Hospital readmission is a high-priority health care quality measure and target for cost reduction. Despite broad interest in readmission, relatively little research has focused on patients with ...diabetes. The burden of diabetes among hospitalized patients, however, is substantial, growing, and costly, and readmissions contribute a significant portion of this burden. Reducing readmission rates of diabetic patients has the potential to greatly reduce health care costs while simultaneously improving care. Risk factors for readmission in this population include lower socioeconomic status, racial/ethnic minority, comorbidity burden, public insurance, emergent or urgent admission, and a history of recent prior hospitalization. Hospitalized patients with diabetes may be at higher risk of readmission than those without diabetes. Potential ways to reduce readmission risk are inpatient education, specialty care, better discharge instructions, coordination of care, and post-discharge support. More studies are needed to test the effect of these interventions on the readmission rates of patients with diabetes.
BACKGROUND:Hospital readmission within 30 days of discharge (30-d readmission) is an undesirable outcome. Readmission of patients with diabetes is common and costly. Most of the studies that have ...examined readmission risk factors among diabetes patients did not include potentially important clinical data.
OBJECTIVES:To provide a more comprehensive understanding of 30-day readmission risk factors among patients with diabetes based on predischarge and postdischarge data.
RESEARCH DESIGN:In this retrospective cohort study, 48 variables were evaluated for association with readmission by multivariable logistic regression.
SUBJECTS:In total, 17,284 adult diabetes patients with 44,203 hospital discharges from an urban academic medical center between January 1, 2004 and December 1, 2012.
MEASURES:The outcome was all-cause 30-day readmission. Model performance was assessed by c-statistic.
RESULTS:The 30-day readmission rate was 20.4%, and the median time to readmission was 11 days. A total of 27 factors were statistically significant and independently associated with 30-day readmission (P<0.05). The c-statistic was 0.82. The strongest risk factors were lack of a postdischarge outpatient visit within 30 days, hospital length-of-stay, prior discharge within 90 days, discharge against medical advice, sociodemographics, comorbidities, and admission laboratory values. A diagnosis of hypertension, preadmission sulfonylurea use, admission to an intensive care unit, sex, and age were not associated with readmission in univariate analysis.
CONCLUSIONS:There are numerous risk factors for 30-day readmission among patients with diabetes. Postdischarge factors add to the predictive accuracy achieved by predischarge factors. A better understanding of readmission risk may ultimately lead to lowering that risk.
To conduct a comprehensive analysis of radiologist-made assessments of glioblastoma (GBM) tumor size and composition by using a community-developed controlled terminology of magnetic resonance (MR) ...imaging visual features as they relate to genetic alterations, gene expression class, and patient survival.
Because all study patients had been previously deidentified by the Cancer Genome Atlas (TCGA), a publicly available data set that contains no linkage to patient identifiers and that is HIPAA compliant, no institutional review board approval was required. Presurgical MR images of 75 patients with GBM with genetic data in the TCGA portal were rated by three neuroradiologists for size, location, and tumor morphology by using a standardized feature set. Interrater agreements were analyzed by using the Krippendorff α statistic and intraclass correlation coefficient. Associations between survival, tumor size, and morphology were determined by using multivariate Cox regression models; associations between imaging features and genomics were studied by using the Fisher exact test.
Interrater analysis showed significant agreement in terms of contrast material enhancement, nonenhancement, necrosis, edema, and size variables. Contrast-enhanced tumor volume and longest axis length of tumor were strongly associated with poor survival (respectively, hazard ratio: 8.84, P = .0253, and hazard ratio: 1.02, P = .00973), even after adjusting for Karnofsky performance score (P = .0208). Proneural class GBM had significantly lower levels of contrast enhancement (P = .02) than other subtypes, while mesenchymal GBM showed lower levels of nonenhanced tumor (P < .01).
This analysis demonstrates a method for consistent image feature annotation capable of reproducibly characterizing brain tumors; this study shows that radiologists' estimations of macroscopic imaging features can be combined with genetic alterations and gene expression subtypes to provide deeper insight to the underlying biologic properties of GBM subsets.
This policy statement revises a previous statement on screening of preterm infants for retinopathy of prematurity (ROP) that was published in 2013. ROP is a pathologic process that occurs in immature ...retinal tissue and can progress to a tractional retinal detachment, which may then result in visual loss or blindness. For more than 3 decades, treatment of severe ROP that markedly decreases the incidence of this poor visual outcome has been available. However, severe, treatment-requiring ROP must be diagnosed in a timely fashion to be treated effectively. The sequential nature of ROP requires that infants who are at-risk and preterm be examined at proper times and intervals to detect the changes of ROP before they become destructive. This statement presents the attributes of an effective program to detect and treat ROP, including the timing of initial and follow-up examinations.
Idiopathic pulmonary fibrosis (IPF) is the most common and devastating of the interstitial lung diseases. Epithelial dysfunction is thought to play a prominent role in disease pathology, and we ...sought to characterize secreted signals that may contribute to disease pathology. Transcriptional profiling of senescent type II alveolar epithelial cells from mice with epithelial-specific telomere dysfunction identified the transforming growth factor-β family member, growth and differentiation factor 15 (
), as the most significantly upregulated secreted protein.
expression is induced in response to telomere dysfunction and bleomycin challenge in mice.
mRNA is expressed by lung epithelial cells, and protein can be detected in peripheral blood and bronchoalveolar lavage following bleomycin challenge in mice. In patients with IPF,
mRNA expression in lung tissue is significantly increased and correlates with pulmonary function. Single-cell RNA sequencing of human lungs identifies epithelial cells as the primary source of
, and circulating concentrations of GDF15 are markedly elevated and correlate with disease severity and survival in multiple independent cohorts. Our findings suggest that GDF15 is an epithelial-derived secreted protein that may be a useful biomarker of epithelial stress and identifies IPF patients with poor outcomes.
The role of incretin-based drugs in the treatment of patients with type 2 diabetes admitted to hospital has not been extensively assessed. In this study, we compared the safety and efficacy of a ...dipeptidyl peptidase-4 inhibitor (sitagliptin) plus basal insulin with a basal-bolus insulin regimen for the management of patients with type 2 diabetes in general medicine and surgery in hospitals.
We did a multicentre, prospective, open-label, non-inferiority randomised clinical trial (Sita-Hospital) in five hospitals in the USA, enrolling patients aged 18-80 years with type 2 diabetes and a random blood glucose concentration of 7·8-22·2 mmol/L who were being treated with diet or oral antidiabetic drugs or had a total daily insulin dose of 0·6 units per kg or less, admitted to general medicine and surgery services. We randomly assigned patients (1:1) to receive either sitagliptin plus basal glargine once daily (the sitagliptin-basal group) or a basal-bolus regimen with glargine once daily and rapid-acting insulin lispro or aspart before meals (the basal-bolus group) during the hospital stay. All other antidiabetic drugs were discontinued on admission. The randomisation was achieved by computer-generated tables with block stratification according to randomisation blood glucose concentrations (ie, higher or lower than 11·1 mmol/L). The primary endpoint of the trial was non-inferiority in mean differences between groups in their daily blood glucose concentrations during the first 10 days of therapy (point-of-care measurements; non-inferiority was deemed a difference <1 mmol/L). The safety endpoints included hypoglycaemia and uncontrolled hyperglycaemia leading to treatment failure. All participants who received at least one dose of study drug were included in the analysis. This study is registered with ClinicalTrials.gov, number NCT01845831.
Between Aug 23, 2013, and July 27, 2015, we recruited 279 patients, and randomly assigned 277 to treatment; 138 to sitagliptin-basal and 139 to basal-bolus. The length of stay in hospital was similar for both groups (median 4 days IQR 3-8 vs 4 3-8 days, p=0·54). The mean daily blood glucose concentration in the sitagliptin-basal group (9·5 mmol/L SD 2·7) was not inferior to that in the basal-bolus group 9·4 mmol/L 2·7) with a mean blood glucose difference of 0·1 mmol/L (95% CI -0·6 to 0·7). No deaths occurred in this trial. Treatment failure occurred in 22 patients (16%) in the sitagliptin-basal group versus 26 (19%) in the basal-bolus group (p=0·54). Hypoglycaemia occurred in 13 patients (9%) in the sitagliptin-basal group and in 17 (12%) in the basal-bolus group (p=0·45). No differences in hospital complications were noted between groups. Seven patients (5%) developed acute kidney injury in the sitagliptin-basal group and six (4%) in the basal-bolus group. One patient (0·7%) developed acute pancreatitis (in the basal-bolus group).
The trial met the non-inferiority threshold for the primary endpoint, because there was no significant difference between groups in mean daily blood glucose concentrations. Treatment with sitagliptin plus basal insulin is as effective and safe as, and a convenient alternative to, the labour-intensive basal-bolus insulin regimen for the management of hyperglycaemia in patients with type 2 diabetes admitted to general medicine and surgery services in hospital in the non-intensive-care setting.
Merck.
Purpose of Review
Acute care re-utilization, i.e., hospital readmission and post-discharge Emergency Department (ED) use, is a significant driver of healthcare costs and a marker for healthcare ...quality. Diabetes is a major contributor to acute care re-utilization and associated costs. The goals of this paper are to (1) review the epidemiology of readmissions among patients with diabetes, (2) describe models that predict readmission risk, and (3) address various strategies for reducing the risk of acute care re-utilization.
Recent Findings
Hospital readmissions and ED visits by diabetes patients are common and costly. Major risk factors for readmission include sociodemographics, comorbidities, insulin use, hospital length of stay (LOS), and history of readmissions, most of which are non-modifiable. Several models for predicting the risk of readmission among diabetes patients have been developed, two of which have reasonable accuracy in external validation. In retrospective studies and mostly small randomized controlled trials (RCTs), interventions such as inpatient diabetes education, inpatient diabetes management services, transition of care support, and outpatient follow-up are generally associated with a reduction in the risk of acute care re-utilization. Data on readmission risk and readmission risk reduction interventions are limited or lacking among patients with diabetes hospitalized for COVID-19. The evidence supporting post-discharge follow-up by telephone is equivocal and also limited.
Summary
Acute care re-utilization of patients with diabetes presents an important opportunity to improve healthcare quality and reduce costs. Currently available predictive models are useful for identifying higher risk patients but could be improved. Machine learning models, which are becoming more common, have the potential to generate more accurate acute care re-utilization risk predictions. Tools embedded in electronic health record systems are needed to translate readmission risk prediction models into clinical practice. Several risk reduction interventions hold promise but require testing in multi-site RCTs to prove their generalizability, scalability, and effectiveness.
Temperate phages are pervasive in bacterial genomes, existing as vertically inherited islands termed prophages. Prophages are vulnerable to predation of their host bacterium by exogenous phages. ...Here, we identify BstA, a family of prophage-encoded phage-defense proteins in diverse Gram-negative bacteria. BstA localizes to sites of exogenous phage DNA replication and mediates abortive infection, suppressing the competing phage epidemic. During lytic replication, the BstA-encoding prophage is not itself inhibited by BstA due to self-immunity conferred by the anti-BstA (aba) element, a short stretch of DNA within the bstA locus. Inhibition of phage replication by distinct BstA proteins from Salmonella, Klebsiella, and Escherichia prophages is generally interchangeable, but each possesses a cognate aba element. The specificity of the aba element ensures that immunity is exclusive to the replicating prophage, preventing exploitation by variant BstA-encoding phages. The BstA protein allows prophages to defend host cells against exogenous phage attack without sacrificing the ability to replicate lytically.
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•BstA is an abortive infection protein found in prophages of Gram-negative bacteria•aba, a short DNA sequence within the bstA locus, acts as a self-immunity element•aba gives BstA-encoding prophages immunity to BstA-driven abortive infection•Variant BstA proteins have distinct and cognate aba elements
Prophages can encode abortive infection proteins that give their bacterial hosts population-level phage defense. Owen et al. show that some of these proteins contain internal self-immunity systems so that the prophage is not self-targeted by its own phage-defense protein.
This multicenter, open-label, randomized trial examined the safety and efficacy of exenatide alone or in combination with basal insulin in non-critically ill patients with type 2 diabetes (T2D).
A ...total of 150 patients with blood glucose (BG) between 140 and 400 mg/dL, treated at home with diet, oral agents, or insulin at a total daily dose <0.5 units/kg, were randomized to exenatide alone (5 μg twice daily), exenatide plus basal insulin, or a basal-bolus insulin regimen. The primary end point was difference in mean daily BG concentration among groups.
Mean daily BG was similar between patients treated with exenatide plus basal and a basal-bolus regimen (154 ± 39 vs. 166 ± 40 mg/dL,
= 0.31), and exenatide plus basal resulted in lower daily BG than did exenatide alone (177 ± 41 mg/dL,
= 0.02). Exenatide plus basal resulted in a higher proportion of BG levels in target range between 70 and 180 mg/dL compared with exenatide and basal-bolus (78% vs. 62% vs. 63%, respectively,
= 0.023). More patients in the exenatide and exenatide plus basal groups experienced nausea or vomiting than in the basal-bolus group (10% vs. 11% vs. 2%,
= 0.17), with three patients (6%) discontinued exenatide owing to adverse events. There were no differences in hypoglycemia <54 mg/dL (2% vs. 0% vs. 4%,
= 0.77) or length of stay (5 vs. 4 vs. 4 days,
= 0.23) among basal plus exenatide, exenatide, and basal-bolus groups.
The results of this pilot study indicate that exenatide alone or in combination with basal insulin is safe and effective for the management of hospitalized general medical and surgical patients with T2D.
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