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Severe hyperglycemia, hypoglycemia increase risk for rehospitalization in adults with diabetes

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July 11, 2017

Adults with diabetes hospitalized for severe hyperglycemia are nearly nine times more likely to be readmitted within 30 days for the same condition, whereas those hospitalized with severe hypoglycemia are five times more likely to be readmitted in the same period, according to findings published in the Journal of General Internal Medicine.

“We already knew that adults with diabetes carry a high risk for hospitalization and unplanned readmission,”Rozalina McCoy, MD, MS, an internal medicine physician and endocrinologist at Mayo Clinic in Rochester, Minnesota, said in a press release. “But the big question was, why? And what role did episodes of very high and very low blood sugar play in this risk? Because if we knew what the problem was, and ultimately why it might be happening, we could then try to prevent it.”

Rozalina McCoy
Rozalina McCoy

McCoy and colleagues conducted a retrospective analysis of medical and pharmacy claims data from OptumLabs Data Warehouse, a database of more than 100 million privately insured and Medicare Advantage enrollees in the United States. The study included all index hospitalizations among adults with diabetes in nonfederal, acute care hospitals lasting at least 1 night with a discharge between 2009 and 2014. Hospitalizations for cancer, psychiatric disease and pregnancy were excluded. For each index hospitalization, researchers assessed length of stay, discharge year and history of another hospitalization in the prior 12 months. Primary outcome was unplanned readmission within 30 days of discharge for any cause, categorized as readmission for dysglycemia or other causes. A secondary analysis stratified patients based on index hospitalization (severe dysglycemia or other causes).

During the study, 342,186 adults with diabetes experienced 594,146 index hospitalizations; 15,644 hospitalizations were for severe dysglycemia among 13,161 patients (2.6%). Among those admitted for dysglycemia, 48.1% were for hypoglycemia and 50.4% were for hyperglycemia; 1.5% were not specified. Heart failure was the most common cause for index hospitalization (5.5%), as well as the most common cause for readmission (8.9%), according to researchers. Severe dysglycemia accounted for 2.5% of readmissions, with 38.3% for hyperglycemia and 61% for hypoglycemia.

Researchers found that the reason readmission after an index hospitalization varied based on whether the index admission was for dysglycemia or other causes. Among patients initially admitted for hypoglycemia, 6.7% were readmitted within 30 days for another severe dysglycemic event. Among those initially admitted for severe hyperglycemia, 20.8% were readmitted within 30 days for another severe dysglycemic event.

The strongest factors predicting readmission for severe dysglycemia were patient age, diabetes complications, an index hospitalization for hyperglycemia or hypoglycemia, and a prior history of severe dysglycemia.

Among patients hospitalized for severe hypoglycemia, the RR ratio for severe dysglycemia readmission was 4.74 (95% CI, 3.81-5.89); however, among those admitted for severe hyperglycemia, the RR ratio for being readmitted for severe dysglycemia was 8.57 (95% CI, 7.08-10.37).

“We were especially concerned to find that, for patients whose index hospitalization was because of severe dysglycemia, if they were readmitted within 30 days, it was very likely to be for another dysglycemia event,” McCoy said in the release. “Nearly 30% experienced back-to-back dysglycemia, rather than readmission for any other cause.”

McCoy noted that health care providers of hospitalized patients with diabetes should develop discharge plans that include follow-up with their primary care provider immediately after discharge and discuss with patients not only the reasons for their hospitalization, but also their diabetes management.

“The hospital follow-up visit allows patients and their providers to discuss the reason for hospitalization, any medication changes, their ability to take care of themselves at home, and potential ways to prevent readmission if problems arise in the future,” McCoy said. “It also provides an opportunity to review the patient’s diabetes management plan and blood sugar levels.” – by Regina Schaffer

Disclosure: One of the authors reports receiving funding from Medtronic and Johnson & Johnson (Janssen), through Yale, to develop methods of clinical trial data sharing; grant funding from Medtronic and the FDA, through Yale, to develop methods for postmarket surveillance of medical devices; works under contract with CMS; serves on advisory boards for Aetna, Element Science, IBM Watson Health Life Science, the Laura and John Arnold Foundation and UnitedHealth; and is the founder of Hugo, a personal health information platform.

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Yuichiro D. Nakai

This does not seem surprising to me. Patients who are very uncontrolled are usually very uncontrolled for a reason, and I'm not surprised to see that issue is not "fixed" in the month after a hospitalization for many patients. Where I practice, patients may not get in to see their primary care provider for weeks after discharge, and with the shortage of endocrinologists, they may take 1 to 2 months to get back in to see me (an endocrinologist) depending on their and my schedule. However, hypoglycemic events are typically more defined, and there are only a few medications that cause severe hypoglycemia, so reducing or eliminating those medications is much easier to do than to fix the underlying hyperglycemia problem with a hospitalization, which is usually geared to address the acute event and not the underlying issues leading to poor glycemic control. Until the system is set up to pay more for good primary care and preventive care for chronic diseases (i.e., primary care providers and endocrinologists receiving more revenue so they can actually have more of these doctors have more time to spend with their patients and to have more funding for certified diabetes educators and registered dieticians), I don't see how we're going to make this better. The system makes it easier for the patient to get admitted to the hospital for acute care than to have enough community outpatient services to significantly diminish these issues in the first place.

Yuichiro D. Nakai, MD

Northern California Medical Associates, Santa Rosa
Disclosure: Nakai reports no relevant financial disclosures.