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Specialized diabetes teams reduce hospital readmissions, costs

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April 13, 2018

Osama Hamdy
Osama Hamdy

Hospitalized patients with diabetes managed by a specialized diabetes team were less likely to be readmitted within 30 days vs. patients managed by a primary service team, according to findings published in BMJ Open Diabetes Research & Care.

In most U.S. hospitals, a primary service team that includes hospitalists, internal or family medicine physicians or general surgery physicians is responsible for diabetes management in medical and surgical noncritical care units, Osama Hamdy, MD, PhD, FACE, medical director of the obesity clinical program and director of inpatient diabetes program at Joslin Diabetes Center, Harvard Medical School, and colleagues wrote in the study background. Diabetes management teams typically include an endocrinologist, diabetes nurse practitioner and a dietitian or certified diabetes educator, working together to provide general diabetes education and coordinate a diabetes discharge and transition plan.

“Approximately 43% of the total diabetes cost, the largest chunk, is related to hospital admission, Hamdy told Endocrine Today. “If you look to any hospital at any single day, one out of every three admitted patients has diabetes, and in the ICU, the ratio is close to one in every two. Cutting diabetes-related cost should start with the hospital. We found when a diabetes team of specialists, including an MD, nurse practitioner, a [certified diabetes educator] and discharge team, work together early upon admission, it shortens the length of stay and reduces 30-day readmission to medical wards by 30%, and also significantly improves adherence to follow-up post-admission. It saves millions of dollars to hospitals and health care system.”Bansal and colleagues conducted a retrospective chart review of 262 adults with a diabetes diagnosis admitted to noncritical care units at a medical center in Boston, with a length of stay from 2 to 10 days between July 2012 and January 2013. Patients in the primary service team group (n = 131; 55%; mean age, 69 years; 4.6% with type 1 diabetes) received care from hospitalists, internal or family medicine physicians or general surgery physicians, whereas patients in the comparative group (n = 131; 58%; mean age, 59 years; 34% with type 1 diabetes) received care from a specialized diabetes team from Joslin Diabetes Center. In the specialized group, the diabetes team coordinated a transition between the medical center and Joslin’s outpatient clinic, where high-risk patients (those discharged using insulin therapy) and patients not using insulin at discharge were scheduled to see primary care physicians, endocrinologists or diabetes nurse practitioners within 4 days or 2 weeks of discharge, respectively. Patients managed by the Joslin group also received general diabetes education for 30 to 60 minutes from a certified diabetes educator during hospital admission, and endocrinologists followed diabetes management protocols based on Joslin guidelines for hospitalized patients. Researchers assessed patient follow-up plans, obtained from discharge papers, and tracked whether patients kept their appointments by reviewing providers’ notes in the medical center’s electronic health records (18% of providers were outside the medical center’s network). Primary outcomes were 30-day readmission rate and frequency, hospital length of stay and estimated hospital cost. Secondary outcomes included glycemic control and glucose variability.

Researchers found that patients in the specialized diabetes team group had a higher mean HbA1c vs. those in the primary service team group (mean, 8.7% vs. 7.4%) and were more likely to have in-hospital secondary complications (60.6% vs. 20.6%), including new infections, acute kidney injury, myocardial infarction, congestive heart failure or transfer to the ICU. Additionally, patients with type 2 diabetes followed by the specialized team had less blood glucose variability vs. patients with type 1 diabetes followed by the same team (mean, 72 mg/dL vs. 87 mg/dL).

When tracking in-network hospital follow-up visits, patients seen by the specialized diabetes team were more likely to keep their appointments with PCPs or endocrinologists after discharge vs. those receiving usual care (P < .001), according to researchers. Additionally, the 30-day readmission rate to medical services in the specialized diabetes team group was 30.5% lower vs. the primary service team group (22.5% vs. 32.4%; P < .001). The 30-day readmission rate to surgical services in the specialized diabetes group was higher vs. the primary service group (26.7% vs. 21.7%; P > .05); however, the frequency of readmission was lower (mean, 1.1 times vs. 1.6 times; P = .015). The most common reasons for readmission were congestive heart failure, pneumonia and acute CV events.

Based on a constructed cost model for 6,695 hospital admissions with diabetes in 2011 and 5,567 hospital admissions with diabetes in 2012, researchers estimated that the full utilization of a specialized diabetes team for all patients with diabetes would have prevented 500 readmissions to medical services in 2011 and 416 readmissions in 2012, while increasing readmissions to surgical services by 36 in 2011 and 44 in 2012.

“Since the national average of hospital costs for patients with diabetes was $7,830 per admission in 2010, we estimate that full utilization of a [specialized diabetes team] for all patients with [diabetes] in noncritical care units of the medical center would save $2.9 million in hospital costs in 2011 and $3.5 million in 2012,” the researchers wrote.

The findings also suggest that consultation with a specialized diabetes team should be initiated early after admission and preferably within 24 hours of admission to reduce hospital length of stay, they wrote.

“We keep seeing our model spreading to many hospitals nationally and internationally,” Hamdy said. “Patients with diabetes are unique and have the highest mortality, in-hospital complications and readmission rates. Leaving them to be managed by hospitalists alone does not help.” – by Regina Schaffer

For more information:

Osama Hamdy , MD, PhD, FACE, can be reached at Joslin Diabetes Center, Inpatient Diabetes Program, One Joslin Place, Boston, MA 02215; email: osama.hamdy@joslin.harvard.edu.

Disclosures: One of the researchers reports he receives research support or consultant fees from Abbott Nutrition, Intarcia, Merck, the National Dairy Council and Novo Nordisk, and serves on an advisory board for AstraZeneca. Another researcher reports he receives consultant fees from Onduo.