Publications

BACKGROUND: Inpatient hyperglycemia is common among adults, and management varies.

PURPOSE: To systematically identify guidelines on inpatient hyperglycemia management.

DATA SOURCES: MEDLINE, Guidelines International Network, and specialty society websites were searched from 1 January 2010 to 14 August 2024.

STUDY SELECTION: Clinical practice guidelines pertaining to blood glucose management in hospitalized adults were included.

DATA EXTRACTION: Two authors screened articles and extracted data, and three assessed guideline quality. Recommendations on inpatient monitoring, treatment targets, medications, and care transitions were collected.

DATA SYNTHESIS: Guidelines from 10 organizations met inclusion criteria, and 5 were assessed to be of high quality per the Appraisal of Guidelines for REsearch & Evaluation II (AGREE II) instrument. All guidelines recommended monitoring blood glucose for patients with diabetes and nine for admission hyperglycemia. Eight guidelines recommended an upper blood glucose target of 180 mg/dL, five with a lower limit of 100 mg/dL and three of 140 mg/dL. Guidelines were in agreement on using capillary blood glucose monitoring, and three guidelines included discussion of continuous monitoring. Hyperglycemia treatment with basal-bolus insulin alone (n = 3) or with correction (n = 5) was most commonly recommended, while sliding scale insulin was advised against (n = 5). Guidance on use of oral diabetes medications was inconsistent. Five guidelines included discussion of transitioning to home medications. Recommendations for hypoglycemia management and diabetes management in older adults were largely limited to outpatient guidance.

LIMITATIONS: Non-English-language guidelines were excluded.

CONCLUSIONS: While there is consensus on inpatient blood glucose monitoring and use of basal-bolus insulin, there is disagreement on treatment targets and use of home medications and little guidance on how to transition treatment at discharge.

BACKGROUND: Timely primary care follow-up after hospitalization is recommended to monitor recovery and coordinate care. Whether follow-up differs for vulnerable populations, such as those with frailty and those discharged to skilled nursing facilities (SNF) prior to returning home, is not known.

METHODS: Retrospective cohort study using a 100% sample of traditional Medicare beneficiaries discharged from hospital to home or from hospital to SNF and then home, between 2010 and 2022. The primary outcome was the receipt of a primary care visit within 30 days of return to home, measured overall and stratified by disposition (discharged home vs. to SNF then home) and by frailty (defined by a claims-based frailty index). Multivariable logistic regression models were used to estimate changes in outcomes over time, overall and stratified by disposition and frailty.

RESULTS: The cohort included 94,248,326 discharges (80.1% age ≥ 65 years, 55.1% female, 36.7% frail) of which 21.5% were discharged to SNF and then home. Between 2010 and 2022, primary care follow-up increased from 51.5% to 57.5% for patients discharged directly home and from 24.3% to 28.4% for patients discharged to SNF then home. In adjusted analyses, compared to those discharged directly home, patients discharged to SNF and then home had an 8.2% point (pp) (95% CI, -8.5 to -7.9) lower predicted probability of ambulatory follow-up in 2022. Among patients discharged directly home, no difference was evident in follow-up between frail and non-frail patients (54.6% vs. 54.1%); difference 0.4 pp (95% CI, -0.1 to 1.0). In contrast, among patients discharged to SNF then home, frail patients had a lower predicted probability of follow-up (42.8% vs. 48.9%); difference - 6.1 pp (95% CI, -7.0 to -5.2).

CONCLUSIONS: Frail patients and patients requiring a short-term SNF stay after hospitalization are less likely to receive timely follow-up upon return to home than other patient groups.