There are numerous risk factors for 30-day readmission among patients with diabetes. Postdischarge factors add to the predictive accuracy achieved by predischarge factors. A better understanding of readmission risk may ultimately lead to lowering that risk.

Hospital readmission within 30 days of discharge (30dRe) is a high-priority quality measure and target for cost reduction. Patients with diabetes are at higher risk of 30dRe than patients without diabetes. There have been no published studies of interventions designed to reduce 30dRe risk specifically among diabetes patients. We conducted a pilot randomized controlled trial (RCT) of the DiaTOHC intervention in adult patients with diabetes admitted to any medical-surgical unit at Temple University Hospital between 10/2017 and 12/2018. Patients predicted to be high risk (>=27%) for 30dRe based on a validated tool (DERRITM) were randomized 1:1 to the intervention (INT) or usual care (UC). The intervention consisted of novel, brief inpatient diabetes education, coordination of care, and post-discharge support by a nurse practitioner and an A1C-based algorithm to adjust diabetes therapy. Patients received weekly calls for 30 days after discharge. The primary outcome was unplanned 30dRe. Follow-up data was available for 26 INT and 30 UC patients. Mean age was 57.5 years, duration of diabetes 17 years, and median admission A1C 7.9%. The cohort was 75% black, 20% white, 13% Hispanic, 55% female, mostly low-income, and mostly insured by Medicare and/or Medicaid. Most patients (95%) had type 2 diabetes. There were few baseline differences between groups, including years of school (13.5 INT, 11.9 UC, p=0.03) and preadmission insulin use (59.6% INT, 40.4% UC, p<0.01). Six INT and 10 UC patients had a 30dRe (23.1%, 33.3%, P=0.40), yielding a non-significant relative risk reduction of 30.6%, absolute risk reduction of 10.2% and number needed to treat of 10. Median A1C at 3 months among the 18 patients with data was 6.7% INT and 8.4% UC, p=0.19. This small pilot trial shows the DiaTOHC intervention is feasible. The non-significant but measurable reductions in readmission risk and A1C merit further investigation in a larger RCT. Disclosure D.J. Rubin: Research Support; Self; AstraZeneca, Boehringer Ingelheim Pharmaceuticals, Inc. S. Golden: Research Support; Self; Merck & Co., Inc. G. Foster: Employee; Self; Weight Watchers International, Inc. S. Fisher: None. C. Vaz: None. H. Zhao: None. S. Tanner: None. D. Recco: None. M. Tivon: None. F.R. Dillard: None. S. Watts: None. K.E. Joyce: None. A. Karunakaran: None. T. Reznick: None. A. Iwamaye: None. E. Miller: None. C. Mathai: None. B.S. Albury: None. Funding National Institute of Diabetes and Digestive and Kidney Diseases (K23DK102963 to D.J.R.)

Unplanned hospital readmission is a high-priority quality measure and target for cost reduction. Patients with diabetes are at higher risk of readmission than patients without diabetes. We previously presented results of a pilot randomized controlled trial (RCT) of an intervention designed to reduce readmission risk (the Diabetes Transition of Hospital Care [DiaTOHC] program) with outcomes assessed 30 days after hospital discharge. Here we present secondary outcomes assessed 90 days after discharge. Patients predicted to be high risk (>=27%) for readmission based on a validated readmission risk tool (DERRITM) were randomized 1:1 to the intervention (INT) or usual care (UC). The intervention consisted of inpatient diabetes education, coordination of care, post-discharge support by a nurse practitioner, adjustment of diabetes therapy, and weekly phone calls for 30 days after discharge. There were 45 INT and 46 UC patients randomized and analyzed by intention-to-treat. Twenty-one INT and 23 UC patients had a readmission (46.7% vs. 50%) while 25 INT and 27 UC patients had a readmission or Emergency Department (ED) visit (55.6% vs. 58.7%). The ratio of the mean estimated cost of readmissions, ED visits, and the intervention in the INT group was 0.51 (0.25-1.02)95%CL the cost of readmissions and ED visits in the UC group. Among the 69 patients with an admission A1C >7%, 14 INT and 17 UC patients had a readmission (41.2% vs. 48.6%), and 18 INT and 21 UC patients had a readmission or ED visit (52.9% vs. 60.0%), yielding relative risk reductions of 15.2% and 11.8%. The INT:UC group ratio of the mean estimated cost was 0.50 (0.22-1.12)95%CL. No differences were statistically significant in this pilot study. The DiaTOHC intervention may modestly reduce readmission risk and cut costs by half within 90 days after discharge among patients with an admission A1C >7%. This merits further investigation in a larger RCT. Disclosure D.J. Rubin: None. S. Watts: None. A. Deak: None. C. Vaz: None. S. Tanner: None. D. Recco: None. M. Tivon: None. F.R. Dillard: None. E. Brzana: None. K.E. Joyce: None. A. Karunakaran: None. A. Iwamaye: None. E. Miller: None. C. Mathai: None. N. Kondamuri: None. B.S. Albury: None. S. Allen: None. M.D. Naylor: None. S. Golden: None. J. Wu: None. Funding National Institute of Diabetes and Digestive and Kidney Diseases (K23DK102963)

This pilot multi-center, open-label, randomized trial determined the safety and efficacy of exenatide alone or in combination with basal insulin in medicine and surgery patients with type 2 diabetes (T2D). A total of 150 patients with blood glucose (BG) between 140-400 mg/dl on home therapy with oral agents or insulin ≤ 0.5 U/kg/day were treated with exenatide, exenatide+basal, or basal-bolus (BB) regimen. Exenatide was started at 5 mcg BID, basal insulin at 0.25 U/kg/d, and BB at 0.5 U/kg/d given half as glargine and half as lispro before meals. At discharge, pre-admission therapy was restarted and patients were randomized to exenatide (titrated to 10 mcg BID) or basal insulin, and followed for up to 3 months. The combination of exenatide and basal insulin resulted in lower hospital mean daily BG and higher proportion of target BG 70-180 mg/dl compared to exenatide or BB, p<0.01 (Table). There were no differences in hospital hypoglycemia, gastrointestinal (GI) adverse events or study withdrawal between groups. After discharge, there was no difference in BG control (p=0.65) but exenatide group had more GI adverse events (p<0.001) compared to basal group.Exenatide (n=47)Exe+Basal (n=51)Basal-Bolus (n=52)P valueRandomization BG, mg/dl196±61195±51201±580.91Admission HbA1c, %8.9±2.28.3±2.08.5±1.70.22Length-of-stay, days, median Q1-Q34.0 (2.0-8.0)5.0 (3.0-7.0)4.0 (2.0-5.0)0.23Mean daily BG, days 2-10, mg/dl177±41154±39166±400.01BG at target 70-180 mg/dl, %61±3978±3163±310.02BG < 54 mg/dl, n (%)0 (0)1 (2.1)2 (4.1)0.77Nausea/vomiting, n (%)5 (10.6)5 (9.8)1 (1.9)0.17Withdrawal due to AE, n (%)3 (6.4)0 (0)0 (0)0.029Post-Discharge DataExenatide (n= 48)Basal Insulin (n= 55)Mean daily BG, mg/dl156±63141.±270.65BG < 54 mg/dl, n (%)*4 (10)4 (11)1.0Hospital re-admission, n (%)17%13%0.59Nausea/vomiting, n (%)20 (53)1 (3)<0.001Withdrawal due to AE, n (%)5 (13)0 (0)0.05HbA1c at 3 months, %8.2±1.97.3±10.07 These preliminary results indicate that inpatient and post-discharge treatment with exenatide in combination with basal insulin is safe and effective for the management of general medicine and surgery patients with T2D. Disclosure M. Fayfman: None. D.L. Mize: None. D.J. Rubin: Research Support; Self; AstraZeneca, Boehringer Ingelheim Pharmaceuticals, Inc.. I. Anzola: None. M.A. Urrutia: None. C. Ramos: None. F.J. Pasquel: Consultant; Self; Merck Sharp & Dohme Corp., Sanofi, Boehringer Ingelheim Pharmaceuticals, Inc.. J. Haw: None. P. Vellanki: Consultant; Self; Boehringer Ingelheim Pharmaceuticals, Inc.. Research Support; Self; Boehringer Ingelheim Pharmaceuticals, Inc., AstraZeneca. H. Wang: None. K.E. Joyce: None. A. Karunakaran: None. B.S. Albury: None. R. Weaver: None. L. Viswanathan: None. S. Jaggi: None. R.J. Galindo: None. G.E. Umpierrez: Research Support; Self; Sanofi US, Merck & Co., Inc., Novo Nordisk Inc., AstraZeneca. Advisory Panel; Self; Sanofi, Intarcia Therapeutics, Inc..

Hospital readmission within 30 days of discharge (30-day readmission) is a high-priority quality measure and cost target. The purpose of this study was to explore the feasibility and efficacy of the Diabetes Transition of Hospital Care (DiaTOHC) Program on readmission risk in high-risk adults with diabetes. This was a non-blinded pilot randomized controlled trial (RCT) that compared usual care (UC) to DiaTOHC at a safety-net hospital. The primary outcome was all-cause 30-day readmission. Between 16 October 2017 and 30 May 2019, 93 patients were randomized. In the intention-to-treat (ITT) population, 14 (31.1%) of 45 DiaTOHC subjects and 15 (32.6%) of 46 UC subjects had a 30-day readmission, while 35.6% DiaTOHC and 39.1% UC subjects had a 30-day readmission or ED visit. The Intervention–UC cost ratio was 0.33 (0.13–0.79) 95%CI. At least 93% of subjects were satisfied with key intervention components. Among the 69 subjects with baseline HbA1c >7.0% (53 mmol/mol), 30-day readmission rates were 23.5% (DiaTOHC) and 31.4% (UC) and composite 30-day readmission/ED visit rates were 26.5% (DiaTOHC) and 40.0% (UC). In this subgroup, the Intervention–UC cost ratio was 0.21 (0.08–0.58) 95%CI. The DiaTOHC Program may be feasible and may decrease combined 30-day readmission/ED visit risk as well as healthcare costs among patients with HbA1c levels >7.0% (53 mmol/mol).