Diabetes-related Hospitalizations Research Articles

Disease and Economic Burden of Hospitalizations Attributable to Diabetes Mellitus and Its Complications: A Nationwide Study in Brazil.

Diabetes is associated with a significant burden globally. The costs of diabetes-related hospitalizations are unknown in most developing countries. The aim of this study was to estimate the total number and economic burden of hospitalizations attributable to diabetes mellitus (DM) and its complications in adults from the perspective of the Brazilian Public Health System in 2014. Data sources included the National Health Survey (NHS) and National database of Hospitalizations (SIH). We considered diabetes, its microvascular (retinopathy, nephropathy, and neuropathy) and macrovascular complications (coronary heart disease, cerebrovascular disease, and peripheral arterial disease), respiratory and urinary tract infections, as well as selected cancers. Assuming that DM patients are hospitalized for these conditions more frequently that non-DM individuals, we estimated the etiological fraction of each condition related to DM, using the attributable risk methodology. We present number, average cost per case, and overall costs of hospitalizations attributable to DM in Brazil in 2014, stratified by condition, state of the country, gender and age group. In 2014, a total of 313,273 hospitalizations due to diabetes in adults were reported in Brazil (4.6% of total adult hospitalization), totaling (international dollar) Int$264.9 million. The average cost of an adult hospitalization due to diabetes was Int$845, 19% higher than hospitalization without DM. Hospitalizations due to cardiovascular diseases related to diabetes accounted for the higher proportion of costs (47.9%), followed by microvascular complications (25.4%) and DM per se (18.1%). Understanding the costs of diabetes and its major complications is crucial to raise awareness and to support the decision-making process on policy implementation, also allowing the assessment of prevention and control strategies.

Improving diabetes control in the community: a nurse managed intervention model in a multidisciplinary clinic

Objective: To assess diabetes management and control measures in a central multidisciplinary primary care clinic, conducted by a nurse. Design: A cross sectional study. Setting: Central, multidisciplinary, primary care clinic. Subjects: Randomly selected 100 people with diabetes. Interventions: People with diabetes with suspected non-optimal glucose control (HbA1c > 7%), were invited to the clinic nurse to discuss optimal personal diabetes control, treatment and follow up. All were provided the necessary referrals to consultants and were called in for follow up visits, and received telephone reminders. All interventions were made according to the current American Diabetes Association Standards of Medical Practice recommendations. Main outcome measures: Retrospective data were collected. Data included demographics and diabetes control measures (e.g. HbA1c, LDL, blood pressure, ophthalmologic examination etc.). Data was collected for three x 6 months periods: 1) six months before the nurse visit; 2) six months following the first nurse visit (the intervention); and 3) for patients who were followed up for at least one year after the intervention, the last six months of follow-up. Results: With a median follow up of 25 months, HbA1c, LDL and systolic blood pressure levels dropped significantly from before starting the clinic through the intervention and remained low in the last half year of follow up. GP, Ophthalmologist and Dietician visits increased significantly during the study. Non-significant trends were observed with total and diabetes-related hospitalisations decreased, foot examination rates increased and mild weight loss. Conclusion: Multidisciplinary intervention managed by a nurse, improve diabetes management and control measures. Observed changes persisted after the intervention period. A cross sectional study.

Unstable Housing and Diabetes-Related Emergency Department Visits and Hospitalization: A Nationally Representative Study of Safety-Net Clinic Patients.

Homelessness is associated with worse diabetes outcomes, but the relationship between other forms of unstable housing and diabetes is not well studied. We assessed whether unstable housing was associated with increased risk for diabetes-related emergency department use or hospitalization. We used data from the 2014 Health Center Patient Survey (HCPS), a cross-sectional, nationally representative survey of patients who receive care at federally funded safety-net health centers. We included nonhomeless adults (aged ≥18 years) with self-reported diabetes. Unstable housing was defined as not having enough money to pay rent or mortgage, moving two or more times in the past 12 months, or staying at a place one does not own or rent. The primary outcome was self-report of diabetes-related emergency department visit or inpatient hospitalization in the last 12 months. We also examined use of housing assistance. Of 1,087 participants, representing 3,277,165 adults with diabetes, 37% were unstably housed. Overall, 13.7% of participants reported a diabetes-related emergency department visit or hospitalization in the past year. In logistic regression analyses adjusted for multiple potential confounders, unstable housing was associated with greater odds of diabetes-related emergency department use or hospitalization (adjusted odds ratio 5.17 [95% CI 2.08-12.87]). Only 0.9% of unstably housed individuals reported receiving help with housing through their clinic. Unstable housing is common and associated with increased risk of diabetes-related emergency department and inpatient use. Addressing unstable housing in clinical settings may help improve health care utilization for vulnerable individuals with diabetes.

A 3-State Analysis of Black-White Disparities in Diabetes Hospitalizations Among Medicaid Beneficiaries.

Introduction:Although diabetes is one of the leading chronic disease in the country, efforts in primary care and patient self-care management could prevent most of the diabetes-related hospitalizations and produce cost savings and improvements in quality of life. We used information from Medicaid beneficiaries in 3 states to predict racial differences in diabetes hospitalizations and demonstrate how they vary across states.Methods:We conducted a cross-sectional study to examine differences between black and white patients with diabetes hospitalizations. Information was obtained from the Medicaid Analytic eXtract files. We used multiple logistic regression models to assess the significance of the differences.Results:Analysis included 10 073 adult Medicaid recipients from the states of Mississippi (51%), Georgia (35%), and Michigan (14%). Blacks were more likely to experience longer hospital stays in Georgia (odds ratio [OR] = 1.040; 95% confidence interval [CI]: 1.03-1.06) and Mississippi (OR = 1.048; 95% CI: 1.03-1.07). A majority of patients in both groups were likely to be discharged to their homes for self-care. Black patients had lower odds of repeated stays in Georgia (OR = 0.670; 95% CI: 0.54-0.84), but higher odds in Michigan (OR = 1.580; 95% CI: 1.12-2.24). Similar differences occurred when patients were matched by age and sex. Blacks had lower odds of qualifying for dual Medicare–Medicaid enrollment benefit in Georgia and Mississippi.Conclusion:Racial differences in diabetes-related hospitalizations reflect possible inefficiencies in the process of care. Identification of race-specific factors for hospitalizations and implementation of primary care strategies that support effective self-management skills would aid in reducing diabetes hospitalizations and related disparities.

Susceptible and Prognostic Genetic Factors Associated with Diabetic Peripheral Neuropathy: A Comprehensive Literature Review.

Type 2 diabetes mellitus (T2D) is a disorder of glucose metabolism. It is a complex process involving the regulation of insulin secretion, insulin sensitivity, gluconeogenesis, and glucose uptake at the cellular level. Diabetic peripheral neuropathy (DPN) is one of the debilitating complications that is present in approximately 50% of diabetic patients. It is the primary cause of diabetes-related hospital admissions and nontraumatic foot amputations. The pathogenesis of diabetic neuropathy is a complex process that involves hyperglycemia-induced oxidative stress and altered polyol metabolism that changes the nerve microvasculature, altered growth factor support, and deregulated lipid metabolism. Recent literature has reported that there are several heterogeneous groups of susceptible genetic loci which clearly contribute to the development of DPN. Several studies have reported that some patients with prediabetes develop neuropathic complications, whereas others demonstrated little evidence of neuropathy even after long-standing diabetes. There is emerging evidence that genetic factors may contribute to the development of DPN. This paper aims to provide an up-to-date review of the susceptible and prognostic genetic factors associated with DPN. An extensive survey of the scientific literature published in PubMed using the search terms “Diabetic peripheral neuropathy/genetics” and “genome-wide association study” was carried out, and the most recent and relevant literature were included in this review.

Avoidable Hospital Admissions From Diabetes Complications In Japan, Singapore, Hong Kong, And Communities Outside Beijing.

Improving the quality of primary care may reduce avoidable hospital admissions. Avoidable admissions for conditions such as diabetes are used as a quality metric in the Health Care Quality Indicators of the Organization for Economic Cooperation and Development (OECD). Using the OECD indicators, we compared avoidable admission rates and spending for diabetes-related complications in Japan, Singapore, Hong Kong, and rural and peri-urban Beijing, China, in the period 2008-14. We found that spending on diabetes-related avoidable hospital admissions was substantial and increased from 2006 to 2014. Annual medical expenditures for people with an avoidable admission were six to twenty times those for people without an avoidable admission. In all of our study sites, when we controlled for severity, we found that people with more outpatient visits in a given year were less likely to experience an avoidable admission in the following year, which implies that primary care management of diabetes has the potential to improve quality and achieve cost savings. Effective policies to reduce avoidable admissions merit investigation.

Global Health Policy.

From the Editor-In-Chief Health AffairsVol. 36, No. 11: Global Health Policy Global Health PolicyAlan R. WeilPUBLISHED:November 2017Free Accesshttps://doi.org/10.1377/hlthaff.2017.1347AboutSectionsView PDFPermissions ShareShare onFacebookTwitterLinked InRedditEmail ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsDownload Exhibits TOPICSDiseasesSystems of careDiabetesGlobal healthPrimary careChildren's healthCost reductionNo matter what may divide countries, when it comes to health we have much in common. The burden of disease is shifting, efficiency and quality improvement are shared goals, and workforce challenges abound. This month’s Health Affairs covers a broad range of global health policy topics. As health systems make progress tackling communicable diseases and life expectancy has increased, countries face a rising burden of noncommunicable diseases such as diabetes, cancer, and cardiovascular disease. Thomas Bollyky and colleagues map the growth of these diseases against each country’s health system functioning. They conclude that “countries that are projected to have the greatest increase in their noncommunicable disease burden as a share of health burden are also ranked lowest (least prepared) in our health system capacity index for noncommunicable diseases,” with African nations particularly at risk. As development assistance has increased dramatically over the past two decades, the risk that those funds will be poorly aligned with recipient countries’ goals has also increased. Melisa Martinez-Alvarez and colleagues examine trends in two dimensions of aid effectiveness—alignment with local strategies and harmonization across donor efforts—for reproductive, maternal, newborn, and child health funding. The authors found little improvement between 2008 and 2013, and some worsening in the area of alignment. One factor in the lack of progress was the donor organizations’ perceived need for control and accountability. Improving health requires knowing which illnesses cause people to die. India, like most low- and middle-income countries, had good information on cause of death for only the small minority of people who die in the hospital. Mireille Gomes and colleagues report findings from India’s Million Death Study, which relied upon verbal autopsies to gather information regarding the likely cause of death for people who died at home. Among the many interesting findings are that deaths related to smoking and malaria have been significantly underreported, estimates of HIV-related deaths have been far too high, and there has been a substantial incidence of sex-selection abortions. Poorly managed diabetes can lead to inpatient hospital stays—which could have been avoided with receipt of appropriate primary care. Jianchao Quan and colleagues analyze avoidable admissions from diabetes complications in Japan, Singapore, Hong Kong, and communities outside Beijing. Overall spending and preventable admission rates increased during 2008–13, but significant improvement was observed in Japan and Beijing. The authors’ results “provide empirical evidence to support the hypothesis that a higher number of…outpatient visits in a given year is correlated with a lower likelihood of a diabetes-related avoidable hospital admission in the following year.” Innovation This issue includes papers on the effects of a broad array of innovations. Adriane Wynn and colleagues show the value of community health workers in South Africa. Duncan Maru and colleagues document how a public-private partnership improved maternal, newborn, and child health services in rural Nepal. Aaron Baum and colleagues explain how microfinance institutions can be a mechanism for delivering care in rural Haiti. And Jessica Cohen and colleagues report the results of a randomized controlled trial that nudged pregnant women in Nairobi, Kenya, to deliver in higher-quality facilities. Sharing Lessons Mark McClellan and colleagues apply a framework for accountable care reform to case studies of accountable care models from around the globe. They note the “development of organizational competencies to implement the innovations, alongside payment and other policy reforms that enable the innovations to succeed and be sustained.” Achieving the promise of universal health coverage requires having the workforce to meet the health needs of the population. Arthika Sripathy and colleagues point out that “a system that focuses solely on producing greater numbers of trained health care workers is not enough.” Based upon case studies from Thailand, Brazil, and India, they explain that addressing workforce shortages depends upon providing appropriate incentives through the entire professional education pipeline. In the search for ways to save money, high-income countries have become more interested in innovations developed in resource-constrained settings, sometimes called frugal innovation. Yasser Bhatti and colleagues create case studies of innovations and analyze them for the lessons they yield. Common features of frugal innovations are use of lower-cost settings and providers, improved communication with patients, and the use of simple processes and organizational structures. Acknowledgment Health Affairs thanks the Qatar Foundation and its World Innovation Summit for Health, Imperial College London, Sidra Medical and Research Center, and Hamad Medical Corporation for their support of this issue. Loading Comments... Please enable JavaScript to view the comments powered by Disqus. DetailsExhibitsReferencesRelated Article Metrics History Published online 6 November 2017 Information© 2017 Project HOPE—The People-to-People Health Foundation, Inc.PDF download

The Impact of an Interdisciplinary, Case-Managed Diabetes Team on Diabetes Self-Management, Diabetes-Related Hospitalizations and Emergency Department Visits

The Impact of an Interdisciplinary, Case-Managed Diabetes Team on Diabetes Self-Management, Diabetes-Related Hospitalizations and Emergency Department Visits

The efficacy of phenytoin dressing in healing of diabetic ulcer: a randomized control study

Background: Diabetic foot infection constitutes up to 10 percent of diabetes-related hospital admissions and the prevalence of diabetes is 2.4% in rural and 12-17% in urban settings. The quest for better wound healing agents for diabetic ulcers is perhaps one of the oldest challenges for medical practice. One such agent that has been tried in wound healing is phenytoin. A common side effect of phenytoin (diphenylhydantoin) treatment for epilepsy is gingival hyperplasia. This stimulatory effect of phenytoin on connective tissue suggested a possibility for its use in wound healing.Methods: 60 patients with diabetic foot ulcer admitted in General Surgery at Mahatma Gandhi Medical College and Research Institute, Puducherry, India were randomly assigned into two groups, the study group consisting of 30 patients who were treated with phenytoin dressing and 30 patients into control group who were treated with conventional saline dressing. Both groups underwent initial debridement and were started on parenteral antibiotics according to wound swab culture and sensitivity. Study group were treated with phenytoin dressing and the wound was assessed based on the rate of ulcer size reduction, the rate of granulation tissue, duration of hospital stays and antibacterial property of phenytoin. Patients were assessed weekly up to 21 days.Results: The rate of granulation tissue in phenytoin group was 90.36% which was statistically significant (p = 0.0011) as compared to control group which was 82.03%. Wound swab cultures repeated on day 21 revealed that there was 50% negative culture in phenytoin group when compared to control group of 24% which also was statistically significant. The mean hospital stay for the patient in phenytoin group was 29.2 days and in control group, it was 26.1 days. It was observed that surface area reduction in phenytoin group was 41.25cm2 to 18.38cm2 and in control group was 40.28cm2 to 20.23cm2 by the end of 21 days, but this was not statistically significant.Conclusions: Phenytoin dressing is effective in increasing the rate of granulation tissue by virtue of its action on stimulating fibroblast proliferation and decreasing collagenase activity. It not only hastens granulation tissue but also decreases bacterial load as compared to conventional dressing by virtue of its intrinsic antibacterial activity and indirectly through their effects on anti-inflammatory cells and neovascularization. Phenytoin prepares the foot ulcer for early grafting thereby improving the overall outcome.

The importance of historical residential address information in longitudinal studies using administrative health data.

When information on changes in address or migration of people to or from a study jurisdiction is unavailable in longitudinal studies, issues relating to loss-to-follow-up and misclassification bias may result. This study investigated how estimations of associations between general practitioner (GP) contact and hospital use were affected by incomplete address and migration data. This was a retrospective population-based cohort study of Western Australians from 1990 to 2004. Linked administrative data including mortality records, hospital admissions, primary care and Electoral Roll records were used. Regularity of GP contact, based on the variance of the number of days between GP visits, was calculated for each person-year. Outcomes were the number and costs (A$2014) of diabetes-related hospital admissions in the following year. Models were estimated separately for cohorts where (i) postcode was ascertained at study commencement and held constant, and (ii) postcode and residency within Western Australia were updated with each change of address recorded on the Electoral Roll over the study period. Updating address data reduced total person-years by 11% and changed the distribution of covariates. Estimations of associations between patterns of GP contact and number of hospitalizations changed; the incidence rate ratios measuring the relationship with the most regular GP contact (baseline of those with <2 GP visits) changed from 0.81 [95% confidence interval (CI) 0.66-1.00] to 0.42 (95% CI 0.33-0.53) after updating postcode information. Impacts on cost models were smaller, though still statistically significant. Longitudinal studies using administrative data may report biased results if they ignore address changes and migration. Researchers should attempt to link to these data wherever possible, or choose study designs which these issues are less likely to affect. Custodians should be aware that such data can be vital to high quality research.

Comparing Clinical Outcomes of a Pharmacist-Managed Diabetes Clinic to Usual Physician-Based Care

Background: This study analyzed the impact of a pharmacist-managed diabetes clinic on clinical outcomes compared to usual care received from primary care providers (PCPs). This comparison may more definitively demonstrate the value of pharmacist management of chronic disease states. Methods: Retrospective observational cohort study conducted in patients referred to a pharmacist-managed pharmacotherapy (PT) clinic from July 2009 to October 2014. Results: For the primary outcome, the absolute change in A1c during the usual care phase was +1.53% (95% confidence interval [CI]: 1.10-1.96, P < .0001) versus an absolute change of −1.63% (95% CI: −1.28 to −1.97, P < .0001) in the intervention phase. For secondary outcomes, diabetes-related hospitalizations (10 vs 6, P = .104) and emergency room (ER) visits (27 vs 8, P = .049) decreased in the intervention phase compared to the usual care phase. The rate of diabetes-related interventions made per patient per year in the usual care phase was 2.7 versus 11.1 in the intervention phase (P < .0001). Conclusion: Patients referred to the PT clinic had worsening blood glucose control prior to referral, and their control improved after referral to the clinic. Furthermore, there was an improvement in all diabetes-related outcomes in the intervention phase compared to the usual care phase.

Impact of a general practitioner-led integrated model of care on the cost of potentially preventable diabetes-related hospitalisations

AimTo estimate potential savings for Australia’s health care system through the implementation of an innovative Beacon model of care for patients with complex diabetes. MethodsA prospective controlled trial was conducted comparing a multidisciplinary, community-based, integrated primary-secondary care diabetes service with usual care at a hospital diabetes outpatient clinic. We extracted patient hospitalisation data from the Queensland Hospital Admitted Patient Data Collection and used Australian Refined Diagnosis Related Groups to assign costs to potentially preventable hospitalisations for diabetes. Results327 patients with complex diabetes referred by their general practitioner for specialist outpatient care were included in the analysis. The integrated model of care had potential for national cost savings of $132.5 million per year. ConclusionsThe differences in hospitalisations attributable to better integrated primary/secondary care can yield large cost savings. Models such as the Beacon are highly relevant to current national health care reform initiatives to improve the continuity and efficiency of care for those with complex chronic disease in primary care.

Poor uptake of an online intervention in a cluster randomised controlled trial of online diabetes education for rural general practitioners

BackgroundIn Australia, rural and remote communities have high rates of diabetes-related death and hospitalisation. General practitioners (GPs) play a major role in diabetes detection and management. Education of GPs could optimise diabetes management and improve patient outcomes at a population level. The study aimed to describe the uptake of a continuing medical education intervention for rural GPs and its impact on the viability of a cluster randomised controlled trial of the effects of continuing medical education on whole-town diabetes monitoring and control.MethodTrial design: the cluster randomised controlled trial involved towns as the unit of allocation and analysis with outcomes assessed by de-identified pathology data (not reported here). The intervention programme consisted of an online active learning module, direct electronic access to specialist advice and performance feedback. Multiple rounds of invitation were used to engage GPs with the online intervention content. Evidence-based strategies (e.g. pre-notification, rewards, incentives) were incorporated into the invitations to enrol in the programme. Recruitment to the programme was electronically monitored through the hosting software package during the study intervention period.ResultsEleven matched pairs of towns were included in the study. There were 146 GPs in the 11 intervention towns, of whom 34 (23.3%) enrolled in the programme, and 8 (5.5%) completed the online learning module. No town had more than 10% of the resident GPs complete the learning module. There were no contacts made by GPs regarding requests for specialist advice. Consequently, the trial was discontinued.ConclusionThere is an ongoing need to engage primary care physicians in improving diabetes monitoring and management in rural areas. Online training options, while notionally attractive and accessible, are not likely to have high levels of uptake, even when evidence-based recruitment strategies are implemented.Trial registrationAustralian New Zealand Clinical Trials Registry, identifier: ACTRN12611000553976. Retrospectively registered on 31 May 2011.

Predictors of type 1 diabetes mellitus outcomes in young adults after transition from pediatric care.

Type 1 diabetes (T1D) is a common chronic disease. Poor health outcomes are often noted after transfer to adult health care. It is important to determine the predictors of such outcomes to decrease morbidity and mortality. The present retrospective study included patients followed for ≥1 year before and ≥1 year after transfer to adult care in a Canadian tertiary diabetes center. Data including demographics, education, comorbidity and pediatric diabetes management-related factors were analyzed as possible independent predictors of adult HbA1c, number of adult diabetes-related hospitalizations, and clinic visits. In all, 102 youths were followed to a mean (±SD) age of 21.8 ± 1.5 years. Predictors of mean adult HbA1c using linear regression were the presence of any comorbidity (0.71%; 95% confidence interval [CI] 0.15-1.27; P = 0.01) and pediatric HbA1c (0.67% per 1% increase in HbA1c; 95% CI 0.51-0.84; P < 0.001). Predictors of hospitalization for hyperglycemia were a history of pediatric hospitalization for hyperglycemia (incidence rate ratio [IRR] 1.20; 95% CI 1.02-1.41; P = 0.029) and high school vs university education (IRR 3.13; 95% CI 1.12-8.73; P = 0.030). Young adults with complicated health histories and less education are more likely to experience poor diabetes outcomes in the years after transfer to adult care. These features may highlight youth requiring closer attention or may be targets for intervention.

Improving the Detection of Foot Abnormalities in Patients With Diabetes.

Diabetes, the most common metabolic disorder in primary care, is the leading cause of cardiovascular disease, renal failure, retinopathy, and lower-extremity amputations (1). Diabetic foot abnormalities, including ulcers and lower-extremity amputations, are associated with substantial morbidity, loss of quality of life, and disability and are very costly for the individuals affected, their families, and society as a whole (2). Approximately 84% of nontraumatic major amputations in individuals with diabetes are preceded by foot abnormalities such as an ulceration (3). According to the Centers for Disease Control and Prevention, the total cost of diagnosed diabetes in the United States was $245 billion in 2012, with the majority of costs attributed to a high occurrence of hospital admissions, including $9 billion associated with foot ulcers alone (2). Diabetes is a treatable condition, yet it is the seventh leading cause of death in South Carolina. South Carolina ranks tenth highest in the nation in the percentage of population with diabetes (4). In 2013, South Carolina had the fourth highest prevalence of diabetes in the United States, with ∼25,000 diabetes-related hospitalizations and emergency visits, costing $367 million. The cost of diabetes care in South Carolina is expected to exceed $3 billion in 2016 and to hit $4 billion by 2020 (5). Many of the costs associated with diabetes could be reduced with preventive intervention in the primary care setting, where diabetes is the most common metabolic disorder encountered. However, gaps occur in the care and management of diabetes, especially in the area of foot care. In 2012, an Institute for Preventive Foot Health/National Purchase Diary survey revealed that only 46% of patients with diabetes reported ever having foot screenings with their primary care provider (6). Foot complications, specifically ulcers and amputations, are the number one reason for hospitalization in patients with diabetes …

A Decade of Diabetes Hospitalizations: Meaningful Information for Community-Based Health Services Administrators for Identifying and Assessing Risk

The American Diabetes Association has established that the largest contributor of expenditures related to the cost of care for diabetes is inpatient hospital care. Research has shown that when multiple hospitalizations have been examined, patients diagnosed with diabetes have higher same year readmission rates. Medicare-enrolled patients with coronary artery disease and diabetes who participated in a diabetes management intervention that included self-care behavior instructions and nurse management had fewer emergency room visits and hospitalizations for diabetes related care. In the US, an aging population and expected changes in the ethnic composition prompts an alert to actively address the need for prevention, early detection, reduction of associated complications experienced, and exploration of a cure of the chronic condition of diabetes. This study’s purpose was two-fold: to examine the variability in hospitalization rates of diabetes by geographical location and age groups from 2000-2011 to examine any statistically significant relationships. The study further proposes the exploration of low-cost technology mechanisms to reduce diabetes related hospitalizations through the use of mHealth. Practical interventions using mHealth technologies are feasible solutions to addressing virtual prevention efforts and improving the outcomes of care among patients diagnosed with diabetes.

Identification of Pathogens Directly From Diabetic Foot Infections by Shotgun Metagenomic Sequencing

Background Diabetic foot infections (DFIs) constitute the most common cause for diabetes-related hospitalization and lower extremity amputations. Current diagnostic methods are slow and in some cases do not detect all potential pathogens. Metagenomics sequencing has the potential to merge rapidity and comprehensive information about causative pathogens in DFIs. The aim of this study was to evaluate the potential of metagenomics strategies for DFIs.Methods Thirty tissue specimens from patients with neuropathic plantar DFIs were analyzed. Specimens were processed using the Molzym Molysis five basic kit to deplete human cells. Microbial DNA was extracted using the Qiagen DNeasy PowerSoil kit. Microbial 16s rRNA was conducted on the Illumina MiSeq instrument. Shotgun metagenomics was conducted using nanopore sequencing for seven samples. Libraries were prepared using the rapid low input PCR library preparation kit (SQK-RI001) and sequenced on a MinION using R9.4 (FLO-MIN 106) flow cells. Real-time identification of pathogens and antimicrobial resistance determinants (ARDs) were conducted using EPI2ME’s WIMP and ARMA applications, respectively.ResultsOverall, the cohort characteristics included: 60% male, mean age 49 years, mean HgA1c 10.2%, and median PEDIS score 3. 16s sequencing identified reads belonging to bacteria isolated by culture, but also identified additional anaerobic pathogens in 70% of the specimens. Nanopore sequencing generated an average of 16.4 Mbp and an average read length of 1620–2700 bp. Shotgun metagenomics correctly detected the pathogens found in culture and in 16s rRNA sequencing; the time to accurate classification thresholds was completed in <1 hour. In two samples, several pathogens including anaerobes and fungi were identified that were not isolated by standard culture methods. The resistome included a range of 8–32 ARDs per sample. Furthermore, the resistomes were highly predictive (sensitivity 98% and specificity 88%) for antimicrobial resistance phenotypes detected by standard susceptibility testing.Conclusion Metagenomics-based sequencing has the potential to offer a rapid (<6 hours sample to result time) and accurate strategy for detecting and identifying pathogens and ARDs involved in DFIs.Disclosures All authors: No reported disclosures.

The Relationship between Diabetes Care Quality and Diabetes-Related Hospitalizations and the Modifying Role of Comorbidity.

To evaluate the impact of comorbidity on diabetes care quality and diabetes-related hospitalizations and to examine whether associations between the likelihood of diabetes-related hospitalizations and compliance with diabetes testing are modified by type of comorbidity. A population-based cohort study of 861 354 adults with diabetes was conducted in Ontario, Canada. The diabetes cohort was categorized into 4 groups defined by their comorbidity statuses: no comorbidity, diabetes-concordant only, diabetes-discordant only, and both concordant and discordant. Outcome variables were defined as having had at least 1 hospitalization for diabetes-related short- or long-term complications between 2009 and 2011. Diabetes-care quality measures included testing for glycated hemoglobin (A1C) and low-density lipoprotein-cholesterol levels and eye examinations between 2007 and 2009. Multivariable logistic regression models were performed to examine the associations between diabetes testing and diabetes-related hospitalizations and the modifying role of comorbidity type. Compliance with all 3 monitoring tests by patients with diabetes had a strong positive impact on reducing hospitalizations for diabetes-related long-term complications, especially in patients with diabetes-concordant conditions. The highest levels of adherence to all 3 diabetes monitoring tests were observed in patients with diabetes-concordant conditions only and in patients with diabetes-discordant conditions. The highest odds of hospitalizations for diabetes-related short-term complications were observed in patients having both discordant and concordant conditions. Meeting diabetes testing goals has the potential to reduce hospitalizations for diabetes-related complications; however, this depends on types of coexisting chronic conditions and diabetes-related complications in patients with diabetes.

Management of Diabetic Bacterial Foot Infections with Organic Extracts of Liverwort Marchantia debilis from Cameroon

Diabetic bacterial foot infections (DBFIs) are limb-threatening complications in patients with diabetes mellitus, accounting for 50% of diabetes related lower limb amputations in developing countries, representing approximately 20 percent of all diabetes-related hospital admissions with significant healthcare-related costs involved. The widespread problem of bacterial resistance to most commonly used antibiotics places a huge economic burden on the healthcare system, with both increased morbidity and mortality among diabetic patients with foot infections. In this study, the antibacterial activity of organic extracts of the fresh liverwort Marchantia debilis from the North West Region of Cameroon is reported. An exit pool system, where patients presenting with DBFIs consented to be involved in the use of phytomedicines, after long term treatment of ulcers with antibiotics and not yielding significant long term benefit, presented themselves at the Phytobiotechnology Research clinic (PRF). Continuous culture of swabs from foot and toe wounds from 30 infected patients on nutrient agar and MacConkey agars in triplicate as well as Gram stain microscopy, revealed the presence of Staphylococcus aureus, Pseudomonas aeruginosa, Escherichia coli, Proteus mirabilis and Bacillus species. Light petroleum and methanol extracts of the whole bryophyte plants at 100% concentration were tested. In vitro inhibition of the tested bacterial isolates from the diabetic foot ulcers by M debilis was observed only with the light petroleum extract. No inhibition by the extracts was observed for the Pseudomonas aeruginosa isolate. The light petroleum extract of M debilis was formulated into a petroleum oil based cream named BryoCream™. This was administered to 20 of the patients with 90% cure rate in a three week time period. The main nonpolar components were determined by GCMS as lepidozene and β-barbatene, and by NMR as stigmasterol and β-sitosterol. In conclusion, nonpolar extracts from bryophytes from Cameroon could, potentially, be used to treat diabetic bacterial foot infections.

Trends in the Care and Outcomes of Medicare Beneficiaries with Type 2 Diabetes, 2002–2011

To summarize characteristics of Medicare beneficiaries with type 2 diabetes and to describe changing trends in care and outcomes. We conducted a retrospective cohort study of a nationally representative 5% sample of fee-for-service Medicare beneficiaries 65 years and older with prevalent type 2 diabetes, between January 1, 2002, and December 31, 2011. The main outcome measures were diabetes-related screening tests, mortality, hospital admissions, dialysis, and lower extremity amputation. The average age of Medicare beneficiaries with diabetes was 76.5 years, 56% were women, and 83% were white. Screening practices in beneficiaries with diabetes improved from 2002 to 2011, with rising rates of foot exams, renal screening, hemoglobin A1c tests, and lipid profile tests. The prevalence of nephropathy and neuropathy increased. Although inpatient admissions declined from 2002 to 2011, diabetes-related emergency department visits increased. Amputation and end-stage renal disease remained static, while 1-year mortality declined over the study period. In this medically complex group of patients with high comorbidity, we observed improvements in screening practices and room for further improvement. Although the mortality rate decreased, other outcomes did not improve consistently. Health care resource has changed over time, with decreased hospital admissions and increased emergency department visits. CCW = Chronic Conditions Data Warehouse ESRD = end-stage renal disease HbA1c = hemoglobin A1c HEDIS = Healthcare Effectiveness Data and Information Set ICD-9-CM = International Classification of Diseases, Ninth Revision, Clinical Modification.