Hospital Readmissions for Fluid Overload among Individuals with Diabetes and Diabetic Kidney Disease: Risk Factors and Multivariable Prediction Models

Abstract

Aims: Hospital readmissions due to recurrent fluid overload in diabetes and diabetic kidney disease can be avoided with evidence-based interventions. We aimed to identify at-risk patients who can benefit by developing risk prediction models for readmissions for fluid overload in people living with diabetes. Methods: Single-center retrospective cohort study of 1531 adults with diabetes and hospitalized for fluid overload, including congestive heart failure, pulmonary edema and generalized edema, between 2015 and 2017. The multivariable regression models for 30-day and 90-day readmission for fluid overload were compared with the LACE score for discrimination, calibration, sensitivity, specificity and net reclassification index (NRI). Results: Readmissions for fluid overload within 30 days and 90 days occurred in 8.6% and 17.2% of patients with diabetes, and 8.2% and 18.3% of patients with diabetic kidney disease, respectively. After adjusting for demographics, comorbidities, clinical parameters, and medications, a history of alcoholism (HR 3.85, 95% CI 1.41-10.55) and prior hospitalization for fluid overload (HR 2.50, 95% CI 1.26- 4.96) were independently associated with 30-day readmission in patients with diabetic kidney disease, as well as in individuals with diabetes. Additionally, current smoking, absence of hypertension and high-dose intravenous furosemide were also associated with 30-day readmission in individuals with diabetes. Prior hospitalization for fluid overload (HR 2.43, 95% CI 1.50-3.94), cardiovascular disease (HR 1.44, 95% CI 1.03-2.02), eGFR ≤45 ml/min/1.73 m2 (HR 1.39, 95% CI 1.003-1.93) were independently associated with 90-day readmissions in individuals with diabetic kidney disease. Additionally, thiazide at discharge reduced 90-day readmission in diabetic kidney disease while high-dose intravenous furosemide predicted 90-day readmission in diabetes. The clinical and clinico-psychological models for 90-day readmission in individuals with diabetes and diabetic kidney disease had better discrimination and calibration than the LACE score. The NRI for the clinico-psychosocial models to predict 30- and 90-day readmissions in diabetes were 22.4% and 28.9%, respectively. The NRI for the clinico-psychosocial models to predict 30- and 90-day readmissions in diabetic kidney disease were 5.6% and 38.9%, respectively. Conclusion: The risk models can potentially be used to identify patients at-risk of readmission for fluid overload for evidence-based interventions such as patient education or transitional care programs to reduce preventable hospitalizations.