With benefits to patient outcomes, provider burden, and health system costs, the goal of reducing hospital readmissions for patients with diabetes mellitus (DM) is multifaceted. Current studies have neither elucidated a clear approach to accurately identify at-risk patients nor implemented reliable interventions to significantly reduce readmissions. We trialed a Quality Improvement project utilizing a diabetes Nurse Practitioner (NP)/Certified Diabetes Care and Education Specialist (CDCES) to see at-risk patients during initial hospitalization and in close clinic follow-up after discharge with an endpoint of reducing future readmissions. Over 21 months, 79 hospitalized patients with DM were identified as high-risk for readmission. Identifying factors included previous admission, DKA/HHS, new DM diagnosis, new to insulin, high-dose steroid use, or provider discretion. The NP/CDCES provided DM management, education, and coordinated discharge. Patients were called shortly after discharge and had a 2-4 week clinic follow-up with the NP/CDCES. The primary endpoint was number of readmissions 180 days post-discharge after NP/CDCES intervention versus number of previous readmissions pre-intervention. Change in hemoglobin A1C, time to post-hospital phone call, and time to outpatient follow-up were also evaluated. Pre- and post-intervention readmission rates remained unchanged; average pre-intervention readmissions per patient was 1.7 versus 1.88 post-intervention readmissions (p=0.74). However, a secondary endpoint of reduction in A1C was statistically significant, with a mean decrease in A1C of 0.97% per patient (p=0.0025). Time to post-hospital phone call and early follow-up did not affect readmission rates. While targeted inpatient-to-outpatient intervention for high-risk patients with DM did not reduce readmission rates, our data suggests coordinated inpatient intervention with close hospital follow-up may improve A1C in high-risk patients with diabetes.
A. Harris: None. K. Grdinovac: None.
