Study Suggests Missed Opportunities to Improve Management of Poorly Controlled Diabetes at VA Hospital Discharge

BACKGROUND:
Clinical inertia, defined as a failure to initiate or intensify therapy when it is clinically indicated, has been documented in the care of diabetes in inpatient and outpatient settings, within the VA and other healthcare systems. Admissions to the hospital represent an important opportunity to improve glycemic control among patients with poorly controlled diabetes by adjusting outpatient medications at the point of discharge — and by providing appropriate outpatient clinical follow-up. This retrospective cohort study evaluated the impact of hospital admission events on the outpatient treatment of Veterans with diabetes. Using VA data, investigators identified 1,359 male Veterans, who were receiving medication therapy for diabetes and had an elevated HgbA1c (> 8%) prior to admission. Patients were included if they were admitted to one of four VA hospitals from 7/02 through 8/09 for causes other than palliative care. The main outcome measure was a change in pre-admission outpatient prescriptions for diabetes at hospital discharge, including an increase or decrease in dose for an existing diabetes medication, addition of a medication, discontinuation of a medication, or change in dose or type of insulin. Prescriptions filled during the 4-month interval before hospital admission were used to determine baseline diabetes therapy. Covariates also were assessed, such as patient demographics, hospital site, most recent HgbA1c, glucose, serum creatinine, and admission service (medical vs. surgical/mixed/other).

FINDINGS:

• Despite evidence of poor diabetes control prior to admission, less than one-quarter (22%) of the Veterans in this study received a change in outpatient diabetes therapy upon hospital discharge, suggesting widespread clinical inertia.
• Nearly one-third of Veterans (32%) had no change in therapy, no documentation of HgbA1c within 60 days of discharge, and no follow-up appointment within 30 days of discharge.
• Patients admitted to surgical, psychiatric, or rehabilitation services were less likely to have a change in outpatient therapy compared to patients admitted to medical services.
• In an adjusted analysis, factors associated with higher odds of a change in diabetes therapy included: inpatient endocrinology consultation, higher pre-admission HgbA1c, higher mean blood glucose during admission, occurrence of inpatient hypoglycemia, and inpatient basal insulin therapy.

LIMITATIONS:

• Some patients may have had contraindications to more intensive diabetes treatment. The study did not assess clinical history collected by providers upon hospital admission regarding recent diabetes parameters (e.g., hypoglycemia).
• Investigators were unable to evaluate discharge counseling which may have addressed need to adjust medication or increase dietary adherence.
• Follow-up appointments with non-VA providers could not be examined.
• This study was not designed to explain provider behavior, only to describe changes made to therapy.

AUTHOR/FUNDING INFORMATION:
Dr. Matheny is supported by an HSR&D Career Development Award and is part of the VA Tennessee Valley Healthcare System.

Griffith M, Boord J, Eden S, and Matheny M. Clinical Inertia of Discharge Planning among Patients with Poorly Controlled Diabetes Mellitus. Journal of Clinical Endocrinology and Metabolism March 30, 2012;e-pub ahead of print.