Take common comorbidity into account to save money

Diabetics consume 30% to 40% more resources

A secret cost driver may be inflating your lengths of stay and costs per case.

Studies show that patients with diabetes spend two to three days longer in the hospital than nondiabetic patients with similar complaints, and they consume 30% to 40% more resources. Even so, clinicians often don’t bother dealing with the disease if it doesn’t seem relevant to the problem that caused the hospitalization.

"It’s a reality. When a diabetic patient enters the hospital for any reason, the focus on diabetes is frequently lost in the inpatient setting," says Robert Stone, MBA, executive vice president of the Diabetes Treatment Centers of America (DTCA) in Nashville, TN.

DTCA says diabetic patients account for:

    • 15% of all hospital admissions;
    • 20% of all hospital days;
    • 20% of all hospital costs.

"In 95% of the cases, the admission has nothing to do with glycemic control," Stone says. "People with diabetes go to the hospital for the same reason[s] everybody else does."

Meeting a huge need’

DTCA, a provider of diabetes education and management services to 69 customer hospitals in 29 states and a contractor with HMOs covering 100,000 diabetic lives, provides something most hospitals don’t have: a comprehensive plan for inpatient diabetic management.

"It’s a huge need," Stone says. "It’s never been done, but we knew when we started this about a year ago that we could help hospital and medical staffs identify issues that contribute to the extra stays and adverse outcomes."

DTCA assembled a panel of primary care physicians, specialists, and other health care professionals representing private practice, health plans, and institutions to develop a set of guidelines for inpatient care. The initial recommendations were reviewed by DTCA’s scientific advisory council and a panel of faculty specialists at Vanderbilt University in Nashville.

In November 1998, DTCA convened a consensus conference of nearly 100 health care professionals in Key Largo, FL, to modify and endorse the plans aimed at improving diabetic inpatient outcomes.

"Continued inattention to the unique needs of the inpatient with diabetes is both costly and professionally unacceptable," the panel wrote in a report.

The panel noted that metabolic control of diabetics requires detailed attention to the patient’s diet, activity, and medications in the outpatient and inpatient settings, but "too often physician orders or even a hospital’s standing orders fail to take into account many aspects of the patients’ preadmission status and self-management regimen."

Whatever the condition that caused the admission, Stone points out, "Diabetes is an underlying concern. Our goal is to reduce costs by improving the health status of the diabetic population."

Hospital staff should be able to discharge patients in better glycemic control, he explains, and avoid readmission for infections or other complications.

The panel began with these five recommended goals:

    Identify all patients with diabetes.
    • Identify and address any special needs of patients with diabetes.
    • Improve outcomes by optimizing glycemic/ metabolic control.
    • Raise the awareness level of the health care team with respect to the unique challenges of diabetes and current standards of care.
    • Strive for a length of stay equal to that of a patient without diabetes.

The guidelines include a detailed baseline assessment to be performed upon admission by the physician, nurse, or other health care provider. They detail protocols for identification, assessment, and laboratory procedures and name the health care professional who should be responsible for each step along the way and the frequency with which each step should be carried out.

The panel recommends screening consistent with the American Diabetes Association guidelines for all patients over the age of 18 to detect undiagnosed diabetes.

In the initial assessment for those with confirmed diagnoses of diabetes, the guidelines recommend a physician-performed detailed history, a documentation of symptoms of diabetes-related comorbidities, and a physical exam with emphasis on diabetes-associated findings.

These laboratory tests also are recommended:

    • serum creatinine;
    • ECG;
    • urinalysis;
    • blood or serum glucose;
    • HbA1c;
    • lipid profile.

Health care professionals also are cautioned to look for conditions that may require special considerations in diabetic patients, including the presence of an insulin pump, pregnancy, coronary and cerebral vascular disease, infectious disease, inpatient surgery, and diabetic ketoacidosis.

It’s also important to perform a nutritional assessment for each diabetic patient upon admission to devise a specific nutritional plan for the patient, to reassess the nutrition plan frequently, and to devise a discharge nutrition plan with the appropriate instructions and follow-up.

While the patient is in the hospital, the guidelines require optimal metabolic control, with four-times-daily glucose monitoring, daily review, and a goal for fasting blood sugars at 80 to 120 mg/dl and bedtime sugars at 100 to 140 mg/dl. Blood sugars should not be allowed to exceed 200 mg/ dl without intervention, the panel recommended.

The guidelines also call for detailed education, discharge planning, and follow-up by the entire health care team, including demonstrations of the use of blood glucose monitors, self-administration of insulin (if needed), and teaching patients how to check their feet.

"This population is undersupported from an educational point of view," Stone says. "This is an adult learning issue that needs reinforcement, support, and encouragement."

DTCA has printed 15,000 copies of the guidelines and plans to distribute them to hospitals, physicians, state licensing boards, payer networks, and anyone else who requests them.

"They are a work in progress, and we anticipate we will issue updated versions as we get additional input and feedback," Stone says.

Copies of the DTCA Inpatient Management Guidelines for People With Diabetes can be ordered from: Diabetes Treatment Centers of America, 1 Burton Hills Blvd., Suite 300, Nashville, TN 37215. Attention: Teresa Mabry.

Robert Stone can be reached at (615) 665-7760.