Background: Endocrinology physicians and clinic staff are burdened by workload created during the download of diabetes devices (insulin pumps, glucometers, and sensors). Inefficiencies caused by data ...interoperability can impact physician well-being and clinic workflow. The aim of this study is to identify physician wellbeing related to Diabetes Technology (DT) and determine whether the use of a single software platform to upload and view diabetes data improves efficiency.
Methods: Physician satisfaction survey related to DT was sent to providers at a single academic endocrinology office. Tidepool®, a free software, was implemented to enable data upload from multiple devices onto a single platform. The time required to have this data available to the provider was recorded pre and post-implementation. The provider was then able to view this data in the patients’ electronic chart.
Results: All providers (n=14) completed the survey. Only 7% felt that pumps were always downloaded on time. Related to DT, 21% felt a sense of dread at work, 36% experienced a lack of enthusiasm, and 43% experienced emotional exhaustion. Almost 80% felt that clinic workflow due to DT contributed to spending less time with patients. Data from a total of 90 devices pre and 144 devices post-Tidepool® were included in the study. There was a significant improvement in the average time of sensor and glucometer data availability; 4.95 vs. 3.2 minutes (CI -2.48 to -1.01, p-value <0.0001). There was no significant change in average time for insulin pump data availability; 8.8 vs. 8.46 minutes (CI -2.6 to 2.1, p-value 0.7) post Tidepool®. Time and resources related to printing the data were saved as well. 100% of staff at the download station felt that Tidepool® was an easier software to use.
Conclusion: Our study shows a high prevalence of physician dissatisfaction and symptoms of burnout related to DT among the providers even at a university academic office with access to the best resources. The use of Tidepool® could potentially improve clinic workflow.
Disclosure
V. Shah: None. D. Pinkhasova: None. E. Karslioglu French: None.
Funding
University of Pittsburgh Medical Center
Patients with diabetes who are hospitalized often have changes in diabetes treatment regimen during hospitalization. In the ReCoDED study done at our institution, it was found that discharge ...instructions provided by Endocrine teams were not always accurately translated into discharge recommendations by primary teams. To address this issue, we implemented a “diabetes discharge recommendations note” (EFR Note) which clearly specifies discharge instructions for primary teams, which we embedded in the institution’s EMR in January 2019. Preliminary data evaluating the efficacy of the EFR Note at our academic center showed significantly improved accuracy in the discharge regimen.
In this study, we investigated the patient data from two other centers, specifically inner-city community hospitals, from January to December 2021. We identified 40 patients through EMR for whom an EFR Note was utilized (EFR Group) and randomly selected 40 patients from the same centers for comparison (Control Group) . There were no significant differences in baseline characteristics between the two groups (All p values > 0.25)
Results: We find that the accuracy of diabetes regimens provided by primary teams at discharge was significantly higher when EFR Note was utilized, relative to control (88% vs. 60%; χ2 (1) = 6.46, p = 0.011) . The most common error was incorrect insulin type/dosing, accounting for 76% of all errors. Insulin dosing errors were similarly less prevalent in the EFR Group relative to control (8% vs. 33%; χ2 (1) = 6.33, p = 0.012) .
Conclusion: These results demonstrate that tools like EFR Note with specific instructions regarding discharge regimen can ameliorate deficiencies in discharge process. We plan to take steps to enhance awareness regarding the efficacy of EFR Note among endocrinology providers at multiple centers within our institution to facilitate a safer transition from inpatient to outpatient setting.
Disclosure
J.Lloyd: None. T.Abdulwahid: None. J.Levin: None. D.Pinkhasova: None.
Abstract
Background
Alpelisib is a phosphatidylinositol-3-kinase (PI3K) inhibitor, recently approved for treatment of metastatic breast cancer with PIK3CA mutation. The PI3K is involved in insulin ...signaling pathway and is responsible for translocation of GLUT-4 transporters in insulin responsive tissues and thus modulates insulin sensitivity. Impairment of PI3K pathway results in insulin resistance. Hyperglycemia is a known side effect of alpelisib, however there are only 5 reported cases of alpelisib induced DKA in literature. We describe a patient with Type 2 DM and metastatic breast cancer started on alpelisib with resultant rapid worsening of insulin resistance requiring substantially increased doses of insulin ultimately leading to DKA. She later had rapid reversal of insulin resistance with discontinuation of alpelisib. The degree and rapid onset/reversal of insulin resistance is highlighted in this case.
Case
59-year-old female with Type-2 DM, metastatic breast cancer with PIK3CA mutation was started on alpelisib 300mg daily after inadequate response to other agents. Her insulin regimen prior to starting was degludec(U100) 35 units daily and humalog(U100) 30 units with meals. In the first week of starting alpelisib, her continuous glucose monitor(CGM) showed a dramatic increase in glucose values >400 mg/dL accompanied with polyuria and polydipsia. Anti-GAD and Islet-cell-antibodies were negative with C-peptide of 1.55 ng/mL with glucose of 378 mg/dL. Patient was hospitalized with DKA during month 4 of treatment after continuous up titration of her insulin therapy outpatient.
With resolution of DKA, patients’ glucoses were well controlled when transitioned to a regimen of degludec 50 units and humalog 12 units with meals. Once alpelisib was restarted during this hospitalization, patient's glucoses increased from 140mg/dL to >400 mg/dL in just 4 hours after administration. Patient was ultimately discharged on a significantly higher dose insulin regimen of degludec 140 units daily and humalog 85 units TID as well as metformin and dulaglutide.
A restaging scan demonstrated progression of her cancer and alpelisib was hence discontinued. We instructed the patient to decrease the dose of insulin from the day alpelisib is discontinued to degludec 10 units (.15 units/kg) and a correction scale with meals to assess new insulin requirements. Within the first 24 hours, patient's glucose improved significantly and remained well controlled with degludec 10 units daily and Humalog 5 units with meals.
Conclusion
The degree of alpelisib induced insulin resistance is often severe with significant increase in insulin requirements. The time to onset and reversal of alpelisib induced insulin resistance is often rapid and providers need to anticipate a rapid increase in insulin requirements within a few days of starting alpelisib and adjust doses promptly to prevent potential complication of DKA. Providers should also anticipate a rapid decrease in insulin requirements within 24 hours of discontinuation to prevent potential hypoglycemic events.
Presentation: Monday, June 13, 2022 12:30 p.m. - 2:30 p.m.
Hospitalized patients with DM represent a group at high risk for readmission. Variability in how instructions for home DM management are provided at discharge can contribute to this risk.
At our ...institution, recommendations made by the endocrine consult service were not always accurately translated into patient discharge orders by the primary service.
Therefore, the EFR embedded within the EMR was developed. We investigated its effectiveness by reviewing the EMR of 48 patients discharged with insulin prior to (group 1) and following implementation (group 2) for fidelity of recommendations carried out by the primary service. Accuracy of the diabetes-related discharge regimen was defined as correct type and dose of insulin, correct administration supplies (syringes vs. pen needles), and provision of appropriate glucose monitoring supplies by the primary team.
About 50% of patients had a change in their DM regimen at discharge. Insulin was added as a new medication in 29% vs. 44% of patients in groups 1 and 2 respectively.
There was significant improvement in the accuracy of the diabetes-related discharge regimen (68% vs. 96%, p = 0.001).
These results demonstrate that deficiencies in the discharge process can be ameliorated by EMR tools which facilitate a safer transition of care from inpatient to outpatient settings for patients with DM.
Disclosure
D. Pinkhasova: None. A. Donihi: None. K. Feterik: None. M.T. Korytkowski: None. E. Karslioglu French: None.
Several risk factors for hospital readmission in patients with diabetes (DM) have been identified. The Diabetes Early Readmission Risk Indicator (DERRITM) is a tool that identifies patients at high ...risk for readmission within 30 days of hospital discharge, but does not incorporate several DM specific factors such as type of DM and pre-discharge glycemic measures. The purpose of this investigation was to prospectively examine DM specific factors and DERRI scores as predictors of readmission risk at 90 days in participants in the Readmission and Comprehension of Discharge Education in Diabetes (RECODED) study. Among the 126 patients, (age mean (STD) 61(12) yrs, BMI 32.9 (9.6) kg/m2, A1c 8.0 (2.2%), 45% women, 22% Black, 85% type 2 DM), readmission occurred in 54 (42.9%) of patients within 90 days of discharge. Factors identified as predicting risk for hospital readmission included the presence of known macrovascular (CAD, p = 0.039; CHF, p = 0.029; CVA, p = 0.054) but not microvascular complications. DERRI scores were higher in those with a readmission compared to those without (27 ± 12% vs. 20 ± 11%, p = 0.006).No differences were observed for age, BMI, type of diabetes, eGFR, history of DM self-management education, inpatient DM service consultation, education level, employment history, A1c, pre-discharge hypoglycemia, hyperglycemia or glycemic variability, or hospital length of stay among those with and without a readmission.
In summary, these results reinforce the complexity of identifying risk factors for hospital readmission in DM patients. Certain macrovascular complications, which are collectively components of the DERRI, individually demonstrate an association with readmission risk at 90 days, as does DERRI. This is the first demonstration of DM related macrovascular complications and DERRI score as a predictor of readmission beyond 30 days of hospital discharge.
Disclosure
D. Pinkhasova: None. J. Swami: None. N. Patel: None. A. Donihi: None. L.M. Siminerio: Research Support; Self; Becton, Dickinson and Company. K. Delisi: None. D.S. Hlasnik: None. D.J. Rubin: None. M.T. Korytkowski: None.
Funding
National Institutes of Health (UL1TR001857)
Background:
Most primary neoplasms of the adrenal gland arise from either adrenal cortical cells or the chromaffin cells of the adrenal medulla. Here we describe a case in which a patient was found ...to have an incidental adrenal mass with both cortical and medullary components on histology.
Clinical Case:
A 51-year-old female with DM2 and HTN, presented with an incidental left (L) adrenal mass. She had a 30-pound weight gain over 6 months with complaints of fatigue and easy bruising. CT of her adrenals demonstrated a 3.1 cm L adrenal mass with pre-contrast HU of 31 and washout >50%, suggesting a lipid poor adenoma with a normal contralateral adrenal gland. Her blood pressure was 165/88 mm Hg and BMI was 34. Dorsocervical fat pad enlargement and supraclavicular fullness were noted. A 1 mg dexamethasone suppression test (DST) was abnormal with a dexamethasone (DEX) level- 209 ng/dL (180-550) and cortisol- 8.2 mcg/dL. A late-night salivary test was normal with a cortisol- 0.05 mcg/dl (0.04-0.56). Basal am ACTH and cortisol levels were 24 pg/mL (6-50) and 20.5 mcg/dL (4-22) respectively. Plasma metanephrine- 114 pg/mL (<57), normetanephrine- 300 pg/mL (<148), and total metanephrine- 414 pg/mL (<205) were elevated. DHEA-S, plasma renin and aldosterone were all within normal range. These results suggested that both pheochromocytoma (Pheo) and Cushing’s syndrome (CS) were present. The differential diagnosis included ACTH- secreting Pheo, pituitary CS coexisting with a Pheo, or corticomedullary adenoma. After L adrenalectomy, histological examination showed positive immunohistochemical staining with chromogranin and intermingled adrenocortical components within the same mass, consistent with a corticomedullary adenoma. ACTH immunostaining was positive in a small subpopulation of cells. Post-operatively, the metanephrine levels normalized. The 1 mg DST improved but remained abnormal (DEX level- 245 ng/dL, cortisol- 3.4 mcg/dl). The basal 8 am ACTH and cortisol were 28 pg/mL and 12.7 mcg/dL respectively. She did not require hydrocortisone replacement. Her HTN improved and insulin was discontinued. There were no mutations found in a hereditary Pheo panel (Invitae- 14 genes).
Conclusion:
Corticomedullary adenomas associated with hypersecretion of cortisol and catecholamines have rarely been reported. All 5 of the previously reported cases have been unilateral with a predilection for females in the third to sixth decades of life
1
. In this case, the histologic diagnosis and clinical improvement after adrenalectomy supports a diagnosis of corticomedullary adenoma as the source of hypersecretion of both cortisol and catecholamines. This case demonstrates the importance of screening for CS and Pheo in all patients when evaluating an incidental adrenal mass.
Reference:
1.Lau
, S., Annals of Diagnostic Pathology, 15:185, 2011
Unless otherwise noted, all abstracts presented at ENDO are embargoed until the date and time of presentation. For oral presentations, the abstracts are embargoed until the session begins. Abstracts presented at a news conference are embargoed until the date and time of the news conference. The Endocrine Society reserves the right to lift the embargo on specific abstracts that are selected for promotion prior to or during ENDO.
Diabetes (DM) is a major contributor to risk for hospital readmission. The Diabetes Early Readmission Risk Indicator (DERRI) is a predictor of 30-day readmission in patients with DM that may allow ...early identification and intervention for high-risk patients. A limitation to DERRI is the absence of DM-specific factors as contributors to this risk. To address this, we investigated HbA1c, glycemic measures and variability (GV), changes in DM therapy at discharge, and patient responses to a novel post-discharge questionnaire directed at Patient Comprehension (PC) of instructions provided for home DM management. Non-critically ill adult patients with DM were contacted by phone within 48 hours of hospital discharge to complete the PC Questionnaire. To date, 70 subjects (type 1 n=9, type 2 n=53, pancreatogenic DM n=8) (mean age 57.2 ± 12.8 years, BMI 31 ± 8.8 kg/m2, 56% men, 71% Caucasian, HbA1c 8.6 ± 2.0%, DM duration 19 ± 12 years, mean BG prior to discharge (210 ± 49 mg/dL), GV (66 ± 35 mg/dl) have been recruited. Of 41 subjects completing the PC questionnaire, those reporting that discharge instructions for home DM management were not provided had lower PC scores (70.6% vs. 81.5%, p=0.025) and more readmissions (OR 5.6, p=0.04) than those reporting that instructions were given. Among the 60 subjects with one-month post-discharge data, 22 patients (37%) reporting ≥1 readmission had higher DERRI scores than those without readmissions (26% vs. 20%, p=0.023). HbA1c, GV and changes in DM treatment regimens were not associated with readmission.
In summary, these results demonstrate that PC of discharge instructions may be a novel mediator of readmission risk and may add an additional measure of risk for hospital readmission.
Disclosure
J. Swami: None. A. Donihi: None. E. Karslioglu French: None. K. Delisi: None. D.S. Hlasnik: None. N. Patel: None. D. Pinkhasova: None. D.J. Rubin: Research Support; Self; AstraZeneca, Boehringer Ingelheim Pharmaceuticals, Inc. M.T. Korytkowski: Advisory Panel; Self; Novo Nordisk Inc.. Other Relationship; Self; JAEB Center For Health Research.
Hospitalized patients with DM are at high risk for early readmission. Improving inpatient education and discharge (DC) processes are proposed interventions for reducing this risk.
We examined the ...contribution of blood glucose (BG) 48 hr prior to DC (nadir, peak, STD, CV) and patient comprehension (PC) of instructions for home DM management following DC to risk for 30d readmission.
Insulin treated non-critically ill patients with DM (N=202) were recruited. Diabetes Early Readmission Risk Indicators (DERRI) were calculated for each participant, who were contacted within 48 hr of DC to complete a PC Questionnaire (PCQ).
Of 126 participants age mean (STD) 61(12) years, BMI 32.9 (9.6) kg/m2, A1c 8.0 (2.2%), 45% women, 22% black, 85% type 2DM who completed the PCQ, 42 (33%) required clarification of misunderstood DC instructions. PC scores were negatively correlated with BG STD (-0.17, 95% CI:-0.32,-0.02) and CV (-0.38, -0.7, -0.05).
There was no difference in median (25ile, 75ile) PC scores between patients with and without 30d readmission (79 (67, 93%) vs.83 (71,100%), p=0.19); however, there were more readmissions in those with PC scores <100% compared to scores of 100% (n = 34) (29% vs. 15%, OR=2.4, 95% CI: 0.83, 6.88).
Among all 202 participants, median DERRI scores were higher in the 25% with 30d readmission (27 (24, 30)) than those without (19 (20, 24), p = 0.002).
In summary, these results demonstrate deficiencies in the hospital DC process as demonstrated by the need for clarification of information in >30% of patients following DC. It is possible that this corrected information may have served as an intervention to reduce readmission risk. PC scores were negatively associated with glycemic variability preceding DC and scores <100% were associated with a higher risk for readmission. DERRI scores were strongly associated with risk for 30d readmissions, representing the first prospective external validation of this tool. These results support proposals to improve the DC process and post-DC follow-up of patients with DM.
Disclosure
D. Pinkhasova: None. J. Swami: None. N. Patel: None. A. Donihi: None. L.M. Siminerio: None. E. Karslioglu French: None. K. Delisi: None. D.S. Hlasnik: None. D.J. Rubin: Research Support; Self; AstraZeneca, Boehringer Ingelheim Pharmaceuticals, Inc. M.T. Korytkowski: None.
Funding
National Institutes of Health (UL1-TR-001857)
Gender differences have been described for glycemic control and prevalence of diabetes related complications in the outpatient setting but have not been examined in the hospitalized population. To ...address this, we investigated gender differences in demographics, glycemic control and variability (GV), macrovascular and microvascular complications, and admission diagnosis in non-critically ill hospitalized patients with a secondary diagnosis of diabetes recruited for the Readmission and Comprehension of Diabetes Education at Discharge (ReCoDED) Study. To date, 111 men and 87 women have been recruited, with the majority having type 2 DM (86 vs. 79%). Participants age (men vs. women) was 60.6 ± 11.7 vs. 57.6 ± 11.8 years, BMI 32.2 ± 8.4 vs. 32.1 ± 10.6 kg/m2, systolic (SBP) 136 ± 26 vs. 127 ± 23 mmHg, diastolic (DBP) 77 ± 13 vs. 75 ± 14 mmHg, HbA1c 8.0 ± 2.3 vs. 8.3% ± 2.5%, and DM duration 14.5 ± 10.4 vs. 14.1 ± 11.6 years. Race, education, and employment were similar. Men had more retinopathy (23 vs. 16%) and nephropathy (40 vs. 28%), but not neuropathy (60 vs. 63%). Women had a lower prevalence of CAD (49 vs. 36%), but a similar prevalence of CHF (37 vs. 37%), stroke (15 vs. 18%), and PVD (18 vs. 17%). The most frequent admission diagnoses were CVD (37 vs. 22%) and infection (10 vs. 19%). Mean blood glucose (BG) (198 ± 51 vs. 200 ± 54 mg/dl), GV (177 ± 80 vs. 182 ± 112 mg/dl), frequency of hypoglycemia (BG < 70 mg/dl) and hyperglycemia (BG >250 mg/dl) were similar in the 48 hours prior to discharge. Length of stay was 7.8 ± 6.9 vs. 8.3 ± 7.4 days.
In summary, this gender-based description of glycemic control and prevalence of diabetes-related complications in an inpatient population demonstrates that hospitalized women with DM have fewer microvascular complications, a lower prevalence of CAD but a similar prevalence of CHF, stroke and PVD when compared to men, despite similar BMI and DM duration. These findings will be examined as a risk factor for hospital readmissions in this ongoing study.
Disclosure
N. Patel: None. D. Pinkhasova: None. A. Donihi: None. E. Karslioglu French: None. L.M. Siminerio: None. K. Delisi: None. D.S. Hlasnik: None. M.T. Korytkowski: None.
The primary objective of this study was to examine the patient comprehension of diabetes self-management instructions provided at hospital discharge as an associated risk of readmission.
...Noncritically ill patients with diabetes completed patient comprehension questionnaires (PCQ) within 48 hours of discharge. PCQ scores were compared among patients with and without readmission or emergency department (ED) visits at 30 and 90 days. Glycemic measures 48 hours preceding discharge were investigated. Diabetes Early Readmission Risk Indicators (DERRIs) were calculated for each patient.
Of 128 patients who completed the PCQ, scores were similar among those with 30-day (n = 31) and 90-day (n = 54) readmission compared with no readmission (n = 72) (79.9 ± 14.4 vs 80.4 ± 15.6 vs 82.3 ± 16.4, respectively) or ED visits. Clarification of discharge information was provided for 47 patients. PCQ scores of 100% were achieved in 14% of those with and 86% without readmission at 30 days (P = .108). Of predischarge glycemic measures, glycemic variability was negatively associated with PCQ scores (P = .035). DERRIs were significantly higher among patients readmitted at 90 days but not 30 days.
These results demonstrate similar PCQ scores between patients with and those without readmission or ED visits despite the need for corrective information in many patients. Measures of glycemic variability were associated with PCQ scores but not readmission risk. This study validates DERRI as a predictor for readmission at 90 days.
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