Background: Hospital admissions are the majority contributor to the cost in caring for diabetes, accounting for about 40% of the costs. As most hospital reimbursements are based upon diagnosis-related groups, hospitals have strong financial incentives for quicker discharges to control length of stay and costs. This can limit the time available to develop a comprehensive discharge plan, which leads to unnecessary readmissions and cost. 1 in 7 hospital readmissions among patients with diabetes are estimated due to substandard transition of care. We initiated a Transition of Care (ToC) program at our institute on 07/01/2013 to investigate if ToC Model at the time of hospital discharge reduces the hospital readmission rates with diabetic ketoacidosis (DKA).
Methods: A retrospective chart review study was conducted at SUNY Upstate Medical University, Syracuse, NY. We reviewed electronic medical records (EMR) of patients > 18 years age admitted with DKA between 01/01/2013-12/31/2013 and collected demographic, clinical and laboratory data. ToC program initiated on 07/01/2013, involved making phone calls/mailing letters to the patients within 48 hours of the hospital discharge by fellows in-training. Patients were inquired about changes in discharge medications/insulin regimens, home blood glucose values and encouraged to follow up at an affiliated Joslin Diabetes Center (JDC). For the purpose of the study, patients admitted between 01/01/2013 to 06/30/2013 were used as controls and from 07/01/2013 to 12/31/2013 (post initiation of ToC) as cases.
Results: 89 patients with DKA were included in the study, of which 54 were cases and 35 controls. The two groups were similar in terms of age, gender and types of diabetes. 10 out of 54 (18.5%) in cases and 6 out 35 (17.1%) in control groups were readmitted > 1 time within next 6 months of hospital discharge. Under ToC model, 34 cases were contacted through phone calls and additional 4 through letter. 33 out of 54(61.1%) patients followed at JDC within 30 days. In control group 17 out 35(48.5%) followed at JDC. Our study could not show statistically significant reduction in hospital readmission rates. Limitation of study was the small sample size. However, a trend towards increased outpatient follow up was seen.
Conclusions:
In our experience, post – hospital discharge phone call is an inexpensive tool to reinforce the discharge plan, clarify misunderstandings, early detection of unexpected outcomes and remind about outpatient follow up. However there is paucity of high quality evidence to explore the beneficial effect of this intervention. The limited data present did not show an evidence of reduced hospital readmissions, as in our study. But similar to our study increased contact with outpatient providers was demonstrated which definitely has important implications and is a potential area for further studies. With changing legislations and payment structures there is an immediate need to develop effective transitional care programs.