Determining insulin dose at the time of discharge in a high-risk population: Is there room for improvement?

Objective: To evaluate the adequacy of the insulin dose prescribed at hospital discharge in a high-risk population and assess patient characteristics that influence insulin dose requirement in the immediate postdischarge period. Methods: This was a retrospective study conducted at Parkland Health System. We included all patients admitted to a medical floor who received an insulin prescription at discharge and had at least one follow-up visit within 6 months of discharge. All data were extracted by a detailed manual review of each electronic medical record. Results: At the postdischarge follow-up (N = 797, median 33 days from discharge), 60% of patients required an insulin dose adjustment; 47% of the patients required a dose decrease. Significant predictors of a decrease insulin requirement postdischarge included (multiple regression beta coefficient [95% confidence interval]): newly diagnosed diabetes, −12.7 (−17.7, −7.7); ketosis-prone diabetes, −8.4 (−15, −1.8); glycated hemoglobin A1c (HbA1c), <10% (86 mmol/mol) −7.0 (−11.4, −2.6); discharge insulin total daily dose, −5.3 (−9.3, −1.3); and metformin prescription, −4.9 (−8.4, −1.3). Conclusion: An insulin dose adjustment (most commonly a decrease) was necessary shortly after discharge in more than half of our patients. A better model to estimate insulin dose at discharge is needed along with short-term follow-up after discharge for insulin titration. A pre-emptive insulin dose reduction at discharge should be considered for patients with newly diagnosed diabetes, ketosis-prone diabetes, metformin prescription, and those with HbA1c <10% at presentation.