Hospital Guidelines To Help Manage T2DM Diabetes in Discharged Patients

The use of a discharge algorithm based on admission HbA1c results in lowered HbA1c levels….

Diabetes is one of the most common conditions exhibited by patients being discharged from hospitals in the United States. Hyperglycemia and uncontrolled diabetes have been linked to increased morbidity and mortality, yet few studies focus on managing diabetes after discharge from the hospital. Guidelines by the Endocrine Society are in place for managing non-intensive care unit patients upon discharge. They recommend those with an HbA1c of less than 7% at time of admission be discharged on the same regimen with which they entered the hospital. Those with an HbA1c between 7 and 9% should see their therapy intensified to accommodate for their suboptimal level. Finally, those with an HbA1c of greater than 9% should be receiving a basal bolus insulin regimen. While these guidelines are based on expert opinion, no trials have been conducted to test their efficacy.

This prospective study examined the efficacy of using a discharge algorithm in general medical and surgical patients with type 2 diabetes based on their admission HbA1c levels. The study included 224 patients to be followed for 12 weeks after hospital discharge. Those with an HbA1c of 9% were discharged on oral diabetes medications as well as glargine or basal bolus insulin at 80% of their daily inpatient dose. The primary outcome studied was the change in HbA1c from baseline after 12 weeks of being discharged.

The pre-admission HbA1c for the cohort was 8.7 + 2.5%. This level decreased to 7.3 + 1.5% at 12 weeks post discharge (P<0.001). The change from baseline to week 12 in the HbA1c <7% group was -0.1 + 0.6% (P<0.001). A decrease in HbA1c was found in the HbA1c 7-9% group (-0.8 + 1.0%, P9% group (-3.2 + 2.4%, P<0.001). 29% of subjects experienced one or more mild hypoglycemic events during the follow-up period, but none required a hospital admission or resulted in a neurological or cardiovascular complication. The results of this study show the benefits using a discharge algorithm can have on managing patients with type 2 diabetes. Customizing a discharge regimen based on admission HbA1c levels resulted in a lower HbA1c in all groups studied. The discharge algorithm also appears safe as no severe events were reported during the weeks following release from the hospital. The use of an algorithm for diabetes patients can be an effective tool to implement in preventing complications after discharge and lowering the rates of readmission. Practice Pearls:

• Guidelines are in place for recommending what medications type 2 diabetes patients should receive following discharge from a hospital, but no trials have been performed to test their efficacy.
• In following a discharge algorithm based on admission HbA1c levels, HbA1c was lower across all groups studied after 12 weeks of release from the hospital.
• The discharge algorithm appears safe as only mild hypoglycemic events were reported with none requiring a hospital admission.

Umpierrez GE, Reyes D, Smiley D, Hermayer K, Khan A, Olson DE et al. Hospital Discharge Algorithm Based on Admission HbA1c for the Management of Patients With Type 2 Diabetes. Diabetes Care. 2014.