Association of diabetes with frequency and cost of hospital admissions: a retrospective cohort study

Characterizing the burden of biliary tract cancers across 28 hospitals in Ontario, Canada

BACKGROUND AND AIMS

The incidence of biliary tract cancers (BTC) appears to be increasing worldwide. We analyzed the characteristics of BTC-related hospitalizations under medical services across 28 hospitals in Ontario, Canada.

METHODS

This study uses data collected by GEMINI, a hospital research data network. BTC-related hospitalizations from 2015 to 2021 under the Department of Medicine or intensive care unit were captured using the International Classification of Diseases, 10th revision, codes for intrahepatic cholangiocarcinoma (iCCA), extrahepatic cholangiocarcinoma, and gallbladder cancers.

RESULTS

A total of 4596 BTC-related hospitalizations (2720 iCCA, 1269 extrahepatic cholangiocarcinoma, 607 gallbladder cancers) were analyzed. The number of unique patients with BTC-related hospitalizations increased over time. For iCCA-related hospitalizations, the total number of hospitalizations increased (from 385 in 2016 to 420 in 2021, p = .005), the hospital length of stay decreased over the study period (mean 10 days [SD, 12] in 2016 to 9 days [SD, 8] in 2021, p = .04), and the number of in-hospital deaths was stable (from 68 [18%] in 2016 to 55 [13%] in 2021, p = .62). Other outcomes such as 30-day readmissions, medical imaging tests, intensive care unit-specific hospitalizations, and length of stay were stable over time for all cohorts. The cost of hospitalization for the BTC cohort increased from median $8203 CAD (interquartile range, 5063-15,543) in 2017 to $8507 CAD (interquartile range, 5345-14,755) in 2021.

CONCLUSIONS

This real-world data analysis showed a rising number of patients with BTC-related hospitalizations and rising number of iCCA-related hospitalizations across 28 hospitals in Ontario between 2015 and 2021.

How Outpatient Diabetes Education Programs Can Support Local Hospitals to Reduce Emergency Department Visits for Adults With Diabetes

OBJECTIVES

Our aim in this study was to assess the level of collaboration between a hospital-based outpatient diabetes education program (DEP) and emergency departments (EDs) for reducing number of ED revisits and hospital admissions by implementing intervention strategies to promote education services and streamlining referral and appointment intake processes.

METHODS

Patients (≥18 years of age) with an ED visit for hyper- or hypoglycemia were analyzed in 2 cohorts based on their intervention exposure. We conducted a single-cohort analysis of the exposed cohort (exposure to the intervention strategies) and compared 2-year outcomes with those of the unexposed cohort. Primary outcomes were hyper- or hypoglycemia-related ED revisit and hospitalization rates. Process outcomes included DEP referrals and DEP attendance.

RESULTS

There were no significant differences in ED revisits and hospital admissions between the exposed and unexposed cohorts. However, patients were more likely to be referred to a DEP by ED physicians (odds ratio [OR], 1.76; p=0.02) and to attend a DEP appointment (OR, 1.96; p<0.01) after intervention exposure. DEP attendees from both cohorts became less likely to revisit an ED (exposed: OR, 0.41; 95% confidence interval [CI], 0.23 to 0.71; unexposed: OR, 0.4; 95% CI, 0.15 to 1.15) at 12-month follow up; however, this reduction was sustained only among the exposed cohort (OR, 0.5; 95% CI, 0.31 to 0.81) and not the unexposed cohort (OR, 1.32; 95% CI, 0.60 to 2.91) at 24 months (p=0.04 when comparing the 2 cohorts).

CONCLUSIONS

Collaboration between outpatient DEPs with local EDs could effectively reduce diabetes-related ED revisits by increasing diabetes program utilization.

An Economic Impact Model for Estimating the Value to Health Systems of a Digital Intervention for Diabetes Primary Care: Development and Usefulness Study

Background

Diabetes is associated with significant long-term costs for both patients and health systems. Regular primary care visits aligned with American Diabetes Association guidelines could help mitigate those costs while generating near-term revenue for health systems. Digital interventions prompting primary care visits among unengaged patients could provide significant economic value back to the health system as well as individual patients, but only few economic models have been put forth to understand this value.

Objective

Our objective is to establish a data-based method to estimate the economic impact to a health system of interventions promoting primary care visits for people with diabetes who have been historically unengaged with their care. The model was built with a focus on a specific digital health intervention, Precision Nudging, but can be used to quantify the value of other interventions driving primary care usage among patients with diabetes.

Methods

We developed an economic model to estimate the financial value of a primary care visit of a patient with diabetes to the health system. This model requires segmenting patients with diabetes according to their level of blood sugar control as measured by their most recent hemoglobin A_1c value to understand how frequently they should be visiting a primary care provider. The model also accounts for the payer mix among the population with diabetes, documenting the percentage of insurance coverage through a commercial plan, Medicare, or Medicaid, as these influence the reimbursement rates for the services. Then, the model takes into consideration the population base rates of comorbid conditions for patients with diabetes and the associated current procedural terminology codes to understand what a provider can bill as well as the expected inpatient revenue from a subset of patients likely to require hospitalization based on the national hospitalization rates for people with diabetes. Physician reimbursement is subtracted from the total. Finally, the model also accounts for the level of patient engagement with the intervention to ensure a realistic estimate of the impact.

Results

We present a model to prospectively estimate the economic impact of a digital health intervention to encourage patients with documented diabetes diagnoses to attend primary care visits. The model leverages both publicly available and health system data to calculate the per appointment value (revenue) to the health system. The model offers a method to understand and test the financial impact of Precision Nudging or other primary care–focused diabetes interventions inclusive of costs driven by comorbid conditions.

Conclusions

The proposed economic model can help health systems understand and evaluate the estimated economic benefits of interventions focused on primary care and prevention for patients with diabetes as well as help intervention developers determine pricing for their product.

Glycosuria Alters Uropathogenic Escherichia coli Global Gene Expression and Virulence

Uropathogenic Escherichia coli (UPEC) is the principal etiology of more than half of urinary tract infections (UTI) in humans with diabetes mellitus. Epidemiological data and studies in mouse model of ascending UTI have elucidated various host factors responsible for increasing the susceptibility of diabetic hosts to UPEC-UTI. In contrast, diabetic urinary microenvironment-mediated alterations in UPEC physiology and its contributions to shaping UPEC-UTI pathogenesis in diabetes have not been examined. To address our central hypothesis that glycosuria directly induces urinary virulence of UPEC, we compared virulence characteristics and gene expression in human UPEC strains UTI89 (cystitis) and CFT073 (pyelonephritis), exposed for 2 h in vitro to urine from either male or female donors that was either plain or supplemented with glucose to mimic glycosuria. Compared to control UPEC exposed to nutrient-rich culture medium, lysogeny broth, glycosuria-exposed UPEC exhibited significant increase in biofilm formation and reduction in the hemagglutination of Guinea pig erythrocytes (a measure of type 1 piliation). In addition, the analysis of UTI89 transcriptome by RNA sequencing revealed that 2-h-long, in vitro exposure to glycosuria also significantly alters expression of virulence and metabolic genes central to urinary virulence of UPEC. Addition of galactose as an alternative carbon source affected biofilm formation and gene expression profile of UPEC to an extent similar to that observed with glucose exposure. In summary, our results provide novel insights into how glycosuria-mediated rapid changes in UPEC fitness may facilitate UTI pathogenesis in the diabetic urinary microenvironment.

IMPORTANCE Uropathogenic Escherichia coli (UPEC) is an important causative agent of urinary tract infections in diabetic humans. We examined the effects of in vitro exposure to glycosuria (presence of glucose in urine) on the virulence and gene expression by UPEC. Our results show that glycosuria rapidly (in 2 h) alters UPEC gene expression, induces biofilm formation, and suppresses type 1 piliation. These results offer novel insights into the pathogenesis of UPEC in the urinary tract.

Reasons for Hospitalisation among Patients with Diabetes in a Secondary Care Hospital in South India: A Retrospective Study

BACKGROUND

Type 2 diabetes mellitus is a rapidly emerging non-communicable disease in India. It is associated with many life-long complications and higher rates of hospitalisations. The characteristics and reasons for hospitalisation among individuals with diabetes have not been documented in India. Such a study would direct policy makers in implementing prevention and education strategies and economic changes as needed.

AIM AND OBJECTIVES

The study aimed to study the characteristics and causes of admission of patients with diabetes admitted to a secondary care unit in South India.

METHODS

Aretrospective observation study of inpatient records of patients with diabetes aged 18 years and above admitted between January to December 2019 in a secondary care unit was done. The details of patient demographics, reason and outcome of admission were retrieved manually from paper-based patient records. Descriptive analysis was done using SPSS version 23. The study was approved by the Institutional Review Board of the institution.

RESULTS

Among the 479 admissions of patients with diabetes during 2019, the mean age of the admitted patients was 57.75 years. The majority of them had only one admission, 15% had re-admissions in the same time period. Approximately 78% of the admitted patients had one or more co-morbidities, 44.6% had hypertension as a co-morbidity. The principal cause of admission was infections (45%), followed by metabolic and endocrine causes (13.5%), cardiovascular disease (10.9%) and renal disease (7.96%). More than 80% of the admissions had a favourable outcome and were discharged.

CONCLUSION

This retrospective study demonstrated that the most common reason for admission among patients with diabetes to a secondary care unit in South India was infection. Many infections are preventable with effective treatment for diabetes and health education. Patients bear the costs of routine treatment for diabetes which is a fraction of the direct cost of hospitalisation and can drive them to huge economic losses. Therefore, interventions to promote standard treatment by primary and secondary care health professionals and self-awareness among patients need to be done to prevent hospitalisations.

Systematic Review of Literature Examining Bacterial Urinary Tract Infections in Diabetes

This systematic review addresses the central research question, "what is known from the published, peer-reviewed literature about the impact of diabetes on the risk of bacterial urinary tract infections (UTI)?" We examine the results from laboratory studies where researchers have successfully adapted mouse models of diabetes to study the pathophysiology of ascending UTI. These studies have identified molecular and cellular effectors shaping immune defenses against infection of the diabetic urinary tract. In addition, we present evidence from clinical studies that in addition to diabetes, female gender, increased age, and diabetes-associated hyperglycemia, glycosuria, and immune impairment are important risk factors which further increase the risk of UTI in diabetic individuals. Clinical studies also show that the uropathogenic genera causing UTI are largely similar between diabetic and nondiabetic individuals, although diabetes significantly increases risk of UTI by drug-resistant uropathogenic bacteria.