OBJECTIVES: Patients with diabetes are at particularly high risk for adverse outcomes after hospitalization. The goals of this study were to design, implement, and evaluate a multipronged transitional care intervention among hospitalized patients with diabetes. METHODS: We randomly assigned inpatients likely to be discharged home on insulin to an intensive transitional care intervention or usual care. The primary outcome was 90-day postdischarge insulin adherence, using prescription refill information to calculate a medication possession ratio. Unadjusted analyses were conducted using Wilcoxon rank sum; adjusted analyses used multivariable linear regression and weighted propensity scoring methods, with general estimating equations to account for clustering by admitting physician. RESULTS: One hundred eighty patients participated. The mean (SD) medication possession ratio to all insulin types was 84.5% (22.6) among intervention and 76.4% (25.1) among usual care patients (difference = 8.1, 95% confidence interval = -1.0 to 17.2, P = 0.06), with a smaller difference for adherence to all medications (86.3% versus 82.0%). A1c levels decreased in both groups but was larger in the intervention arm (1.09 and 0.11, respectively) (difference = -0.98, 95% confidence interval = -2.03 to -0.07, P = 0.04). Differences between study arms were not significant for rates of hypoglycemic episodes, 30-day readmissions, or emergency department visits. In adjusted/clustered analyses, the difference in A1c reduction remained statistically significant, whereas differences in all other outcomes remained nonsignificant. CONCLUSIONS: The intervention was associated with improvements in glycemic control, with nonsignificant trends toward greater medication adherence. Further research is needed to optimize and successfully implement interventions to improve patient safety and health outcomes during care transitions.
OBJECTIVES: Patients with diabetes are at particularly high risk for adverse outcomes after hospitalization. The goals of this study were to design, implement, and evaluate a multipronged transitional care intervention among hospitalized patients with diabetes. METHODS: We randomly assigned inpatients likely to be discharged home on insulin to an intensive transitional care intervention or usual care. The primary outcome was 90-day postdischarge insulin adherence, using prescription refill information to calculate a medication possession ratio. Unadjusted analyses were conducted using Wilcoxon rank sum; adjusted analyses used multivariable linear regression and weighted propensity scoring methods, with general estimating equations to account for clustering by admitting physician. RESULTS: One hundred eighty patients participated. The mean (SD) medication possession ratio to all insulin types was 84.5% (22.6) among intervention and 76.4% (25.1) among usual care patients (difference = 8.1, 95% confidence interval = -1.0 to 17.2, P = 0.06), with a smaller difference for adherence to all medications (86.3% versus 82.0%). A1c levels decreased in both groups but was larger in the intervention arm (1.09 and 0.11, respectively) (difference = -0.98, 95% confidence interval = -2.03 to -0.07, P = 0.04). Differences between study arms were not significant for rates of hypoglycemic episodes, 30-day readmissions, or emergency department visits. In adjusted/clustered analyses, the difference in A1c reduction remained statistically significant, whereas differences in all other outcomes remained nonsignificant. CONCLUSIONS: The intervention was associated with improvements in glycemic control, with nonsignificant trends toward greater medication adherence. Further research is needed to optimize and successfully implement interventions to improve patient safety and health outcomes during care transitions.
Authors: Stephen Clement; Susan S Braithwaite; Michelle F Magee; Andrew Ahmann; Elizabeth P Smith; Rebecca G Schafer; Irl B Hirsch; Irl B Hirsh Journal: Diabetes Care Date: 2004-02 Impact factor: 19.112
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Authors: Brian W Jack; Veerappa K Chetty; David Anthony; Jeffrey L Greenwald; Gail M Sanchez; Anna E Johnson; Shaula R Forsythe; Julie K O'Donnell; Michael K Paasche-Orlow; Christopher Manasseh; Stephen Martin; Larry Culpepper Journal: Ann Intern Med Date: 2009-02-03 Impact factor: 25.391
Authors: Jeffrey L Schnipper; Jennifer L Kirwin; Michael C Cotugno; Stephanie A Wahlstrom; Brandon A Brown; Emily Tarvin; Allen Kachalia; Mark Horng; Christopher L Roy; Sylvia C McKean; David W Bates Journal: Arch Intern Med Date: 2006-03-13
Authors: Rosalind Fabunmi; Loretta L Nielsen; Ralph Quimbo; Brock Schroeder; Derek Misurski; Matthew Wintle; Ron Wade Journal: Curr Med Res Opin Date: 2009-03 Impact factor: 2.580