with 89.6 % of patients being male in both groups. Average baseline HbA1c in the control group was 9.3 % vs. 11.2 % in the intervention group. 3.2. Outcomes For the primary outcome of HbA1c reduction at 3 months, absolute difference from baseline to 3 months in the intervention was -2.9 % compared to 0.8% in the control group (p < 0.001) Table 1 Baseline characteristics. Characteristic Gender, %a Male Female Age in years, mean SDb Classification of Diabetesa Type 1 Diabetes, % Type 2 Diabetes, % Subcategorization on Admissiona Newly Diagnosed Diabetes, % Uncontrolled Diabetes, % HbA1c, %c Charlson Comorbidity Indexc Insulin Oral agents Insulin + oral agents No medications a b c
Control, N=67 Intervention, N=67 P value 1 89.6 10.4 62 9.5
89.6 10.4 63 8.4
1.5 98.5
1.5 98.5
1.5 98.5 9.31 4.3 34.3 31.3 26.9 7.5
14.9 85.1 11.27 4.3 34.3 29.9 11.9 23.9
0.95 1
< 0.01
< 0.01 1 1 0.85 0.08 <0.01
Pearson chi-square (categorical variables). Two-sample t tests (normal distribution). Mann-Whitney test (nonparametric).
Please cite this article in press as: A. Powers, et al., Impact of inpatient diabetes transitions of care consult on glycemic control, Patient Educ Couns (2020), https://doi.org/10.1016/j.pec.2020.01.010
G Model PEC 6498 No. of Pages 3
A. Powers et al. / Patient Education and Counseling xxx (2019) xxx–xxx Table 2 HbA1c at 3 months.
Mean Variance Observations Pooled Variance Hypothsized Mean Difference df t Stat P(T<=t) one-tail t Critical one-tail P(T<=) two-tail t Critical two-tail
3
Declaration of Competing Interest Control
Intervention
0.88 3.34 35 6.29 0 73 3.63 <0.01 1.67 <0.01 1.99
2.99 8.87 40
The authors of this manuscript have nothing to disclose. Acknowledgements This material is the result of work supported with resources and the use of the facilities at the Columbia VA Health Care System. The contents and views expressed in this article are those of the authors and do not represent the views of the U.S. Department of Veterans Affairs or the United States Government. References
(Table 2). HbA1c at 6 months post-discharge was reduced on average by 2.5 % in the intervention group, compared to 0.9 % in the control group (p = 0.031). Seventy-seven percent of patients in the intervention group had a HbA1c value of <9.0 % (75 mmol/mol) at 6 months post-discharge, compared to 72 % of patients in the control group (p = 0.427). There was no statistically significant difference in unscheduled 30-day readmissions or average length of stay. Rates of emergency department visits for hypoglycemia and hyperglycemia were also similar between groups. 4. Discussion Our study suggests that participation in a pharmacist led transitions-of-care program can improve glycemic control via reduction in HbA1c at 3 months and 6 months post-discharge. Our observations are similar to those of Brumm et al. [16] who reported average A1c reduction of 2.2 % measured 2–8 months after enrollment in a diabetes transitions of care program. Our findings also bolster earlier findings from Dungan et al. that individualized inpatient diabetes education and transition programs are associated with a significant reduction in HbA1c dependent on baseline HbA1c, older age and initiation of insulin [17]. Our study has several limitations. As HbA1c is based on normal hemoglobin, increased red blood cell hemolysis with some hemoglobin variants or decreased number of white blood cells (i.e. anemia) may cause falsely low HbA1c values [18]. We did not exclude patients with hemoglobin variants (i.e. sickle cell trait) or anemia, thus the effect may not have been as large. Our study also has potentially limited generalizability due to the small sample size, single center study design and retrospective study design. 5. Conclusion A consult-based diabetes transitions of care service decreased HbA1c versus usual care. 6. Practical implications Our findings indicate that inpatient diabetes education and short-term follow-up post discharge is a value-added service. Funding
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Please cite this article in press as: A. Powers, et al., Impact of inpatient diabetes transitions of care consult on glycemic control, Patient Educ Couns (2020), https://doi.org/10.1016/j.pec.2020.01.010