In the House: How Inpatient Diabetes Teams Can Improve Patient Outcomes and Reduce Costs

Becoming more common in academic institutions, diabetes management teams can play an important role in community hospitals by reducing lengths of stay and readmissions.

Evidence continues to mount that focusing on patients’ diabetes through inpatient management services when they are in the hospital for other conditions pays dividends in lowering re-admissions and short-term mortality — a model that can be adapted to community hospitals.

Two new studies show the success of these programs, while a third highlights the risks of discharging patients without attention to their glucose levels.

Inpatient diabetes management teams have become more common in large academic hospitals, and a study published last year in BMJ Open Diabetes Research & Care compared the outcomes in diabetes patients at a tertiary referral medical center in Boston. Some patients were cared for by a standard primary service team and others received care from a specialized diabetes team (SDT) that included an endocrinologist, diabetes nurse practitioner, certified diabetes nurse educator, and discharge/transition coordinators.

“Inpatient diabetes management by an SDT significantly reduces 30-day readmission rate to medical services, reduces inpatient diabetes cost, and improves transition of care and adherence to follow-up. SDT consultation during the first 24 hours of admission was associated with a significantly shorter hospital [length of stay],” concluded the study team, led by Osama Hamdy, MD, an endocrinologist at the Joslin Diabetes Center in Boston.

Treatment by the team reduced the 30-day readmission rate to non-critical medical units by around 30% compared with standard care by the primary service team.

“Although the number of hospitals in the nation is four times higher than the number of practicing endocrinologists, the best investment that any hospital can do is to utilize a specialized diabetes team to manage patients with diabetes,” Hamdy says.

Small-Hospital Endocrinology

Mihail Zilbermint, MD, sought to replicate the large-hospital results at his community hospital.

Zilbermint is director of endocrinology, diabetes, and metabolism at Suburban Hospital, a 240-bed facility in Bethesda, Md., that is part of Johns Hopkins Medicine.

Zilbermint says endocrinologist involvement in community hospitals has waned in recent years due to changes in care and payment models. “When I was moonlighting at Suburban Hospital as a hospitalist while training in endocrinology, I noticed that patients with diabetes were getting suboptimal care at a time when diabetes management was becoming more complex,” Zilbermint says. He was shocked to learn that for many of his colleagues, the only endocrinology consult available was to log on to UpToDate.

After Zilbermint joined the staff, he created an inpatient diabetes management service similar in make-up to the one at the Boston hospital, modeled on a successful program at Johns Hopkins Hospital in Baltimore. His team recently published its results in the Journal of Community Hospital Internal Medicine Perspectives.

“When I was moonlighting at Suburban Hospital as a hospitalist while training in endocrinology, I noticed that patients with diabetes were getting suboptimal care at a time when diabetes management was becoming more complex.” –  Mihail Zilbermint, MD, director of endocrinology, diabetes, and metabolism, Suburban Hospital, Bethesda, Md.

Community Hospital Tests Model

The Suburban Hospital study tracked 4,700 patients with diabetes admitted to Suburban Hospital over a 16-month period. About 18% of the patients, mostly with higher severity of illness scores than the comparison group, were co-managed by the diabetes service.

Patients cared for by the diabetes team actually had a longer median length of stay than the control group, probably because they were sicker on admission. However, over time there was a statistically significant decline in the length of stay of the diabetes team group, and no significant change in the length of stay of the control group.

Over the study period, 30-day re-admissions in the treated group declined by 11%, with no change seen in the control group. There was a 27% decrease in the length of stay for co-managed patients, which the hospital estimated represented a potential savings of nearly $1 million.

Zilbermint tells Endocrine News that many of these patients were being managed outside of the hospital by their primary care physicians, with no contact with endocrinologists, and that endocrine expertise could have long-term benefits for their care. For example, many patients in the hospital for cardiovascular problems had never been introduced to diabetes drugs such as SGLT2 inhibitors and GLP-1 receptor agonists, which provide cardiovascular health benefits. “We assess the patients and start them on those newer medications if needed. We’ve established a close collaboration with the cardiothoracic team,” Zilbermint says.

Zilbermint sees an opportunity for “a brand-new field of the ‘hospitalist endocrinologist’ that I hope will gain popularity.” He has brought in an endocrinologist to fill this role in another community hospital in the Johns Hopkins system in Columbia, Md.

Glucose Levels on Discharge

The danger of not focusing on diabetes was made clear by a study in The Journal of Clinical Endocrinology & Metabolism from a team led by Elias Spanakis, MD, an assistant professor of medicine in the division of endocrinology, diabetes, and nutrition at the University of Maryland School of Medicine and a staff physician at the Baltimore VA hospital.

This nationwide study of more than 800,000 patients with diabetes admitted to Veterans Affairs hospitals over a 14-year period examined the association between the patients’ glucose values during their last day of hospitalization and several measures: 30-day readmission rate; 30-day, 90-day, and 180-day mortality rates; and combined 30-day readmission/mortality rate.

It concluded that “patients with diabetes who had hypoglycemia or near normal glucose values during the last day of hospitalization had higher rates of 30-day readmission and post-discharge mortality.” The rate for all five negative outcomes increased progressively as patients’ minimum glucose concentrations decreased below the 100 mg/dl range, compared those above 100 mg/dl.

Spanakis says that he expected bad outcomes associated with hypoglycemia, but was surprised that even patients whose glucose values were in the low normal range experienced a higher rate of adverse outcomes.

“Although future studies are needed, physicians should avoid discharging patients with diabetes from the hospital until glucose values above 100 mg/dl are achieved during the last day of the hospitalization,” Spanakis says. The study recommends that endocrinologists could reduce the risk in these patients by modifying their outpatient diabetes medications and advising them on performing frequent glucose monitoring or using continuous glucose monitoring devices.

Benefits of Education

The Boston study recommends that consultations with the diabetes team should be initiated as soon as possible after admission, and preferably within the first 24 hours of admission, to improve results and reduce the patient’s length of stay.

“No patient with diabetes should leave the hospital without knowing where and when to go for diabetes follow-up. We found that managing patients by a diabetes team increased the adherence to follow-up with primary care physicians and diabetes specialists.” – Osama Hamdy, MD, endocrinologist, Joslin Diabetes Center, Boston, Mass.

“That is why the new standards of diabetes care of the American Diabetes Association recommend utilization of specialized diabetes teams,” Hamdy says. “Education on the floor, especially on meters and insulin injections, was shown to be extremely helpful to our patients. No patient with diabetes should leave the hospital without knowing where and when to go for diabetes follow-up. We found that managing patients by a diabetes team increased the adherence to follow-up with primary care physicians and diabetes specialists.”

With payment models moving toward penalizing hospitals for early patient re-admissions, these kinds of efforts could pay dividends for institutions that implement them.

— Seaborg is a freelancer writer living in Charlottesville, Va., and a frequent contributor to Endocrine News. He wrote about the Endocrine Society clinical practice guideline on treating older patients with diabetes in the July issue.

 

 

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