Background:
Patients with diabetes and comorbid cardiovascular disease may be at particularly high risk for medication nonadherence and adverse outcomes after hospital discharge. The objective of this study was to design, implement, and evaluate an intensive discharge intervention for inpatients with type 2 diabetes.
Methods:
We randomly assigned inpatients on medicine and cardiology services with type 2 diabetes and comorbid cardiac disease, likely to be discharged home on insulin therapy, to a strategy of an intensive transitional intervention or to usual care. The intervention involves a multidisciplinary team and includes (1) a nurse practitioner to coordinate care and patient education, (2) an inpatient pharmacist to perform intensive medication reconciliation and patient counseling, (3) standardized visiting nurse visits, (4) a postdischarge clinic visit staffed by the nurse practitioner and an outpatient pharmacist, and (5) telemonitoring of point‐of‐care glucose levels. The primary end point is adherence to insulin 90 days after discharge based on pharmacy prescription refill information.
Results:
To date, we have enrolled 125 patients of a planned 200 patients in the study. One hundred nine patients are beyond the 30‐day poststudy discharge period, including 53 in the intervention arm and 56 in the usual care arm. To date, we have 90‐day postdischarge pharmacy refill data on 37 patients (15 in the intervention arm and 22 in usual care). The mean medication possession ratio among all insulin types is 85.9% (SD, 26.5%) among the intervention patients and 79.0% (SD, 22.2%) among usual care patients (difference, 6.9; 95% CI, 10.41–24.22; P = 0.23). There was no difference in adherence to cardiac medications. Intervention patients had a 1.02 decrease in their 90‐day A1c levels compared with a 0.83 decrease among usual care patients (P = 0.61). No significant differences have been found to date in 30‐day emergency department or readmission rates or rates of hypo‐ or severe hyperglycemia per monitored patient‐day, although there was a nonsignificant trend toward increased patient self‐reported hypoglycemia in the intervention arm (48.1% vs. 25% of patients with at least 1 episode, P = 0.10).
Conclusions:
To date, the intervention is associated with a nonsignificant but promising trend toward increased adherence to insulin in the 90 days after discharge. The study demonstrates the feasibility of implementing a multidisciplinary transitional intervention in medically complex patients with diabetes and in the use of a promising method of determining insulin adherence using pharmacy refill data.