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.
Abstract
Introduction: Sarcoidosis is a granulomatous disease of unknown etiology often involving multiple organ systems. Sarcoidosis most frequently affects the lungs, but in upto 30% of cases, can ...present with extrapulmonary manifestations. Less than 10% of patients with sarcoidosis present with disease at extrapulmonary sites. 10%-20% patients with sarcoidosis present with hypercalcemia. Hypercalcemia in sarcoidosis is secondary to increased intestinal calcium absorption due to increased levels of 1,25-dihydroxy Vitamin D. Clinical Case: 71-year-old Caucasian male presenting to his primary care physician with 3-week duration of fatigue, anorexia, mild confusion and unintentional weight loss was found to have moderate hypercalcemia and acute kidney injury. He was admitted the hospital for evaluation and management. Labs at admission revealed albumin-corrected calcium of 13.5 mg/dL (normal 8.5-11.0 mg/dL), creatinine of 1.78 mg/dL (normal 0.7- 1.3mg/dL) and alkaline phosphatase of 173 U/L (normal 45-117 U/L). Workup noted low PTH (3,normal 14-72 pg/mL), normal 25-hydroxy Vitamin D (50.7,normal 30-100 ng/dL), normal PTHrP and normal serum electrophoresis and immunofixation indicating non-PTH dependent hypercalcemia. 1,25-dihydroxy Vitamin D (125, normal 18-64 pg/mL) and ACE levels (159 U/L, normal 16-85 U/L) were elevated. Patient denied being on any Vitamin D supplements. A CT chest, abdomen and pelvis was done to look for occult malignancy and hepatosplenomegaly was noted with only mild compressive atelectasis of lungs. Abdominal ultrasound confirmed hepatomegaly with lobulated outer contour consistent with cirrhosis. Acute hepatitis, infectious and autoimmune work up was negative. Patient was discharged with mild improvement in calcium and mental status with hydration. Due to high suspicion for granulomatous disease, a liver biopsy was done. Liver biopsy confirmed granulomatous hepatitis with stage 2 of 4 fibrosis with numerous foci of non-caseating granulomatous inflammation. With negative acid-fast staining, no fungal organisms, absence of foreign material, normal eosinophil counts and low clinical suspicion for Crohn’s disease, a diagnosis of abdominal sarcoidosis was made. The patient was started on 10 mg prednisone daily and within one week, his albumin- corrected calcium levels improved to 10.4 mg/dL with significant improvement in appetite and mental status. Conclusion: While isolated extrapulmonary sarcoidosis is rare, it is an important cause of hypercalcemia due to elevated 1,25-dihydroxyvitamin D levels. Management of hypercalcemia secondary to sarcoidosis often consists of initiating glucocorticoids which act mainly by inhibition of 1,25-dihydroxy vitamin D synthesis in addition to inhibiting calcium absorption and osteoclast activity.
Abstract
Background: Hypoglycemia is rare in patients without diabetes. A low capillary glucose concentration is not sufficient to make a diagnosis of a hypoglycemic disorder. In fact, this has ...multiple sources of error. Fulfillment of Whipple’s triad is an essential step for establishing the diagnosis of a hypoglycemic disorder. Clinical case: A 47-year old Caucasian male with past medical history of paranoid schizophrenia was admitted to the ICU from an outside facility with catatonia and apneic spells following an acute change in mental status. He was diagnosed with neuroleptic malignant syndrome and Endocrinology was consulted after 137 days in the hospital for concerns of severe and recurrent hypoglycemia. The patient was non-verbal on evaluation and despite multiple capillary blood glucose readings of <70 mg/dL, including measurements as low as 29 mg/dL, he remained asymptomatic with absence of any clinical signs of an adrenergic response to hypoglycemic episodes. He was on continuous tube feeding through a PEG tube. The low capillary blood glucose measurements prompted rapid management with intravenous or oral dextrose based on the hypoglycemia protocol designed by the hospital. As a last resort, the patient was placed on a continuous dextrose infusion in addition to tube feeding to prevent hypoglycemia.Diagnostic evaluation: Following consultation, we ordered for a corresponding plasma glucose measurement to be done with any capillary blood glucose measurement of < 55 mg/dL prior to correction for hypoglycemia. For a capillary blood glucose measured at 48 mg/dL, corresponding plasma glucose was 95 mg/dL. Whipple’s triad was not fulfilled and no additional work up was pursued. We recommended calibration of the glucose monitors for the hospital unit where the patient was admitted with recommendations to stop monitoring capillary blood glucose in this patient in the absence of diabetes, signs/symptoms of hypoglycemia, medications implicated to cause hypoglycemia and ongoing nutrition with tube feeding. Follow-up: The patient remains in the hospital and is waiting placement at an extended care facility. Plasma blood glucose measurements remain within normal range.Clinical lesson: Artifactual hypoglycemia, though uncommon, is an important consideration when evaluating and managing hypoglycemia. Whipple’s triad is essential to make a diagnosis of true hypoglycemia. Several factors; patient, operator and machine-related, can impact measurements of capillary blood glucose measurements and often result in unnecessary treatment measures often causing inefficient and often preventable wastage of hospital resources and sometimes even harm the patient.
The complexity of diabetes management is further complicated when patients are admitted to the hospital, where changes in nutrition and diabetes medications frequently accompany acute illness.15,16 ...Patients receiving glucocorticoid therapy in the hospital represent a particularly vulnerable group for post-discharge glycemic excursions if adequate instructions for adjusting insulin according to steroid doses are not provided.11,12 The frequency of hospital readmission observed in the diabetes patient population raises important questions relevant to how well patients understand instructions for ongoing therapy provided at time of discharge.12 Many hospitals do not have established guidelines for how instructions for ongoing diabetes therapy provided at time of discharge.12 There are several reported initiatives addressing the safe transition of patients with diabetes from hospital to home in a way that targets reductions in hospital readmissions.17-20 These initiatives include some combination of comprehensive diabetes survival skill education (SSE) coordinated with scheduled timely follow-up after discharge either in person or by phone.17-20 In one study, these components were paired with assessment of patient knowledge and medication adherence in 125 patients with hyperglycemia identified at hospital admission or ER visit, resulting in a 62% decrease in the number hospital readmissions over the following 3months (14 vs. 5.3%, p=0.058).19 Whether these observed improvements can be sustained over a longer time period in a larger number of subjects is worthy of additional investigation. Current strategies and future directions, Annu Rev Med, Vol. 65, 2014, 471-485 3., D.J. Rubin, E.A. Handorf, S.H. Golden, D.B. Nelson, M.E. McDonnell, H. Zhao, Development and validation...
Abstract
Background: Medullary thyroid cancer (MTC) is a neuroendocrine tumor of the parafollicular or C cells of the thyroid gland, accounting for 1-2% of thyroid cancers in the United States. About ...25% MTCs are familial as a part of the MEN2 syndrome or familial MTC (FMTC). Germline mutations in codon 891 are predominantly associated with FMTC. Case: 65-year-old Caucasian male was referred to the Endocrinology clinic after bilateral thyroid nodules were found on thyroid US. The patient had requested an ultrasound of his thyroid after his brother was diagnosed with MTC following fine-needle aspiration for an incidental thyroid nodule prompting total thyroidectomy and genetic testing. The patient’s brother was found to be heterozygous for RET mutation (c.2617T>G;pSer891Ala). This resulted in screening of the other siblings including this patient, also found to be heterozygous for this mutation. Both parents were deceased, and their clinical history is not known. Only one of the remaining two siblings had genetic testing; one brother refused testing for the mutation and one sister was positive for the mutation but had no thyroid nodules on ultrasound. She underwent prophylactic thyroidectomy. Neither the patient, nor his siblings, have any progeny. The patient screened negative for primary hyperparathyroidism and pheochromocytoma. Calcitonin (739, normal </=14.3 pg/mL)and CEA levels (31.7, 0-3.0 ng/mL) were elevated. Thyroid ultrasound (US) showed two solid hypoechoic nodules with lobulated margins and internal coarse calcifications in the right and two in the left thyroid lobe; 1.5 cm and 1.2 cm in maximum diameter, and 1.2 cm and 3 mm in maximum diameter, respectively. Based on elevated calcitonin and CEA levels, known RET mutation and evidence for thyroid nodules, we recommended a total thyroidectomy and central neck dissection. Pathology revealed multifocal, bilateral medullary carcinoma (largest focus of 1.5 cm), with 4/4 lymph nodes positive for metastasis. This was classified as mpT1bN1aM0 (Stage III). Patient was started on levothyroxine with plans to repeat calcitonin and CEA levels and neck ultrasound, 3 months following surgery. CT chest, abdomen and pelvis did not reveal any distant metastasis. Conclusion: Inherited MTCs are rare. Early diagnoses by screening of at-risk family members in MEN2 kindreds is important because MTC can be life-threatening and can be cured and prevented by early thyroidectomy. While our suspicion for FMTC in this patient and his siblings is high, FMTC is now considered a variant of MEN2A and ongoing screening for pheochromocytoma and primary hyperparathyroidism is recommended.
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)
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)
The purpose of this prospective observational cohort study was to examine sex differences in glycemic measures, diabetes-related complications, and rates of postdischarge emergency room (ER) visits ...and hospital readmissions in non-critically ill, hospitalized patients with diabetes.
Demographic data including age, body mass index, race, blood pressure, reason for admission, diabetes medications at admission and discharge, diabetes-related complications, laboratory data (hematocrit, creatinine, hemoglobin A1c, point-of-care blood glucose measures), length of stay (LOS), and discharge disposition were collected. Patients were followed for 90 days following hospital discharge to obtain information regarding ER visits and readmissions.
120 men and 100 women consented to participate in this study. There were no sex differences in patient demographics, diabetes duration or complications, or LOS. No differences were observed in the percentage of men and women with an ER visit or hospital readmission within 30 (39% vs 33%, p=0.40) or 90 (60% vs 49%, p=0.12) days of hospital discharge. More men than women experienced hypoglycemia prior to discharge (18% vs 8%, p=0.026). More women were discharged to skilled nursing facilities (p=0.007).
This study demonstrates that men and women hospitalized with an underlying diagnosis of diabetes have similar preadmission glycemic measures, diabetes duration, and prevalence of diabetes complications. More men experienced hypoglycemia prior to discharge. Women were less likely to be discharged to home. Approximately 50% of men and women had ER visits or readmissions within 90 days of hospital discharge.
NCT03279627.
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