Table 1.
Baseline characteristics of Intervention and Usual Care groups.
| Variable | All Patients N = 91 |
Intervention n = 45 |
Usual Care n = 46 |
|---|---|---|---|
| Age, years | 58.7 ± 12.7 | 58.5 ± 13.7 | 58.9 ± 11.7 |
| Female | 47 (51.6) | 21 (46.7) | 26 (56.5) |
| Income, USD | |||
| Less than $12,060 | 25 (27.5) | 9 (20.0) | 16 (34.8) |
| $12,060–$16,239 | 16 (17.6) | 8 (17.8) | 8 (17.4) |
| $16,240–$24,599 | 15 (16.5) | 9 (20.0) | 6 (13.0) |
| $24,600–$49,999 | 22 (24.2) | 11 (24.4) | 11 (23.9) |
| $50,000 or more | 13 (14.3) | 8 (17.8) | 5 (10.9) |
| Race | |||
| Black | 65 (71.4) | 29 (64.4) | 36 (78.3) |
| Other | 1 (1.1) | 0 (0.0) | 1 (2.2) |
| White | 25 (27.5) | 16 (35.6) | 9 (20.0) |
| Hispanic | 13 (14.3) | 9 (20.0) | 4 (8.7) |
| Education, years | 12.6 ± 2.5 | 13.0 ± 3.0 | 12.1 ± 1.8 |
| Employment Status | |||
| Disabled | 64 (70.3) | 32 (71.1) | 32 (69.6) |
| Employed | 1 (1.1) | 1 (2.2) | 0 (0.0) |
| Retired | 16 (17.6) | 6 (13.3) | 10 (21.7) |
| Unemployed | 10 (11.0) | 6 (13.3) | 4 (8.7) |
| Insurance | |||
| Medicaid only | 16 (18.0) | 9 (20.9) | 7 (15.2) |
| Medicare and Medicaid | 17 (19.1) | 9 (20.9) | 8 (17.4) |
| Medicare only | 24 (27.0) | 10 (23.3) | 14 (30.4) |
| None | 3 (3.4) | 2 (4.7) | 1 (2.2) |
| Private | 29 (32.6) | 13 (30.2) | 16 (34.8) |
| Smoking | |||
| Current smoker | 18 (19.8) | 9 (20.0) | 9 (19.6) |
| Former smoker | 40 (44.0) | 20 (44.4) | 20 (43.5) |
| Never | 33 (36.3) | 16 (35.6) | 17 (37.0) |
| Body mass index (kg/m2) | 35.2 ± 10.9 | 36.2 ± 11.7 | 34.2 ± 10.0 |
| Type of Diabetes | |||
| Type 1 | 5 (5.5) | 3 (6.7) | 2 (4.3) |
| Type 2 | 86 (94.5) | 42 (93.3) | 44 (95.7) |
| Diabetes duration, years | 15.1 ± 10.0 | 13.6 ± 8.5 | 16.6 ± 11.2 |
| A1c at admission | 8.7 (7.1–10.6) | 8.9 (7.2–11.1) | 8.5 (7.1–10.0) |
| A1c at admission >7.0% (53 mmol/mol) | 69 (76.7) | 34 (77.3) | 35 (76.1) |
| Preadmission Home Medication Route | |||
| Insulin only | 52 (57.1) | 27 (60.0) | 25 (54.3) |
| No medications | 7 (7.7) | 1 (2.2) | 6 (13.0) |
| Oral & insulin | 19 (20.9) | 13 (28.9) | 6 (13.0) |
| Oral only | 11 (12.1) | 3 (6.7) | 8 (17.4) |
| Other | 2 (2.2) | 1 (2.2) | 1 (2.2) |
| Preadmission sulfonylurea use | 8 (8.8) | 3 (6.7) | 5 (10.9) |
| Preadmission metformin use | 19 (20.9) | 9 (20.0) | 10 (21.7) |
| Preadmission insulin use | 73 (80.2) | 42 (93.3) | 31 (67.4) |
| Preadmission statin use | 64 (70.3) | 28 (62.2) | 36 (78.3) |
| Preadmission glucocorticoid use | 18 (19.8) | 8 (17.8) | 10 (21.7) |
| Preadmission blood pressure medications | |||
| None | 14 (15.4) | 9 (20.0) | 5 (10.9) |
| ACE-i or ARB and Non-ACE/ARB | 25 (27.5) | 13 (28.9) | 12 (26.1) |
| Only ACE-i or ARB | 23 (25.3) | 6 (13.3) | 17 (37.0) |
| Only non-ACE or ARB | 29 (31.9) | 17 (37.8) | 12 (26.1) |
| History of severe hypoglycemia | 34 (37.8) | 17 (37.8) | 17 (37.8) |
| Current or prior DKA or HHS | 9 (9.9) | 5 (11.1) | 4 (8.7) |
| Microvascular complications | |||
| 0 | 35 (38.5) | 15 (33.3) | 20 (43.5) |
| 1 | 35 (38.5) | 20 (44.4) | 15 (32.6) |
| 2 | 15 (16.5) | 7 (15.6) | 8 (17.4) |
| 3 | 6 (6.6) | 3 (6.7) | 3 (6.5) |
| Macrovascular complications | |||
| 0 | 25 (27.5) | 13 (28.9) | 12 (26.1) |
| 1 | 38 (41.8) | 20 (44.4) | 18 (39.1) |
| 2 | 21 (23.1) | 9 (20.0) | 12 (26.1) |
| 3 | 6 (6.6) | 2 (4.4) | 4 (8.7) |
| 4 | 1 (1.1) | 1 (2.2) | 0 (0.0) |
| Anemia diagnosis | 62 (68.1) | 33 (73.3) | 29 (63.0) |
| Discharged within 90 days before index admission | 81 (89.0) | 45 (100.0) | 36 (78.3) |
| ED visit within 90 days before index admission | 24 (30.4) | 10 (26.3) | 14 (34.1) |
| Admission priority | |||
| Emergent | 75 (82.4) | 37 (82.2) | 38 (82.6) |
| Planned | 4 (4.4) | 2 (4.4) | 2 (4.3) |
| Urgent | 12 (13.2) | 6 (13.3) | 6 (13.0) |
| Home zip code within 5 miles of hospital | 78 (85.7) | 40 (88.9) | 38 (82.6) |
| Discharge status | |||
| Against medical advice | 1 (1.1) | 0 (0.0) | 1 (2.2) |
| Home with nursing care | 28 (30.8) | 14 (31.1) | 14 (30.4) |
| Home without additional services | 56 (61.5) | 29 (64.4) | 27 (58.7) |
| Subacute facility (rehabilitation or skilled nursing) | 5 (5.5) | 2 (4.4) | 3 (6.5) |
| No discharge within prior year | 1 (1.1) | 0 (0.0) | 1 (2.2) |
| Predicted risk of readmission within 30 days, % | 38.4 ± 7.6 | 39.2 ± 7.8 | 37.5 ± 7.5 |
| Admission blood glucose, mg/dL | 208.1 ± 107.7 | 188.7 ± 95.6 | 227.1 ± 116.4 |
| Admission blood glucose, mmol/L | 11.6 ± 6.0 | 10.5 ± 5.3 | 12.6 ± 6.5 |
| Admission serum sodium, mmol/L | 136.0 ± 4.9 | 136.3 ± 4.9 | 135.7 ± 5.0 |
| Admission serum potassium, mmol/L | 4.3 ± 0.8 | 4.3 ± 0.9 | 4.2 ± 0.7 |
| Admission serum creatinine, mg/dL | 1.7 (1.1–3.2) | 2.0 (1.1–3.2) | 1.5 (1.1–3.2) |
| Admission eGFR, mL/min | 39.8 ± 20.6 | 39.8 ± 20.5 | 39.8 ± 20.9 |
| Admission hematocrit, % | |||
| High | 2 (2.2) | 2 (4.4) | 0 (0.0) |
| Low | 69 (75.8) | 30 (66.7) | 39 (84.8) |
| Normal | 20 (22.0) | 13 (28.9) | 7 (15.2) |
| Brief Health Literacy Screen Score | 11.9 ± 2.9 | 12.3 ± 3.0 | 11.6 ± 2.7 |
| PHQ–2 Score | 1.0 (0.0–2.0) | 1.0 (0.0–2.0) | 2.0 (1.0–3.0) |
| Diabetes Knowledge Test Score | 57.3 ± 15.6 | 59.1 ± 15.7 | 55.5 ± 15.5 |
| Problem Areas in Diabetes Score | 30.6 ± 24.3 | 36.3 ± 25.1 | 25.1 ± 22.4 |
| Predicted risk of readmission within 30 days, % * | 38.4 ±7.6 | 39.2 ± 7.8 | 37.5 ± 7.5 |
Values are mean ± SD, median (IQR), or n (%) unless otherwise stated. * Predicted risk based on Diabetes Early Readmission Risk Indicator (DERRITM). IQR (interquartile range), ACE-i (angiotensin-converting enzyme inhibitors), ARB (angiotensin II receptor blockers), DKA (diabetic ketoacidosis), HHS (hyperosmolar hyperglycemic state), eGFR (estimated glomerular filtration rate), PHQ (patient health questionnaire).