Clinical inertia of discharge planning among patients with poorly controlled diabetes mellitus

J Clin Endocrinol Metab. 2012 Jun;97(6):2019-26. doi: 10.1210/jc.2011-3216. Epub 2012 Mar 30.

Abstract

Objective: We examined the effect of hospital admissions on the medical treatment of poorly controlled diabetes mellitus among Veterans Affairs (VA) patients.

Research design and methods: This retrospective cohort study included male patients admitted to one of three VA hospitals from July 1, 2002, to August 31, 2009, who were receiving medication therapy for diabetes with hemoglobin A1c (HgbA1c) greater than 8.0%. The primary outcome was a change in preadmission and outpatient prescriptions for diabetes at hospital discharge. Covariates for multivariable logistic regression analysis of the primary outcome were defined a priori and retrieved from the electronic health record.

Results: Of 2025 admissions for 1359 patients, 454 had some change in diabetes medications at discharge (rate of change 22.4%). In an adjusted analysis, higher preadmission HgbA1c [odds ratio (OR) 1.12 per 1.0 U increase; 95% confidence interval (CI) 1.12-1.05; P < 0.001], higher mean blood glucose during admission (OR 1.07 per 10 mg/dl increase; 95% CI 1.05-1.10; P < 0.0001), occurrence of inpatient hypoglycemia (blood glucose < 50 mg/dl; OR 1.82, 95% CI 1.32-2.51, P < 0.001), and inpatient basal insulin therapy (OR 1.71; 95% CI 1.25-2.35; P < 0.001) were associated with higher odds of change in therapy. A total of 656 admissions (32%) demonstrated aggregate clinical inertia with no change in therapy, no documentation of HgbA1c within 60 d of discharge, and no follow-up appointment within 30 d of discharge.

Conclusions: In this multicenter, retrospective study of patients with poorly controlled diabetes and at least one hospitalization, less than a quarter received a change in outpatient diabetes therapy upon discharge, suggesting widespread clinical inertia. Nearly one third had no change in therapy or subsequent follow-up scheduled.

Publication types

  • Multicenter Study
  • Research Support, U.S. Gov't, Non-P.H.S.

MeSH terms

  • Aged
  • Ambulatory Care / standards
  • Ambulatory Care / statistics & numerical data*
  • Cohort Studies
  • Continuity of Patient Care / standards
  • Continuity of Patient Care / statistics & numerical data*
  • Diabetes Mellitus, Type 1 / drug therapy*
  • Diabetes Mellitus, Type 1 / epidemiology*
  • Diabetes Mellitus, Type 1 / metabolism
  • Follow-Up Studies
  • Glycated Hemoglobin A / metabolism
  • Hospitalization / statistics & numerical data
  • Hospitals, Veterans / standards
  • Hospitals, Veterans / statistics & numerical data
  • Humans
  • Hypoglycemic Agents / therapeutic use
  • Insulin / therapeutic use*
  • Male
  • Middle Aged
  • Multivariate Analysis
  • Outcome and Process Assessment, Health Care
  • Patient Discharge / standards
  • Patient Discharge / statistics & numerical data*
  • Retrospective Studies

Substances

  • Glycated Hemoglobin A
  • Hypoglycemic Agents
  • Insulin
  • hemoglobin A1c protein, human