PracticeUpdate Diabetes March 2019

EDITOR’S PICKS 17

Risk Factors for Readmission of InpatientsWith Diabetes Journal of Diabetes and Its Complications Take-home message • This systematic review was performed to identify risk factors associ- ated with hospital readmission among people with diabetes. • The authors identified 76 risk factors among 48 studies of the 83 included in the review, including the comorbidity burden, age, race, and type of insurance.

A Dose–Response Relationship Between Insulin Glargine

100 Units/mL and Glycemic Control Diabetes, Obesity & Metabolism Take-home message

• In this meta-analysis of three trials (458 patients), the authors developed a basal insulin clinical response curve in order to assess the efficacy of increasing insulin doses on glycemic measures, body weight and hypoglycemia. Specifically, they evaluated HbA1c values, fasting plasma glucose, body weight, and incidence of hypo- glycemia. They determined that basal insulin is associated with many small improvements in fasting plasma glucose and HbA1c levels at doses >0.3 IU/kg/day, and, at doses >0.5 IU/kg/ day, is associated with weight gain. • The authors concluded that, after a threshold of 0.5 IU/kg/day of basal insulin, clinicians should consider other antihyperglycemic treatment adjuncts to reduce glycemic measures. Abstract AIMS One option recommended by treatment guidelines for the management of patients with uncontrolled type 2 diabe- tes and post-prandial excursions is adding prandial insulin when basal insulin dose is >0.5 IU/kg/day. This recommenda- tion is based on expert opinion, with limited clinical evidence for this threshold dose. In this post-hoc analysis, we con- struct a clinical-response curve for basal insulin, assessing the impact of increasing doses on glycemic measures, body weight, and hypoglycemia. RESEARCH DESIGN AND METHODS We included data from pro- spective, randomized controlled treat-to-target trials of ≥24 weeks duration conducted between 1997 and 2007 in patients with type 2 diabetes, uncontrolled on metformin and sulfony- lurea, and treated with insulin glargine U100, who had at least six fasting plasma glucose (FPG) measurements. The impact of insulin dose on A1C values, FPG, hypoglycemia incidence (<70 mg/dL, 3.9 mmol/L), and body weight was analyzed. 458 patients from three eligible trials were included. RESULTS The observed relationship between higher basal insulin doses and glycemic control was non-linear, with increasing insulin dose leading to smaller reductions of FPG and A1C for doses >0.3 IU/kg/d, with a plateauing of effect at 0.5 IU/kg/d. Total daily dose of insulin >0.5 IU/kg/d resulted in greater weight gain, but without higher rates of hypogly- cemia compared to insulin doses ≤0.5 IU/kg/d. CONCLUSIONS This analysis indicates that basal insulin doses >0.5 IU/kg/d have diminishing additional impact on improv- ing glycemic measures, with the disadvantage of additional weight gain. Clinicians should consider antihyperglycemic treatment intensification at doses approaching 0.5 IU/kg/d. When Basal Insulin is Not Enough: A Dose Response Rela- tionship Between Insulin Glargine 100 Units/mL (U100) and Glycemic Control. Diabetes Obes Metab 2019 Feb 05;[EPub Ahead of Print], GE Umpierrez, N Skolnik, T Dex, et al. www.practiceupdate.com/c/79548

COMMENT By Enrico Cagliero MD H ospital readmissions in patients with diabetes occur at a higher rate than for the general population and are a signif- icant medical and economic issue. Moreover, some readmissions are preventable, but our capac- ity to identify patients at high risk for readmission is still limited. The current article by Robbins et al is a comprehensive review of the stud- ies available on readmission rates in patients with diabetes. A total of 76 risk factors were identified out of 83 studies as statistically signif- icant in univariate analysis, some obvious (age and comorbidity burden) and some not (increased hematocrit, distance from hospi- tal). Unfortunately, because of the

design of the studies analyzed, a quantitative analysis of effect size and a multivariate model could not be performed, thus limiting the clin- ical significance of these findings. There is clearly a need for further studies in this area to develop clin- ically relevant and actionable risk calculators so that patients with dia- betes admitted to hospitals will be able to avoid further preventable readmissions.

Dr. Cagliero is Associate Professor of Medicine at Harvard Medical School and Associate Physician at Massachusetts

General Hospital in Boston, Massachusetts.

Abstract AIM We have limited understanding of which risk factors contribute to increased readmission rates amongst people discharged from hospital with diabetes. We aim to complete the first review of its kind, to identify, in a systematic way, known risk factors for hospital readmission amongst people with diabetes, in order to better understand this costly complication. METHOD The reviewwas prospectively registered in the PROSPEROdatabase. Risk factors were identified through systematic review of literature in PubMed, EMBASE & SCOPUS databases, performed independently by two authors prior to data extraction, with quality assessment and semi-quantitative synthesis according to PRISMA guidelines. RESULTS Eighty-three studies were selected for inclusion, predominantly from the United States, and utilising retrospective analysis of local or regional data sets. 76 distinct statistically significant risk factors were identified across 48 studies. The most commonly identified risk factors were; co-morbidity burden, age, race and insurance type. Few studies conducted power calculations; unstandardized effect sizes were calculated for the majority of statistically significant risk factors. CONCLUSION This review is important in assessing the current state of the literature and in supporting development of interventions to reduce readmission risk. Further- more, it provides an important foundation for development of rigorous, pre-specified risk prediction models. Risk Factors for Readmission of Inpatients With Diabetes: A Systematic Review. J Diabetes Complicat 2019 Jan 30;[EPub Ahead of Print], TD Robbins, SNLC Keung, S Sankar, et al. www.practiceupdate.com/c/79310

VOL. 3 • NO. 1 • 2019