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Diabetes is a major source of morbidity and mortality in the USA with over 1.5 million new cases diagnosed every year.[1] Diabetes is monitored using hemoglobin A1c (HbA1c) as it correlates with burden of disease.[2]-[4] Clinical practice guidelines recommend HbA1c be repeated every 3 months if a patient's value is above 7%, because a higher HbA1c correlates with worse outcomes.[5]-[9] Complications are particularly high in patients with an HbA1c above 10% and even a 1% reduction in HbA1c can reduce complications by 21%.[5] Thus, while regular monitoring of above-goal HbA1c levels is recommended, ensuring patients with an HbA1c over 10% have timely follow-up testing is especially important. Using this trigger, we found that delayed follow-up HbA1c testing is extremely common among those with poorly controlled diabetes, with 45% of patients with an HbA1c over 10% not receiving follow-up testing within 6 months. The initial numerator, representing patients without an appropriate follow-up HbA1c result, was defined as patients without a follow-up clinic visit within 3 months of the index HbA1c test. [Extracted from the article]

Background: Intensive glycemic control is of unclear benefit and carries increased risk for older adults with diabetes. The American Geriatrics Society's (AGS) Choosing Wisely (CW) guideline promotes less aggressive glycemic targets and reduction in pharmacologic therapy for older adults with type II diabetes. Meanwhile, behavioral economic (BE) approaches offer promise in influencing hard-to-change behavior, and previous studies have shown the benefits of using electronic health record (EHR) technology to encourage guideline adherence. Objective: This study aimed to develop and pilot test an intervention that leverages BE with EHR technology to promote appropriate diabetes management in older adults. Design: A pilot study within the New York University Langone Health (NYULH) EHR and Epic system to deliver BE-inspired nudges at five NYULH clinics at varying time points from July 12, 2018, through October 31, 2019. Participants: Clinicians across five practices in the NYULH system whose patients were older adults (age 76 and older) with type II diabetes. Interventions: A BE-EHR module comprising six nudges was developed through a series of design workshops, interviews, user-testing sessions, and clinic visits. BE principles utilized in the nudges include framing, social norming, accountable justification, defaults, affirmation, and gamification. Main Measures: Patient-level CW compliance. Key Results: CW compliance increased 5.1% from a 16-week interval at baseline to a 16-week interval post intervention. From February 14 to June 5, 2018 (prior to the first nudge launch in Vanguard clinics), CW compliance for 1278 patients was mean (95% CI)—16.1% (14.1%, 18.1%). From July 3 to October 22, 2019 (after BE-EHR module launch at all five clinics), CW compliance for 680 patients was 21.2% (18.1%, 24.3%). Conclusions: The BE-EHR module shows promise for promoting the AGS CW guideline and improving diabetes management in older adults. A randomized controlled trial will commence to test the effectiveness of the intervention across 66 NYULH clinics. NIH Trial Registry Number: NCT03409523 [ABSTRACT FROM AUTHOR]

Background: Hospital care on weekends has been associated with delays in care, reduced quality, and poor clinical outcomes.Objective: The purpose of this study was to evaluate the impact of a weekend hospital intervention on processes of care and clinical outcomes. The multifaceted intervention included expanded weekend diagnostic services, improved weekend discharge processes, and increased physician and care management services on weekends.Design and Patients: This was an interrupted time series observational study of adult non-obstetric patients hospitalized at a single academic medical center between January 2011 and January 2014. The study included 18 months prior to and 19 months following the implementation of the intervention. Data were analyzed using segmented regression analysis with adjustment for confounders.Main Measures: The primary outcome was average length of stay. Secondary outcomes included percent of patients discharged on weekends, 30-day readmission rate, and in-hospital mortality rate.Key Results: The study included 57,163 hospitalizations. Following implementation of the intervention, average length of stay decreased by 13 % (95 % CI 10-15 %) and continued to decrease by 1 % (95 % CI 1-2 %) per month as compared to the underlying time trend. The proportion of weekend discharges increased by 12 % (95 % CI 2-22 %) at the time of the intervention and continued to increase by 2 % (95 % CI 1-3 %) per month thereafter. The intervention had no impact on readmissions or mortality. During the post-implementation period, the hospital was evacuated and closed for 2 months due to damage from Hurricane Sandy, and a new hospital-wide electronic health record was introduced. The contributions of these events to our findings are not known. We observed a lower inpatient census and found differences in patient characteristics, including higher rates of Medicaid insurance and comorbidities, in the post-Hurricane Sandy period as compared to the pre-Sandy period.Conclusions: The intervention was associated with a reduction in length of stay and an increase in weekend discharges. Our longitudinal study also illuminated the challenges of evaluating the effectiveness of a large-scale intervention in a real-world hospital setting. [ABSTRACT FROM AUTHOR]

The article presents a study that examined the risk factors in seasonal differences in relation to hospital admission or due to seasonal variations in risk strata. It explores the predicted risk among hospitalized Medicare beneficiaries in seasonal variation for readmission of patients with cardiorespiratory conditions especially in winter months. The high prevalent cardiorespiratory conditions include heart failure, pneumonia, and chronic obstructive pulmonary disease (COPD).

The article presents the authors' views on a research paper, published in this issue on a randomized control trial conducted by researcher D. Edelman and colleagues to evaluate the effectiveness of a telephone-based nurse behavioral management intervention among diabetics and hypertension patients. They opine that a lesser role in the observed lack of effectiveness of a patient-level intervention is played by differences in settings.