Utility of Computer-Guided Decision Support System in Discharge Insulin Dosing and Diabetes-Related Readmissions

Diabetes-related readmission and adverse events are cited as consequences of inadequate discharge planning, lack of standardized protocols, and insufficient post-discharge support.¹ Despite research showing improved outcomes with better blood glucose (BG) control, there is widespread inertia when modifying the diabetes treatment regimen on admission and at hospital discharge. Recognizing the gaps in the evidence for optimal discharge insulin regimens, we conducted a study titled “Glucommander Utilization In Discharge Effectiveness, GUIDE-Home Study” to assess the safety and efficacy of the Hospital to Home (H2H) discharge treatment protocol.

We enrolled 49 patients with type 2 diabetes between the ages 18-80 years of age, with an HbA1c level above 7%. The study participants had inpatient insulin dosing with Glucommander™ (GM), an electronic glucose management software, for a minimum of two days before discharge and a fasting BG of 100-180 mg/dL on the day of discharge. All participants required insulin therapy at the time of discharge and the dosing was provided by the software. A certified diabetes care and education specialist conducted weekly data gathering phone interviews for four weeks after discharge.

The results of this study revealed an average HbA1c of 9.5% with an average admission BG of 230 mg/dL. BG during the hospital stay averaged 163 mg/dL with no severe hypoglycemia (BG <40 mg/dL) and mild-moderate hypoglycemia (BG 41-70 mg/dL) of 0.46% of BGs. The discharge BG averaged 153 mg/dL. The insulin-dosing regimen derived from the H2H software module in GM achieved the goal BG control as observed with fasting and mean daily BG averages during the 30-day post discharge ranging from 129 to 133 mg/dL, and a hypoglycemia rate <40 mg/dL of 2.1% and <70 mg/dL of 19.1%. There was one urgent care visit and one emergency room visit. The hospital system’s 30-day readmissions had an overall 15% all-cause readmission rate and 25% hospital readmission rate for patients with diabetes compared to the study participants group which had a 12% readmission rate for all causes and no readmission attributed to diabetes or glucose issues as seen in Figure 1. BG results showed there were no significant differences between the first blood glucose (FBG) values (n = 31), (133 ± SD 49.6, r² = 0.76) in readmitted patients and the first BG values (n = 141), (128 ± SD = 29.5, r² = 0.9) in non-readmitted patients (P = 2.032)

Figure 1.

The percent of 30-day hospital readmission rates comparing all inpatients, all patients with diabetes-related causes, all study participants for any cause, and all study patient readmitted with glucose-related causes.

This study examined the safety of discharge insulin dosing transition using the GM software. This software is based on a discharge diabetes medication algorithm for patients with type 2 diabetes published by Umpierrez et al. This algorithm uses a tiered approach based on admission HbA1c.² The study participants showed improved glucose control, reduced emergency department visits, and readmissions compared with the general readmission rate of the hospital. Utilization of the software was found to help inpatient providers safely and effectively order personalized home insulin therapy at discharge and possibly prevent costly ED visits and readmission. This is the first study using discharge recommending software feature to help providers safely and effectively order personalized home insulin therapy at discharge.