med surg case study diabetes

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On March 6th, 2019, Maria Fernandez, a 19-year-old female, presented to the Emergency Department with complaints of nausea, vomiting, abdominal pain, and lethargy. She reveals a recent diagnosis of type 1 diabetes but admits to noncompliance with treatment. At the time of admission, Maria’s vital signs were as follows: BP 87/50, HR 118, RR 28, O2 95% on room air, diffuse abdominal pain at a level of 5, on a verbal numeric 1-10 scale, with non-radiating pain beginning that morning. She was A&O x3, oriented to self, place, and situation, but sluggish. Upon assessment it is revealed that she is experiencing blurry vision, Kussmaul respirations, dry, flushed skin, poor skin turgor, weakness, and a fruity breath smell. Labs were drawn. During the first hour of admission, Maria requested water four times and urinated three times.

Code status:  Full code

Medical hx : Type 1 Diabetes

Insurance : None

Allergies : NKA

Significant Lab Values

• Blood glucose 388
• ABGs: pH 7.25, Bicarb 12 mEq/L, paCO2 30 mm Hg, anion gap 20 mEq/L, paO2 94%
• Urinalysis: Ketones and acetone present, BUN 25 mL/dL, Cr 2.1 ml/dL
• Chemistry: sodium 111 mEq/L, potassium 5.5 mEq/L, chloride 90 mEq/L, phosphorus 2.5 mg/dL, Magnesium 2.0 mg/dL
• CBC: WBC 13,000 mcL, RBC 4.7 mcL, Hgb 12.6 g/dL , Hct 37% (Wolters Kluwer, 2018).

Diagnosis:  Diabetes Ketoacidosis

• Oxygen administration by nasal cannula on 2L and airway management
• Establish IV access
• IV fluid administration with 0.9% NS; prepare to titrate to 0.45% normal saline as needed
• Monitor blood glucose levels
• Administer 0.1-0.15 unit/kg IV bolus of regular insulin
• IV drip infusion at 0.1 unit/kg/hr of regular insulin to hyperglycemia after bolus,
• Addition of Dextrose to 0.9% NS as glucose levels decreases to 250 mg/dL
• Monitor potassium levels
• Potassium replacement via IV when the potassium level is 5.0 mg/dL or less and urine output is adequate
• Assess for signs of hypokalemia or hyperkalemia
• Monitor vital signs and cardiac rhythm
• Q1-2hr fingerstick blood glucose checks initially, then q4-6hr once stabilized
• Monitor blood pH, I&O
• Assess level of consciousness; provide seizure and safety precautions (Henry et al., 2016)
• Notify MD of any critical changes

Maria Fernandez was then transferred to the ICU unit for close observation, maintenance of IV insulin drip, cardiac monitoring, fluid resuscitation, and correction for metabolic acidosis.

Upon discharge, Maria was reeducated on Type 1 Diabetes Mellitus through the use of preferred learning materials.

• What is the priority assessment data that supports DKA diagnosis?
• What education strategies would you consider implementing to improve treatment adherence after discharge?
• What considerations, services, or resources would you anticipate to be offered by case management or social services?

Henry, N.J., McMichael, M., Johnson, J., DiStasi, A., Ball, B.S., Holman, H.C., Elkins, C.B., Janowski, M.J., Hertel, R.A., Barlow, M.S., Leehy, P., & Lemon, T. (2016).  RN adult medical surgical nursing: Review module  (10 th  ed.). Leawood, KS: Assessment Technologies Institute.

Wolters Kluwer. (2018). Lippincott Nursing Advisor (Version 4.1.0) [Mobile application software]. Retrieved from  http://itunes.apple.com

Nursing Case Studies by and for Student Nurses Copyright © by jaimehannans is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License , except where otherwise noted.

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Impact of a care plan: diabetes case study

Naeem qureshi.

General practitioner, Gordon House Surgery, Ealing, London, UK

In order to ensure anonymity, precise information on age and gender of the patient, as well as geographic location, has been omitted.

This paper records the Multi-Disciplinary Group (MDG) discussion of a patient presented by a clinician at a West London meeting of the Integrated Care Pilot.

The problem(s) as perceived by the presenting clinician

A 65-year-old gentleman had been seeing his general practitioner (GP) for the treatment of type 2 diabetes for many years. He was advised on several occasions that the oral therapy was not controlling his blood glucose to the recommended levels. He had ischaemic heart disease and suffered from intermittent vascular claudication. On each occasion he would ask for a few more months to alter his lifestyle to improve the control of his diabetes rather than start insulin. On several occasions he was offered a referral to dietician's clinic or to diabetic specialist nurse's clinic, but he did not accept these. His HbA 1c was persistently running around 10% (86 mmol/mol). His blood pressure and cholesterol remained within the suggested target, although his body mass index was 30. The clinician thought that the problem was that the patient was resistant to starting insulin.

Ways to think about the problem

The MDG put forward reasons why he may be resistant to insulin initiation.

Psychological resistance:

• Insulin therapy represents failure of self-care
• Pain/fear of injections
• Belief that insulin therapy is complicated
• Fear of loss of independence
• Fear of change of lifestyle – will not be able to eat out/drive/travel
• Fear that insulin therapy is prescribed in the last stages of disease
• Fear of losing job/financial concerns
• Stigma related to injections/needle use
• Needle-phobia

Perceived harmful effects:

• Hypoglycaemia
• Weight gain
• Failure-of-treatment stories from family members/friends
• Perceived side-effects

Healthcare provider resistance to Insulin initiation:

• Time constraints
• Fear of patient's lack of adherence
• Fear of patient's lack of response

Suggestions made by team members about the problem(s) raised

How to overcome barriers.

The Diabetes Attitudes, Wishes and Needs (DAWN) study, a large international trial, found that only 27% of noninsulin-dependent patients believed that insulin could help manage their disease. It is important for him to replace misconceptions with facts. Make it clear that insulin use is not a punishment or evidence of personal failure, but a therapeutic option that most patients need as their diabetes progresses.

Was the GP putting barriers on himself?

In general, physician barriers centre on the fact that managing insulin therapy can be a cumbersome task for which they may not have the time or the resources. A study of clinician encounters with patients with type 2 diabetes in primary care clinics supports that belief. Each additional concern raised by a patient during the course of a visit was associated with a 49% reduction in the likelihood of a change in medication. Time constraint was the biggest factor in the GP's delay in starting insulin for this gentleman. On each occasion he wanted to delay the decision and the GP accepted his request without further pursuing the matter.

Action points

It was decided at the multidisciplinary group meeting that a care plan should be filled with the patient. Almost one hour was set aside to do this care plan.

The GP went through the care plan template with the patient and reached the section of “patient's goals”, the patient started to engage with the discussion. He started to show interest and began to discuss his concerns. We went through his fears and misconceptions in detail. By the end of discussion he agreed to initiate injections, albeit not insulin. He was offered a referral to the diabetic specialist nurse clinic and he agreed to the referral.

The matter was resolved by discussing the problem in an orderly manner with the help of the template and with protected time. The GP felt that the template proved to be a strong tool for both the patient and the GP. The patient could see the sequence of events in front of him and the GP had the opportunity to have less time constraint to discuss patient's fears, concerns and barriers towards insulin treatment. The diabetes specialist nurse reported to the group that the patient attended the clinic and started GLP-1 analogue injections. His HbA 1c improved to 9% (75 mmol/mol).

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Med-Surg Endocrine System, part 10: Diabetes Insipidus and SIADH

In this article, we cover two disorders, diabetes insipidus and syndrome of inappropriate ADH (SIADH). These are disorders that result from improper amounts of ADH in the body, so we begin with a quick review of ADH. Knowing the pathophysiology, symptoms, diagnosis and treatment for these two disorders will be key in your Med-Surg exams as well as your nursing practice.

These disorders are covered in our Medical-Surgical Flashcards (Endocrine system).

Medical-Surgical Nursing - Flashcards

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What is the difference between SIADH and DI?

With diabetes insipidus, the body has too little antidiuretic hormone (ADH), and with SIADH, the body has too much ADH.

If you would like more in-depth information about ADH, we gave an overview of ADH in the pathophysiology section of this playlist.

Antidiuretic hormone review

As a quick overview, ADH is released by the posterior pituitary gland in response to:

• Low blood volume
• Low blood pressure
• Hypernatremia (increased blood osmolarity)

If the body senses any of these three things, it will release ADH from the posterior pituitary gland, which will cause the kidneys to reabsorb more water, which helps to:

• Increase blood volume
• Increase blood pressure
• Dilute the blood so the blood osmolarity drops to a normal level

Diabetes insipidus

Diabetes insipidus is sometimes jokingly called “the other diabetes,” meaning it’s not related to the much more common diabetes mellitus. The word diabetes comes from Latin and Greek meaning “siphon” or “to pass through,” referring to excessive urination common with the disease. The word insipidus comes from Latin meaning “tasteless,” referring to the diluteness of the urine.

Pathophysiology

Neurogenic diabetes insipidus.

Neurogenic diabetes insipidus happens when there is some kind of trauma or tumor in the hypothalamus or pituitary gland which is causing insufficient ADH to be released. Without enough ADH being released from the posterior pituitary gland, the kidneys are not getting the signal to reabsorb water.

The prefix neuro- in neurogenic means nervous system, or more specifically, brain. The hypothalamus and pituitary gland are in the brain, so that’s how you can remember neurogenic diabetes insipidus.

Nephrogenic diabetes insipidus

With nephrogenic diabetes insipidus, the posterior pituitary gland is actually releasing the correct amount of ADH. But there’s a problem with the kidneys. They are not responding appropriately to the ADH signal. They are getting the ADH, but they don’t respond and don’t reabsorb more water.

Why don’t the kidneys respond to the ADH? It may be due to some kind of kidney infection or damage. Sometimes kidney damage occurs from use of nephrotoxic medications.

The prefix nephro- in nephrogenic means kidneys, so that’s how you can remember nephrogenic diabetes insipidus is a problem with the kidneys. Pretty easy!

If you’d like to learn more about prefixes and suffixes that can help you easily decode disease names, check out our Medical Terminology Flashcards .

Signs and symptoms of diabetes insipidus

One of the telltale symptoms of diabetes insipidus is large amounts of dilute urine. Dilute urine is urine that has a higher concentration of water than is expected -- in this case, because the kidneys are not reabsorbing the water. Dilution or concentration of urine is measured by the urine specific gravity test, which we will cover shortly.

Another key symptom of diabetes insipidus is polydipsia, which is excessive thirst. If you think about it, these two symptoms will exacerbate one another. If you are very thirsty, you will increase your water intake, but drinking tons of water will cause you to excrete large quantities of diluted urine, which can cause even more thirst in response to fluid loss!

Easy way to remember polydipsia

Other signs and symptoms of diabetes insipidus include dehydration, hypotension, and loss of appetite.

Lab values associated with diabetes insipidus

Urine specific gravity.

A urine specific gravity test measures the relative densities of a patient’s urine to the density of water. More specifically, it’s a ratio of the mass of urine to the mass of an equal volume of water, so it measures how dense or heavy the urine is compared to water. The closer the urine specific gravity ratio is to 1, the closer the urine’s density is to water.

The expected range for urine specific gravity is 1.010 - 1.025. Lower than that is dilute urine, and higher than that is concentrated urine. Very low urine specific gravity, under 1.005, can indicate diabetes insipidus.

Urine osmolality

A urine osmolality test measures urine concentration, or the amount of dissolved substances in the urine.

The expected range for urine osmolality is 300 - 900 mOsm/kg. Lower than that is dilute urine, and higher than that is concentrated urine. Very low urine osmolality, under 200, can indicate diabetes insipidus.

Serum osmolality (blood osmolality)

Blood (serum) osmolality is the amount of dissolved substances in the liquid part ( plasma ) of the blood. A large portion of these substances is sodium. Remember that one of the tasks that ADH gives the kidneys is to dilute the blood so its osmolality drops to a normal level. Without the kidneys doing that job, the blood becomes more concentrated and its osmolality rises.

The expected range for serum osmolality is 275-295 mOsm/L. Lower than that is dilute blood, and higher than that is concentrated blood. Very high serum osmolality, over 300, can indicate diabetes insipidus. This is opposite of the urine osmolality, because the fluid shifting into the urine results in excessively dilute urine, but significant fluid loss from the blood.

Sodium is an electrolyte that’s important for nerve and muscle function and maintaining fluid balance. Remember that a large portion of the substances in the blood is sodium — so as blood fluid levels drop and serum osmolality increases, sodium (Na) levels will also be high in a patient with diabetes insipidus.

The expected range for sodium (na) is 136 - 145 mEq/L. Lower than that can indicate hyponatremia, and higher than that can indicate hypernatremia. In diabetes insipidus, the expected sodium level would be above 145 mEq/L.

Having trouble remembering all these lab values? Urine specific gravity, urine osmolality, serum osmolality, and sodium are all covered in our Lab Values Flashcards . You can use these to practice for your nursing exams and as a reference guide if you’re a practicing nurse.

Diagnosis of diabetes insipidus

Water deprivation test.

Remember that one of the symptoms of diabetes insipidus is producing large volumes of dilute urine. Well, large volumes of dilute urine can also be a result of drinking large volumes of water.

A water deprivation test basically checks to see what happens when you take the water away. Does the body behave normally when the water is taken away, or abnormally? Is the dilute urine due to too much water, or is the body actually unable to concentrate urine?

Normally, water deprivation would cause increased production of ADH, which would trigger the kidneys to preserve fluid, resulting in smaller volumes of more concentrated urine. But if the patient is deprived of water in this test, and still produces dilute urine, this is abnormal and can indicate diabetes insipidus

Vasopressin test

The vasopressin test helps differentiate between neurogenic and nephrogenic diabetes insipidus. Remember that neuro means brain (pituitary gland) and nephro means kidneys.

Vasopressin is a drug used as a hormone replacement for ADH. We expect it to do the same thing as ADH: trigger the kidneys to reabsorb water. If we give a patient vasopressin and their kidneys do not reabsorb water, we know it’s a kidney problem and we have nephrogenic diabetes insipidus. If we give the patient vasopressin and their kidneys successfully reabsorb water, then we know it was a problem with the pituitary gland not producing enough ADH, and we have neurogenic diabetes insipidus.

Treatment (medications) for diabetes insipidus

In the case of neurogenic diabetes insipidus, we can provide the patient medications like vasopressin or desmopressin (DDAVP) as an ADH replacement. Check out Cathy’s easy way to remember the side effects of antidiuretic hormones .

Nursing care for diabetes insipidus

When a patient has diabetes insipidus, you will want to montior their intake and output (I&Os), urine specific gravity, and daily weight. Weight is important because weight loss can occur with excessive fluid loss.

Also, monitor for signs of fluid volume deficit: tachycardia, hypotension, poor skin turgor, dry/sticky mucus membranes.

Syndrome of inappropriate ADH (SIADH)

Pathophysiology of siadh.

You can think of SIADH as basically the opposite of diabetes insipidus. With SIADH, there is excess secretion of ADH from the posterior pituitary gland.

Why does excess ADH get released? It can be due to a brain tumor, head injury, meningitis, or because of a medication. This excess ADH will be released even when serum osmolality is low (when the blood is diluted). This results in the kidneys reabsorbing more water — meaning the body retains too much water.

Signs and symptoms of SIADH

The key symptom of SIADH is a very small amount of concentrated urine. The body is holding onto the water so it’s not being released in the urine.

There will also be signs and symptoms of fluid volume excess. This includes tachycardia (fast heart rate), hypertension (high blood pressure), crackles, jugular vein distention, and weight gain. Some other symptoms the patient may have are headache, weakness, and muscle cramping.

With the blood diluted, this can lead to hyponatremia (abnormally low sodium), and one symptom of hyponatremia is confusion, especially in elderly patients.

Check out Cathy’s nursing tip for the easy way to remember SIADH symptoms !

Labs values associated with SIADH

Remember that SIADH is the opposite of diabetes insipidus. With DI, the patient has dilute urine and concentrated blood — with SIADH, the patient has concentrated urine and dilute blood

With SIADH a patient has concentrated urine, so that means a high urine specific gravity — the urine is a lot denser than water. Urine specific gravity will be over 1.03.

This concentrated urine will also result in a high urine osmolality, over 900 mOsm/kg.

The blood will be very dilute, which means a decreased serum osmolality, under 270 mOsm/L.

Remember that a large portion of the substances in the blood is sodium — so when serum osmolality is low, sodium (Na) levels will also be low in a patient with SIADH. Sodium levels will be under 136 mEq/L, indicating hyponatremia.

Treatment (medications) for SIADH

One of the important medications for SIADH is a diuretic to try to eliminate the excess fluid. Within diuretics, you have loop diuretics (furosemide), thiazide diuretics (hydrochlorothiazide), osmotic diuretics (mannitol), and potassium sparing diuretics (spironolactone).

Want to learn about diuretics in more detail? These medications are covered in our Pharmacology Flashcards .

We can also give the patient a vasopressin antagonist. Remember that vasopressin is ADH and an antagonist blocks — blocking production of ADH makes sense for a patient with excess or uncontrolled ADH production.

A patient with SIADH and hyponatremia can also be given hypertonic saline, an IV sodium solution, to slowly raise the sodium levels in their body and allow their electrolytes to balance.

Nursing care for SIADH

For a patient with SIADH, you will monitor their intake & output and weigh daily, just like the patient with diabetes insipidus.

You will restrict fluids and replace sodium as ordered by the provider.

Monitor for fluid volume excess . If the patient has too much fluid volume overload, that can lead to pulmonary edema which is life threatening, so it’s important to monitor for that.

In the case of pulmonary edema, along with calling the healthcare provider, the nurse's priority action is to sit the patient up in tripod position over the bedside table.

Remember that hyponatremia can lead to confusion. So you will want to monitor the patient’s neurological status for that. Also, you may need to implement seizure precautions, because hyponatremia can lead to seizures if it becomes severe.

Diabetes insipidus vs. SIADH labs

Cathy’s teaching on these disorders is intended to help prepare you for Medical-Surgical nursing exams. The Medical-Surgical Nursing video series is intended to help RN and PN nursing students study for nursing school exams, including the ATI, HESI and NCLEX.

Full Transcript: Med-Surg Endocrine System, part 10: Diabetes Insipidus and SIADH

In this video we are going to talk about diabetes insipidus, as well as SIADH. These are two very important topics. If you happen to be following along with cards, I'm on card 23 [in the endocrine system section of the Medical-Surgical flashcards ], and you'll notice the next four cards, there's a lot of bold and red text on them, because there are several very important nursing concepts for you to know related to these disorders.

So both of these disorders have to do with ADH, either too much ADH, not enough ADH, or the organs in your body aren't responding appropriately to ADH. So let's do a quick review of ADH, and if you want more details about ADH, I did make a whole other video about it. But if you recall, ADH is released by the posterior pituitary gland in response to low blood volume in the body, low blood pressure, or to hypernatremia, or increased blood osmolarity. So if the body senses any of these three things, it will release ADH from the posterior pituitary gland, which will cause the kidneys to reabsorb more water, which helps to bring up that blood pressure, bring up that blood volume, and dilute the blood so that the blood osmolarity is back to a normal level.

So with diabetes insipidus, we have one of two things going on.

We may have neurogenic diabetes insipidus, which means that there is some kind of injury or tumor in the hypothalamus or the pituitary gland such that insufficient ADH is being released from the posterior pituitary gland. So if the posterior pituitary gland is not releasing enough ADH, the kidneys aren't getting the signal to reabsorb that water. So that is neurogenic diabetes insipidus.

The other thing we may have going on is something called nephrogenic diabetes insipidus. So in this situation, the posterior pituitary gland is doing its job fine. It's releasing ADH. But there's some problem in the kidneys and they are not responding appropriately to that signal. Right? They're getting the ADH but they're kind of like, "Ehh." They're not reabsorbing more water. This may be due to some kind of kidney infection, or maybe the kidneys have been damaged due to nephrotoxic medications. But this is called nephrogenic diabetes insipidus.

So in terms of signs and symptoms of diabetes insipidus, the key symptom is that the patient will have large amounts of dilute urine. So we're just dumping water. We're just peeing out tons of dilute urine. We're not reabsorbing that water as we should be. The patient will exhibit polydipsia, so this is where they have excessive thirst. And one way that I remember this symptom, if you look at the word diabetes insipidus, diabetes inSIPidus will make you want to SIP more water, because you're super thirsty.

Other signs and symptoms include dehydration, hypotension, and anorexia.

So in terms of labs, labs are definitely going to be important to know.

The urine, like we talked about, is going to be very dilute. So the specific gravity of the urine will be very low, or under 1.005. Also the osmolarity of the urine will also be very low, because it's very dilute. So it will be under 200, and then we would expect kind of decreased sodium levels in the urine as well.

In the blood though, that's a totally different story. Because we're getting rid of all those fluids, the blood's going to be really concentrated, so the serum, or blood osmolarity is going to be over 300, and the sodium levels are also going to be really high, so we're going to see hypernatremia.

In terms of diagnosis of diabetes insipidus, we can do a water deprivation test to test the ability of the kidneys to concentrate urine. We can also do a vasopressin test. So vasopressin is essentially the same as ADH. And if we give the patient vasopressin, we would expect their kidneys to reabsorb water. If their kidneys don't do that, then we know it's a problem with the kidneys and we have nephrogenic diabetes insipidus. If we give the patient vasopressin and their kidneys do do their job and reabsorb water, then we know it was an issue with the pituitary gland not producing enough ADH.

And if that is the case, then we can provide medications such as vasopressin or desmopressin, which you can find on Pharm card 110 [in our Pharmacology Flashcards ] in terms of getting more information about those medications.

So in terms of nursing care, when a patient has diabetes insipidus, we're definitely going to want to monitor the patient's I&Os, as well as their urine specific gravity and their daily weight.

Let's move on to syndrome of inappropriate ADH, or SIADH. With SIADH, we have excess release of ADH from the posterior pituitary gland due to a brain tumor, head injury, meningitis, or because of a medication. So even though the blood is very dilute, the posterior pituitary gland still releases ADH, even though it should not. So because it's releasing all this extra ADH inappropriately, it's causing the kidneys to reabsorb more water.

So signs and symptoms of SIADH will include a very small amount of very concentrated urine. And then we'll have signs and symptoms of fluid volume excess because we have all this extra fluid being reabsorbed. So the patient may exhibit signs and symptoms such as tachycardia, hypertension, crackles, jugular vein distention, as well as weight gain. They may also complain of a headache, weakness, and muscle cramping. And then they may also exhibit confusion because we have hyponatremia due to all this dilution, and that can cause the patient to be confused.

So one way to remember what SIADH does, if you look at the first two letters of that, S-I, you can think of super inflated, and that's basically what happens. When you have SIADH, you reabsorb all this extra fluid, and you are super inflated.

In terms of labs, we're going to have, basically, the exact opposite as we saw with diabetes insipidus.

So the urine with SIADH will be super concentrated. So the urine specific gravity will be elevated. It will be over 1.03, and the urine osmolality or osmolarity will also be increased because it's so concentrated.

The blood or the serum will be a completely different story. It will be very dilute, so the serum osmolality will be decreased. It will be under 270 and we'll see hyponatremia because the sodium is diluted with all this extra fluid volume.

In terms of treatment, we're definitely going to give the patient diuretics to try to get rid of some of this excess fluid. We can also give them a vasopressin antagonist, and then we can also give them hypertonic saline to help bring up the sodium levels and allow for those electrolyte levels to be more in balance.

In terms of nursing care, again, we're going to want to monitor the patient's I&Os, we're going to weigh our patients daily, and we're going to restrict fluids and replace sodium as ordered by the provider. We're going to monitor for fluid volume excess. So if we have too much fluid volume overload, we can end up with pulmonary edema, which is life threatening. So we're definitely going to want to monitor for that. And then we're going to want to continually monitor the patient's neurologic status because of the confusion that can result from hypernatremia, and we're also going to need to implement seizure precautions, because hypernatremia can result in seizures if it gets too bad.

So hopefully that was useful in terms of a review of diabetes insipidus, and SIADH. If you appreciated this review, be sure to like our video and subscribe to us here. Take care.

I learned a lot. thanks!

Very good review of DI vs SIADH

Thank you much – had worse 1st time doc appointment w Diabetes ,Osteoporosis,Endocrinologist -In & out in less than 1/2 hr-didnt fill out all paperwork before saw / moved to 2 dif. Rms blood pressure cuff not working-heard nurse comment on meds taking through closed door,and when did see doc she seemed rude ,didn’t explain why thought had SIADH

Very helpful information.

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Patient medication management, understanding and adherence during the transition from hospital to outpatient care - a qualitative longitudinal study in polymorbid patients with type 2 diabetes

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• Giacomo Gastaldi   ORCID: orcid.org/0000-0001-6327-7451 3 &
• Marie P. Schneider   ORCID: orcid.org/0000-0002-7557-9278 1 , 2  

BMC Health Services Research volume  24 , Article number:  620 ( 2024 ) Cite this article

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Continuity of care is under great pressure during the transition from hospital to outpatient care. Medication changes during hospitalization may be poorly communicated and understood, compromising patient safety during the transition from hospital to home. The main aims of this study were to investigate the perspectives of patients with type 2 diabetes and multimorbidities on their medications from hospital discharge to outpatient care, and their healthcare journey through the outpatient healthcare system. In this article, we present the results focusing on patients’ perspectives of their medications from hospital to two months after discharge.

Patients with type 2 diabetes, with at least two comorbidities and who returned home after discharge, were recruited during their hospitalization. A descriptive qualitative longitudinal research approach was adopted, with four in-depth semi-structured interviews per participant over a period of two months after discharge. Interviews were based on semi-structured guides, transcribed verbatim, and a thematic analysis was conducted.

Twenty-one participants were included from October 2020 to July 2021. Seventy-five interviews were conducted. Three main themes were identified: (A) Medication management, (B) Medication understanding, and (C) Medication adherence, during three periods: (1) Hospitalization, (2) Care transition, and (3) Outpatient care. Participants had varying levels of need for medication information and involvement in medication management during hospitalization and in outpatient care. The transition from hospital to autonomous medication management was difficult for most participants, who quickly returned to their routines with some participants experiencing difficulties in medication adherence.

Conclusions

The transition from hospital to outpatient care is a challenging process during which discharged patients are vulnerable and are willing to take steps to better manage, understand, and adhere to their medications. The resulting tension between patients’ difficulties with their medications and lack of standardized healthcare support calls for interprofessional guidelines to better address patients’ needs, increase their safety, and standardize physicians’, pharmacists’, and nurses’ roles and responsibilities.

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Introduction

Continuity of patient care is characterized as the collaborative engagement between the patient and their physician-led care team in the ongoing management of healthcare, with the mutual objective of delivering high-quality and cost-effective medical care [ 1 ]. Continuity of care is under great pressure during the transition of care from hospital to outpatient care, with a risk of compromising patients’ safety [ 2 , 3 ]. The early post-discharge period is a high-risk and fragile transition: once discharged, one in five patients experience at least one adverse event during the first three weeks following discharge, and more than half of these adverse events are drug-related [ 4 , 5 ]. A retrospective study examining all discharged patients showed that adverse drug events (ADEs) account for up to 20% of 30-day hospital emergency readmissions [ 6 ]. During hospitalization, patients’ medications are generally modified, with an average of nearly four medication changes per patient [ 7 ]. Information regarding medications such as medication changes, the expected effect, side effects, and instructions for use are frequently poorly communicated to patients during hospitalization and at discharge [ 8 , 9 , 10 , 11 ]. Between 20 and 60% of discharged patients lack knowledge of their medications [ 12 , 13 ]. Consideration of patients’ needs and their active engagement in decision-making during hospitalization regarding their medications are often lacking [ 11 , 14 , 15 ]. This can lead to unsafe discharge and contribute to medication adherence difficulties, such as non-implementation of newly prescribed medications [ 16 , 17 ].

Patients with multiple comorbidities and polypharmacy are at higher risk of ADE [ 18 ]. Type 2 diabetes is one of the chronic health conditions most frequently associated with comorbidities and patients with type 2 diabetes often lack care continuum [ 19 , 20 , 21 ]. The prevalence of patients hospitalized with type 2 diabetes can exceed 40% [ 22 ] and these patients are at higher risk for readmission due to their comorbidities and their medications, such as insulin and oral hypoglycemic agents [ 23 , 24 , 25 ].

Interventions and strategies to improve patient care and safety at transition have shown mixed results worldwide in reducing cost, rehospitalization, ADE, and non-adherence [ 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 ]. However, interventions that are patient-centered, with a patient follow-up and led by interprofessional healthcare teams showed promising results [ 34 , 35 , 36 ]. Most of these interventions have not been implemented routinely due to the extensive time to translate research into practice and the lack of hybrid implementation studies [ 37 , 38 , 39 , 40 , 41 ]. In addition, patient-reported outcomes and perspectives have rarely been considered, yet patients’ involvement is essential for seamless and integrated care [ 42 , 43 ]. Interprofessional collaboration in which patients are full members of the interprofessional team, is still in its infancy in outpatient care [ 44 ]. Barriers and facilitators regarding medications at the transition of care have been explored in multiple qualitative studies at one given time in a given setting (e.g., at discharge, one-month post-discharge) [ 8 , 45 , 46 , 47 , 48 ]. However, few studies have adopted a holistic methodology from the hospital to the outpatient setting to explore changes in patients’ perspectives over time [ 49 , 50 , 51 ]. Finally, little is known about whether, how, and when patients return to their daily routine following hospitalization and the impact of hospitalization weeks after discharge.

In Switzerland, continuity of care after hospital discharge is still poorly documented, both in terms of contextual analysis and interventional studies, and is mainly conducted in the hospital setting [ 31 , 35 , 52 , 53 , 54 , 55 , 56 ]. The first step of an implementation science approach is to perform a contextual analysis to set up effective interventions adapted to patients’ needs and aligned to healthcare professionals’ activities in a specific context [ 41 , 57 ]. Therefore, the main aims of this study were to investigate the perspectives of patients with type 2 diabetes and multimorbidities on their medications from hospital discharge to outpatient care, and on their healthcare journey through the outpatient healthcare system. In this article, we present the results focusing on patients’ perspectives of their medications from hospital to two months after discharge.

Study design

This qualitative longitudinal study, conducted from October 2020 to July 2021, used a qualitative descriptive methodology through four consecutive in-depth semi-structured interviews per participant at three, 10-, 30- and 60-days post-discharge, as illustrated in Fig.  1 . Longitudinal qualitative research is characterized by qualitative data collection at different points in time and focuses on temporality, such as time and change [ 58 , 59 ]. Qualitative descriptive studies aim to explore and describe the depth and complexity of human experiences or phenomena [ 60 , 61 , 62 ]. We focused our qualitative study on the 60 first days after discharge as this period is considered highly vulnerable and because studies often use 30- or 60-days readmission as an outcome measure [ 5 , 63 ].

This qualitative study follows the Consolidated Criteria for Reporting Qualitative Research (COREQ). Ethics committee approval was sought and granted by the Cantonal Research Ethics Commission, Geneva (CCER) (2020 − 01779).

Recruitment took place during participants’ hospitalization in the general internal medicine divisions at the Geneva University Hospitals in the canton of Geneva (500 000 inhabitants), Switzerland. Interviews took place at participants’ homes, in a private office at the University of Geneva, by telephone or by secure video call, according to participants’ preference. Informal caregivers could also participate alongside the participants.

Study flowchart

Researcher characteristics

All the researchers were trained in qualitative studies. The diabetologist and researcher (GG) who enrolled the patients in the study was involved directly or indirectly (advice asked to the Geneva University Hospital diabetes team of which he was a part) for most participants’ care during hospitalization. LS (Ph.D. student and community pharmacist) was unknown to participants and presented herself during hospitalization as a “researcher” and not as a healthcare professional to avoid any risk of influencing participants’ answers. This study was not interventional, and the interviewer (LS) invited participants to contact a healthcare professional for any questions related to their medication or medical issues.

Population and sampling strategy

Patients with type 2 diabetes were chosen as an example population to describe polypharmacy patients as these patients usually have several health issues and polypharmacy [ 20 , 22 , 25 ]. Inclusions criteria for the study were: adult patients with type 2 diabetes, with at least two other comorbidities, hospitalized for at least three days in a general internal medicine ward, with a minimum of one medication change during hospital stay, and who self-managed their medications once discharged home. Exclusion criteria were patients not reachable by telephone following discharge, unable to give consent (patients with schizophrenia, dementia, brain damage, or drug/alcohol misuse), and who could not communicate in French. A purposive sampling methodology was applied aiming to include participants with different ages, genders, types, and numbers of health conditions by listing participants’ characteristics in a double-entry table, available in Supplementary Material 1 , until thematic saturation was reached. Thematic saturation was considered achieved when no new code or theme emerged and new data repeated previously coded information [ 64 ]. The participants were identified if they were hospitalized in the ward dedicated to diabetes care or when the diabetes team was contacted for advice. The senior ward physician (GG) screened eligible patients and the interviewer (LS) obtained written consent before hospital discharge.

Data collection and instruments

Sociodemographic (age, gender, educational level, living arrangement) and clinical characteristics (reason for hospitalization, date of admission, health conditions, diabetes diagnosis, medications before and during hospitalization) were collected by interviewing participants before their discharge and by extracting participants’ data from electronic hospital files by GG and LS. Participants’ pharmacies were contacted with the participant’s consent to obtain medication records from the last three months if information regarding medications before hospitalization was missing in the hospital files.

Semi-structured interview guides for each interview (at three, 10-, 30- and 60-days post-discharge) were developed based on different theories and components of health behavior and medication adherence: the World Health Organization’s (WHO) five dimensions for adherence, the Information-Motivation-Behavioral skills model and the Social Cognitive Theory [ 65 , 66 , 67 ]. Each interview explored participants’ itinerary in the healthcare system and their perspectives on their medications. Regarding medications, the following themes were mentioned at each interview: changes in medications, patients’ understanding and implication; information on their medications, self-management of their medications, and patients’ medication adherence. Other aspects were mentioned in specific interviews: patients’ hospitalization and experience on their return home (interview 1), motivation (interviews 2 and 4), and patient’s feedback on the past two months (interview 4). Interview guides translated from French are available in Supplementary Material 2 . The participants completed self-reported and self-administrated questionnaires at different interviews to obtain descriptive information on different factors that may affect medication management and adherence: self-report questionnaires on quality of life (EQ-5D-5 L) [ 68 ], literacy (Schooling-Opinion-Support questionnaire) [ 69 ], medication adherence (Adherence Visual Analogue Scale, A-VAS) [ 70 ] and Belief in Medication Questionnaire (BMQ) [ 71 ] were administered to each participant at the end of selected interviews to address the different factors that may affect medication management and adherence as well as to determine a trend of determinants over time. The BMQ contains two subscores: Specific-Necessity and Specific-Concerns, addressing respectively their perceived needs for their medications, and their concerns about adverse consequences associated with taking their medication [ 72 ].

Data management

Informed consent forms, including consent to obtain health data, were securely stored in a private office at the University of Geneva. The participants’ identification key was protected by a password known only by MS and LS. Confidentiality was guaranteed by pseudonymization of participants’ information and audio-recordings were destroyed once analyzed. Sociodemographic and clinical characteristics, medication changes, and answers to questionnaires were securely collected by electronic case report forms (eCRFs) on RedCap®. Interviews were double audio-recorded and field notes were taken during interviews. Recorded interviews were manually transcribed verbatim in MAXQDA® (2018.2) by research assistants and LS and transcripts were validated for accuracy by LS. A random sample of 20% of questionnaires was checked for accuracy for the transcription from the paper questionnaires to the eCRFs. Recorded sequences with no link to the discussed topics were not transcribed and this was noted in the transcripts.

Data analysis

A descriptive statistical analysis of sociodemographic, clinical characteristics and self-reported questionnaire data was carried out. A thematic analysis of transcripts was performed, as described by Braun and Clarke [ 73 ], by following six steps: raw data was read, text segments related to the study objectives were identified, text segments to create new categories were identified, similar or redundant categories were reduced and a model that integrated all significant categories was created. The analysis was conducted in parallel with patient enrolment to ensure data saturation. To ensure the validity of the coding method, transcripts were double coded independently and discussed by the research team until similar themes were obtained. The research group developed and validated an analysis grid, with which LS coded systematically the transcriptions and met regularly with the research team to discuss questions on data analysis and to ensure the quality of coding. The analysis was carried out in French, and the verbatims of interest cited in the manuscript were translated and validated by a native English-speaking researcher to preserve the meaning.

In this analysis, we used the term “healthcare professionals” when more than one profession could be involved in participants’ medication management. Otherwise, when a specific healthcare professional was involved, we used the designated profession (e.g. physicians, pharmacists).

Patient and public involvement

During the development phase of the study, interview guides and questionnaires were reviewed for clarity and validity and adapted by two patient partners, with multiple health conditions and who experienced previously a hospital discharge. They are part of the HUG Patients Partners + 3P platform for research and patient and public involvement.

Interviews and participants’ descriptions

A total of 75 interviews were conducted with 21 participants. In total, 31 patients were contacted, seven refused to participate (four at the project presentation and three at consent), two did not enter the selection criteria at discharge and one was unreachable after discharge. Among the 21 participants, 15 participated in all interviews, four in three interviews, one in two interviews, and one in one interview, due to scheduling constraints. Details regarding interviews and participants characteristics are presented in Tables  1 and 2 .

The median length of time between hospital discharge and interviews 1,2,3 and 4 was 5 (IQR: 4–7), 14 (13-20), 35 (22-38), and 63 days (61-68), respectively. On average, by comparing medications at hospital admission and discharge, a median of 7 medication changes (IQR: 6–9, range:2;17) occurred per participant during hospitalization and a median of 7 changes (5–12) during the two months following discharge. Details regarding participants’ medications are described in Table  3 .

Patient self-reported adherence over the past week for their three most challenging medications are available in Supplementary Material 3 .

Qualitative analysis

We defined care transition as the period from discharge until the first medical appointment post-discharge, and outpatient care as the period starting after the first medical appointment. Data was organized into three key themes (A. Medication management, B. Medication understanding, and C. Medication adherence) divided into subthemes at three time points (1. Hospitalization, 2. Care transition and 3. Outpatient care). Figure  2 summarizes and illustrates the themes and subthemes with their influencing factors as bullet points.

Participants’ medication management, understanding and adherence during hospitalization, care transition and outpatient care

A. Medication management

A.1 medication management during hospitalization: medication management by hospital staff.

Medications during hospitalization were mainly managed by hospital healthcare professionals (i.e. nurses and physicians) with varying degrees of patient involvement: “At the hospital, they prepared the medications for me. […] I didn’t even know what the packages looked like.” Participant 22; interview 1 (P22.1) Some participants reported having therapeutic education sessions with specialized nurses and physicians, such as the explanation and demonstration of insulin injection and glucose monitoring. A patient reported that he was given the choice of several treatments and was involved in shared decision-making. Other participants had an active role in managing and optimizing dosages, such as rapid insulin, due to prior knowledge and use of medications before hospitalization.

A.2 Medication management at transition: obtaining the medication and initiating self-management

Once discharged, some participants had difficulties obtaining their medications at the pharmacy because some medications were not stored and had to be ordered, delaying medication initiation. To counter this problem upstream, a few participants were provided a 24-to-48-hour supply of medications at discharge. It was sometimes requested by the patient or suggested by the healthcare professionals but was not systematic. The transition from medication management by hospital staff to self-management was exhausting for most participants who were faced with a large amount of new information and changes in their medications: “ When I was in the hospital, I didn’t even realize all the changes. When I came back home, I took away the old medication packages and got out the new ones. And then I thought : « my God, all this…I didn’t know I had all these changes » ” P2.1 Written documentation, such as the discharge prescription or dosage labels on medication packages, was helpful in managing their medication at home. Most participants used weekly pill organizers to manage their medications, which were either already used before hospitalization or were introduced post-discharge. The help of a family caregiver in managing and obtaining medications was reported as a facilitator.

A.3 Medication management in outpatient care: daily self-management and medication burden

A couple of days or weeks after discharge, most participants had acquired a routine so that medication management was less demanding, but the medication burden varied depending on the participants. For some, medication management became a simple action well implemented in their routine (“It has become automatic” , P23.4), while for others, the number of medications and the fact that the medications reminded them of the disease was a heavy burden to bear on a daily basis (“ During the first few days after getting out of the hospital, I thought I was going to do everything right. In the end, well [laughs] it’s complicated. I ended up not always taking the medication, not monitoring the blood sugar” P12.2) To support medication self-management, some participants had written documentation such as treatment plans, medication lists, and pictures of their medication packages on their phones. Some participants had difficulties obtaining medications weeks after discharge as discharge prescriptions were not renewable and participants did not see their physician in time. Others had to visit multiple physicians to have their prescriptions updated. A few participants were faced with prescription or dispensing errors, such as prescribing or dispensing the wrong dosage, which affected medication management and decreased trust in healthcare professionals. In most cases, according to participants, the pharmacy staff worked in an interprofessional collaboration with physicians to provide new and updated prescriptions.

B. Medication understanding

B.1 medication understanding during hospitalization: new information and instructions.

The amount of information received during hospitalization varied considerably among participants with some reporting having received too much, while others saying they received too little information regarding medication changes, the reason for changes, or for introducing new medications: “They told me I had to take this medication all my life, but they didn’t tell me what the effects were or why I was taking it.” P5.3

Hospitalization was seen by some participants as a vulnerable and tiring period during which they were less receptive to information. Information and explanations were generally given verbally, making it complicated for most participants to recall it. Some participants reported that hospital staff was attentive to their needs for information and used communication techniques such as teach-back (a way of checking understanding by asking participants to say in their own words what they need to know or do about their health or medications). Some participants were willing to be proactive in the understanding of their medications while others were more passive, had no specific needs for information, and did not see how they could be engaged more.

B.2 Medication understanding at transition: facing medication changes

At hospital discharge, the most challenging difficulty for participants was to understand the changes made regarding their medications. For newly diagnosed participants, the addition of new medications was more difficult to understand, whereas, for experienced participants, changes in known medications such as dosage modification, changes within a therapeutic class, and generic substitutions were the most difficult to understand. Not having been informed about changes caused confusion and misunderstanding. Therefore, medication reconciliation done by the patient was time-consuming, especially for participants with multiple medications: “ They didn’t tell me at all that they had changed my treatment completely. They just told me : « We’ve changed a few things. But it was the whole treatment ». ” P2.3 Written information, such as the discharge prescription, the discharge report (brief letter summarizing information about the hospitalization, given to the patient at discharge), or the label on the medication box (written by the pharmacist with instructions on dosage) helped them find or recall information about their medications and diagnoses. However, technical terms were used in hospital documentations and were not always understandable. For example, this participant said: “ On the prescription of valsartan, they wrote: ‘resume in the morning once profile…’[once hypertension profile allows]… I don’t know what that means.” P8.1 In addition, some documents were incomplete, as mentioned by a patient who did not have the insulin dosage mentioned on the hospital prescription. Some participants sought help from healthcare professionals, such as pharmacists, hospital physicians, or general practitioners a few days after discharge to review medications, answer questions, or obtain additional information.

B.3 Medication understanding in the outpatient care: concerns and knowledge

Weeks after discharge, most participants had concerns about the long-term use of their medications, their usefulness, and the possible risk of interactions or side effects. Some participants also reported having some lack of knowledge regarding indications, names, or how the medication worked: “I don’t even know what Brilique® [ticagrelor, antiplatelet agent] is for. It’s for blood pressure, isn’t it?. I don’t know.” P11.4 According to participants, the main reasons for the lack of understanding were the lack of information at the time of prescribing and the large number of medications, making it difficult to search for information and remember it. Participants sought information from different healthcare professionals or by themselves, on package inserts, through the internet, or from family and friends. Others reported having had all the information needed or were not interested in having more information. In addition, participants with low medication literacy, such as non-native speakers or elderly people, struggled more with medication understanding and sought help from family caregivers or healthcare professionals, even weeks after discharge: “ I don’t understand French very well […] [The doctor] explained it very quickly…[…] I didn’t understand everything he was saying” P16.2

C. Medication adherence

C.2 medication adherence at transition: adopting new behaviors.

Medication adherence was not mentioned as a concern during hospitalization and a few participants reported difficulties in medication initiation once back home: “I have an injection of Lantus® [insulin] in the morning, but obviously, the first day [after discharge], I forgot to do it because I was not used to it.” P23.1 Participants had to quickly adopt new behaviors in the first few days after discharge, especially for participants with few medications pre-hospitalization. The use of weekly pill organizers, alarms and specific storage space were reported as facilitators to support adherence. One patient did not initiate one of his medications because he did not understand the medication indication, and another patient took her old medications because she was used to them. Moreover, most participants experienced their hospitalization as a turning point, a time when they focused on their health, thought about the importance of their medications, and discussed any new lifestyle or dietary measures that might be implemented.

C.3 Medication adherence in outpatient care: ongoing medication adherence

More medication adherence difficulties appeared a few weeks after hospital discharge when most participants reported nonadherence behaviors, such as difficulties implementing the dosage regimen, or intentionally discontinuing the medication and modifying the medication regimen on their initiative. Determinants positively influencing medication adherence were the establishment of a routine; organizing medications in weekly pill-organizers; organizing pocket doses (medications for a short period that participants take with them when away from home); seeking support from family caregivers; using alarm clocks; and using specific storage places. Reasons for nonadherence were changes in daily routine; intake times that were not convenient for the patient; the large number of medications; and poor knowledge of the medication or side effects. Healthcare professionals’ assistance for medication management, such as the help of home nurses or pharmacists for the preparation of weekly pill-organizers, was requested by participants or offered by healthcare professionals to support medication adherence: “ I needed [a home nurse] to put my pills in the pillbox. […] I felt really weak […] and I was making mistakes. So, I’m very happy [the doctor] offered me [home care]. […] I have so many medications.” P22.3 Some participants who experienced prehospitalization non-adherence were more aware of their non-adherence and implemented strategies, such as modifying the timing of intake: “I said to my doctor : « I forget one time out of two […], can I take them in the morning? » We looked it up and yes, I can take it in the morning.” P11.2 In contrast, some participants were still struggling with adherence difficulties that they had before hospitalization. Motivations for taking medications two months after discharge were to improve health, avoid complications, reduce symptoms, reduce the number of medications in the future or out of obligation: “ I force myself to take them because I want to get to the end of my diabetes, I want to reduce the number of pills as much as possible.” P14.2 After a few weeks post-hospitalization, for some participants, health and illness were no longer the priority because of other life imperatives (e.g., family or financial situation).

This longitudinal study provided a multi-faceted representation of how patients manage, understand, and adhere to their medications from hospital discharge to two months after discharge. Our findings highlighted the varying degree of participants’ involvement in managing their medications during their hospitalization, the individualized needs for information during and after hospitalization, the complicated transition from hospital to autonomous medication management, the adaptation of daily routines around medication once back home, and the adherence difficulties that surfaced in the outpatient care, with nonadherence prior to hospitalization being an indicator of the behavior after discharge. Finally, our results confirmed the lack of continuity in care and showed the lack of patient care standardization experienced by the participants during the transition from hospital to outpatient care.

This in-depth analysis of patients’ experiences reinforces common challenges identified in the existing literature such as the lack of personalized information [ 9 , 10 , 11 ], loss of autonomy during hospitalization [ 14 , 74 , 75 ], difficulties in obtaining medication at discharge [ 11 , 45 , 76 ] and challenges in understanding treatment modifications and generics substitution [ 11 , 32 , 77 , 78 ]. Some of these studies were conducted during patients’ hospitalization [ 10 , 75 , 79 ] or up to 12 months after discharge [ 80 , 81 ], but most studies focused on the few days following hospital discharge [ 9 , 11 , 14 , 82 ]. Qualitative studies on medications at transition often focused on a specific topic, such as medication information, or a specific moment in time, and often included healthcare professionals, which muted patients’ voices [ 9 , 10 , 11 , 47 , 49 ]. Our qualitative longitudinal methodology was interested in capturing the temporal dynamics, in-depth narratives, and contextual nuances of patients’ medication experiences during transitions of care [ 59 , 83 ]. This approach provided a comprehensive understanding of how patients’ perspectives and behaviors evolved over time, offering insights into the complex interactions of medication management, understanding and adherence, and turning points within their medication journeys. A qualitative longitudinal design was used by Fylan et al. to underline patients’ resilience in medication management during and after discharge, by Brandberg et al. to show the dynamic process of self-management during the 4 weeks post-discharge and by Lawton et al. to examine how patients with type 2 diabetes perceived their care after discharge over a period of four years [ 49 , 50 , 51 ]. Our study focused on the first two months following hospitalization and future studies should focus on following discharged and at-risk patients over a longer period, as “transitions of care do not comprise linear trajectories of patients’ movements, with a starting and finishing point. Instead, they are endless loops of movements” [ 47 ].

Our results provide a particularly thorough description of how participants move from a state of total dependency during hospitalization regarding their medication management to a sudden and complete autonomy after hospital discharge impacting medication management, understanding, and adherence in the first days after discharge for some participants. Several qualitative studies have described the lack of shared decision-making and the loss of patient autonomy during hospitalization, which had an impact on self-management and created conflicts with healthcare professionals [ 75 , 81 , 84 ]. Our study also highlights nuanced patient experiences, including varying levels of patient needs, involvement, and proactivity during hospitalization and outpatient care, and our results contribute to capturing different perspectives that contrast with some literature that often portrays patients as more passive recipients of care [ 14 , 15 , 74 , 75 ]. Shared decision-making and proactive medication are key elements as they contribute to a smoother transition and better outcomes for patients post-discharge [ 85 , 86 , 87 ].

Consistent with the literature, the study identifies some challenges in medication initiation post-discharge [ 16 , 17 , 88 ] but our results also describe how daily routine rapidly takes over, either solidifying adherence behavior or generating barriers to medication adherence. Participants’ nonadherence prior to hospitalization was a factor influencing participants’ adherence post-hospitalization and this association should be further investigated, as literature showed that hospitalized patients have high scores of non-adherence [ 89 ]. Mortel et al. showed that more than 20% of discharged patients stopped their medications earlier than agreed with the physician and 25% adapted their medication intake [ 90 ]. Furthermore, patients who self-managed their medications had a lower perception of the necessity of their medication than patients who received help, which could negatively impact medication adherence [ 91 ]. Although participants in our study had high BMQ scores for necessity and lower scores for concerns, some participants expressed doubts about the need for their medications and a lack of motivation a few weeks after discharge. Targeted pharmacy interventions for newly prescribed medications have been shown to improve medication adherence, and hospital discharge is an opportune moment to implement this service [ 92 , 93 ].

Many medication changes were made during the transition of care (a median number of 7 changes during hospitalization and 7 changes during the two months after discharge), especially medication additions during hospitalization and interruptions after hospitalization. While medication changes during hospitalization are well described, the many changes following discharge are less discussed [ 7 , 94 ]. A Danish study showed that approximately 65% of changes made during hospitalization were accepted by primary healthcare professionals but only 43% of new medications initiated during hospitalization were continued after discharge [ 95 ]. The numerous changes after discharge may be caused by unnecessary intensification of medications during hospitalization, delayed discharge letters, lack of standardized procedures, miscommunication, patient self-management difficulties, or in response to an acute situation [ 96 , 97 , 98 ]. During the transition of care, in our study, both new and experienced participants were faced with difficulties in managing and understanding medication changes, either for newly prescribed medication or changes in previous medications. Such difficulties corroborate the findings of the literature [ 9 , 10 , 47 ] and our results showed that the lack of understanding during hospitalization led to participants having questions about their medications, even weeks after discharge. Particular attention should be given to patients’ understanding of medication changes jointly by physicians, nurses and pharmacists during the transition of care and in the months that follow as medications are likely to undergo as many changes as during hospitalization.

Implication for practice and future research

The patients’ perspectives in this study showed, at a system level, that there was a lack of standardization in healthcare professional practices regarding medication dispensing and follow-up. For now, in Switzerland, there are no official guidelines on medication prescription and dispensation during the transition of care although some international guidelines have been developed for outpatient healthcare professionals [ 3 , 99 , 100 , 101 , 102 ]. Here are some suggestions for improvement arising from our results. Patients should be included as partners and healthcare professionals should systematically assess (i) previous medication adherence, (ii) patients’ desired level of involvement and (iii) their needs for information during hospitalization. Hospital discharge processes should be routinely implemented to standardize hospital discharge preparation, medication prescribing, and dispensing. Discharge from the hospital should be planned with community pharmacies to ensure that all medications are available and, if necessary, doses of medications should be supplied by the hospital to bridge the gap. A partnership with outpatient healthcare professionals, such as general practitioners, community pharmacists, and homecare nurses, should be set up for effective asynchronous interprofessional collaboration to consolidate patients’ medication management, knowledge, and adherence, as well as to monitor signs of deterioration or adverse drug events.

Future research should consolidate our first attempt to develop a framework to better characterize medication at the transition of care, using Fig. 2   as a starting point. Contextualized interventions, co-designed by health professionals, patients and stakeholders, should be tested in a hybrid implementation study to test the implementation and effectiveness of the intervention for the health system [ 103 ].

Limitations

This study has some limitations. First, the transcripts were validated for accuracy by the interviewer but not by a third party, which could have increased the robustness of the transcription. Nevertheless, the interviewer followed all methodological recommendations for transcription. Second, patient inclusion took place during the COVID-19 pandemic, which may have had an impact on patient care and the availability of healthcare professionals. Third, we cannot guarantee the accuracy of some participants’ medication history before hospitalization, even though we contacted the participants’ main pharmacy, as participants could have gone to different pharmacies to obtain their medications. Fourth, our findings may not be generalizable to other populations and other healthcare systems because some issues may be specific to multimorbid patients with type 2 diabetes or to the Swiss healthcare setting. Nevertheless, issues encountered by our participants regarding their medications correlate with findings in the literature. Fifth, only 15 out of 21 participants took part in all the interviews, but most participants took part in at least three interviews and data saturation was reached. Lastly, by its qualitative and longitudinal design, it is possible that the discussion during interviews and participants’ reflections between interviews influenced participants’ management, knowledge, and adherence, even though this study was observational, and no advice or recommendations were given by the interviewer during interviews.

Discharged patients are willing to take steps to better manage, understand, and adhere to their medications, yet they are also faced with difficulties in the hospital and outpatient care. Furthermore, extensive changes in medications not only occur during hospitalization but also during the two months following hospital discharge, for which healthcare professionals should give particular attention. The different degrees of patients’ involvement, needs and resources should be carefully considered to enable them to better manage, understand and adhere to their medications. At a system level, patients’ experiences revealed a lack of standardization of medication practices during the transition of care. The healthcare system should provide the ecosystem needed for healthcare professionals responsible for or involved in the management of patients’ medications during the hospital stay, discharge, and outpatient care to standardize their practices while considering the patient as an active partner.

Data availability

The anonymized quantitative survey datasets and the qualitative codes are available in French from the corresponding author on reasonable request.

Abbreviations

adverse drug events

Adherence Visual Analogue Scale

Belief in Medication Questionnaire

Consolidated Criteria for Reporting Qualitative Research

case report form

standard deviation

World Health Organization

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Acknowledgements

The authors would like to thank all the patients who took part in this study. We would also like to thank the Geneva University Hospitals Patients Partners + 3P platform as well as Mrs. Tourane Corbière and Mr. Joël Mermoud, patient partners, who reviewed interview guides for clarity and significance. We would like to thank Samuel Fabbi, Vitcoryavarman Koh, and Pierre Repiton for the transcriptions of the audio recordings.

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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LS, GG, and MS conceptualized and designed the study. LS and GG screened and recruited participants. LS conducted the interviews. LS, GG, and MS performed data analysis and interpretation. LS drafted the manuscript and LS and MS worked on the different versions. MS and GG approved the final manuscript.

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Solh Dost, L., Gastaldi, G. & Schneider, M. Patient medication management, understanding and adherence during the transition from hospital to outpatient care - a qualitative longitudinal study in polymorbid patients with type 2 diabetes. BMC Health Serv Res 24 , 620 (2024). https://doi.org/10.1186/s12913-024-10784-9

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Richard J. Shrot , Frances M. Sahebzamani , H. James Brownlee; Case Study: Screening and Treatment of Pre-Diabetes in Primary Care. Clin Diabetes 1 April 2004; 22 (2): 98–100. https://doi.org/10.2337/diaclin.22.2.98

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J.M., a 48-year-old Hispanic man, was seen in the primary care clinic for routine follow-up of hypertension, for which he had been treated for the past 8 years. His only medication was lisinopril, 20 mg/day. Home blood pressure monitoring averaged 128/82 mmHg. He had a family history for hypertension, type 2 diabetes, and coronary artery disease. J.M. reported a 20-lb weight gain over the past year, along with a sedentary lifestyle with no regular exercise routine. Other medical history was negative, including symptoms of fatigue, polyuria, or polydipsia. He denied past or current tobacco use.

J.M. presented with a waist size of 42 inches, BMI of 34 kg/m 2 , and blood pressure of 125/80 mmHg. A subsequent lipoprotein profile demonstrated the common pattern associated with pre-diabetes, including a low HDL cholesterol (30 mg/dl) and a high triglyceride level (185 mg/dl). The LDL was mildly elevated (132 mg/dl), and total cholesterol was 199 mg/dl. His fasting glucose was 111 mg/dl, with a repeat value of 115 mg/dl one week later.

Does this patient have pre-diabetes?

When should patients be screened for pre-diabetes?

How should pre-diabetes be treated in primary care settings?

Type 2 diabetes is a significant cause of death, disability, and health care burden in the United States, affecting an estimated 16 million Americans. A prodromal phase of this disease, in which patients manifest impaired glucose metabolism, has recently been identified as “pre-diabetes” by the U.S. Secretary of Health and Human Services. 1 Pre-diabetes is also a major health care burden estimated to affect at least an additional 16 million Americans, 2 and possibly as many as 43 million with the new criteria for impaired fasting glucose (IFG) being reduced to 100 mg/dl. 3 Pre-diabetes is highly associated with concomitant cardiovascular risk factors and has been found to confer an increased risk of cardiovascular complications including myocardial infarction, stroke, and death. 1  

Pre-diabetes is clinically defined by either an IFG between 100 and 125 mg/dl or by a 2-hour oral glucose tolerance test (OGTT) result of 140–199 mg/dl, indicating impaired glucose tolerance (IGT), or both 4 ( Table 1 ). The normal fasting glucose level was recently adjusted downward from 110 to 100 mg/dl, after analysis by the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. 5 (This report is reprinted in full in this issue starting on p. 71 .) The committee recognized that IGT was more common in most populations by the older criteria. Lowering the impaired fasting level to 100 mg/dl should make the predictive value of future diabetes more concordant, regardless of whether IFG or IGT is used.

With the favorable results of the Diabetes Prevention Program for Type 2 Diabetes (DPP) published in 2002, 6 a recent position statement of the American Diabetes Association proposes screening recommendations for pre-diabetes to be done as part of a health care visit and suggests screening in individuals age ≥ 45 years, especially those who are overweight (BMI ≥ 25 kg/m 2 ) 1 ( Table 2 ). Screening should also be considered in individuals who are < 45 years old and overweight in the presence of other risk factors, such as a first-degree relative with diabetes, history of gestational diabetes, high-risk ethnicity, hypertension, or dyslipidemia. Asian Americans may be screened at a lower BMI (≥ 23 kg/m 2 ).

Based on these screening recommendations, J.M. was a candidate for screening with age, ethnicity, BMI, dyslipidemia, family history, sedentary lifestyle, and hypertension as prevailing risk factors. His low HDL, high triglyceride level, waist circumference, and hypertension made him a likely candidate for the diagnosis of pre-diabetes. These four risk factors, along with impairment of glucose tolerance, were established as clinical markers for insulin resistance by the National Cholesterol Education Program, Adult Treatment Panel III, and are used to confirm a diagnosis of the metabolic syndrome 7 ( Table 3 ).

J.M.’s fasting glucose results of 111 and 115 mg/dl confirmed the diagnosis of pre-diabetes. To exclude a diagnosis of diabetes, a 2-hour OGTT was ordered. Its result of 173 mg/dl indicated that J.M. had IGT in addition to IFG. A recent analysis of glucose progression over several decades in the Baltimore Longitudinal Study of Aging suggests that IFG and IGT may represent different phenotypes in the natural history of progression to type 2 diabetes. 8 This suggestion, however, was based on the older definition of IFG.

The results of recent clinical trials to prevent or delay progression to type 2 diabetes demonstrate the benefit of identifying patients at risk and implementing early aggressive intervention. Although intensive lifestyle and selected pharmacological interventions have demonstrated effective outcomes in preventing or delaying progression to diabetes, many questions, including that of cost-effectiveness, persist in the translation of these interventions into primary care settings. Based on the DPP and the Finnish study, 9 successful treatment of pre-diabetes requires thorough patient education, counseling, and support in lifestyle changes targeting a 5–7% reduction in total body weight and an exercise goal of 150 minutes/week. J.M. was provided with the necessary counseling for dietary intervention, and, following a pre-exercise treadmill stress test, a titrated exercise program was initiated.

Aggressive management of J.M.’s comorbidities may also help slow progression to diabetes. Studies of selected angiotensin-converting enzyme inhibitors (ramipril) and statins (pravastatin) have suggested that these drugs may delay the progression of pre-diabetes to diabetes. 10 , 11 Results of studies such as the Diabetes Reduction Assessment with Ramipril and Rosiglitazone Medications (DREAM) trial are needed to confirm these findings. J.M.’s blood pressure was well controlled with lisinopril, 20 mg/day. A statin was added to treat his dyslipidemia. Both of these interventions may help to delay the progression to diabetes. Aspirin therapy was initiated to reduce cardiovascular risk.

The use of the insulin sensitizers—metformin and the thiazolidinediones (TZDs)—has been shown to be beneficial in delaying the progression from pre-diabetes to diabetes. 6 , 12 In the DPP, metformin, 850 mg twice daily, reduced the relative risk of progression to type 2 diabetes by 31%. Metformin may additionally improve outcomes by inducing weight loss. Although conducted in women with a history of gestational diabetes, the Troglitazone in the Prevention of Diabetes (TRIPOD) study demonstrated a 56% reduction in relative risk in progression of pre-diabetes to diabetes. Although treatment was discontinued because of the withdrawal of troglitazone from the U.S. market, persistent protective treatment effects were observed more than 8 months after discontinuation. Long-term clinical trial data are not yet available for the newer TZDs, but there is a reasonable expectation that the currently available medications in this drug class may provide similar benefits. Until further clinical trial data become available, clinician judgment–based individualized patient characteristics will determine the use of insulin sensitizers in pre-diabetes. However, lifestyle modifications are first-line treatment for pre-diabetes ( Table 4 ).

J.M. met with a dietitian and a physical therapist for initial instruction. Brisk walking was the starting baseline exercise for 30 minutes each day, 5 days per week, with the use of a pedometer to measure distances. Calorie counting and knowledge of healthy choices from the food pyramid were discussed, but the intensive case management approach, as used in the DPP, was not possible because of insurance reimbursement issues and a lack of availability of individual case managers.

After a 6-month trial of diet and exercise, J.M. was only able to exercise for 20 minutes or less each week, had gained 7 lb, and had an increase in fasting glucose to 117 mg/dl. Although not approved by the Food and Drug Administration for this indication or recommended by the American Diabetes Association, metformin remains an alternative.

Pre-diabetes is diagnosed by a fasting glucose between 100 and 125 mg/dl (IFG) or a 2-hour OGTT result between 140 and 199 mg/dl (IGT), or both, confirmed.

The onset of type 2 diabetes can be prevented or delayed.

Screening for pre-diabetes should be considered for patients at age 45 years, especially for overweight or obese patients, and earlier for patients with a BMI of 25 kg/m 2 or more with additional risk factors such as hypertension or dyslipidemia.

A dyslipidemic pattern of low HDL cholesterol and high triglycerides, in addition to hypertension and large waist size, are clinical markers for insulin resistance and impaired glucose metabolism.

Aggressive management of concomitant comorbidities, such as hypertension and dyslipidemia, may delay progression of pre-diabetes to diabetes.

Aggressive lifestyle modification has delayed the progression of diabetes by about 60%, while medications such as metformin have reduced progression by about 30%.

Efforts should be made to secure insurance reimbursement for intensive lifestyle modification, including classes and case managers such as those used in the DPP.

Definition of Pre-Diabetes

Routine Screening Recommendations for Pre-Diabetes

Definition of Metabolic Syndrome from National Cholesterol Education Program Adult Treatment Panel III

Successful Treatment of Pre-Diabetes

Richard J. Schrot, MD, CDE, is an associate professor, Frances M. Sahebzamani, PhD, ARNP, is an assistant professor, and H. James Brownlee, Jr., MD, is a professor and chairman in the Department of Family Medicine at the University of South Florida (USF) School of Medicine in Tampa, Fla. Dr. Schrot is a member of the research working group, and Dr. Sahebzamani and Dr. Brownlee are co-directors of the USF Pre-Diabetes Treatment and Research Center. Dr. Schrot has been director of the Ambulatory Care Diabetes Clinic at the James A. Haley VA Hospital in Tampa, Fla.

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Metformin Use and Age-Related Macular Degeneration in Patients Without Diabetes

• 1 Pritzker School of Medicine, University of Chicago, Chicago, Illinois
• 2 The Center for Health and the Social Sciences, University of Chicago, Chicago, Illinois
• 3 Department of Ophthalmology and Visual Science, University of Chicago, Chicago, Illinois

Question   Is there an association between the use of metformin and protection against the development of age-related macular degeneration (AMD) among patients without diabetes?

Findings   In this case-control study of 231 142 cases with AMD and 232 879 matched controls, none of whom had a diagnosis of diabetes, metformin use was associated with 17% lower odds of AMD development. This association was not dose dependent.

Meaning   Findings of this study suggest that metformin may be useful as a therapeutic tool for protection against AMD development in patients without diabetes.

Importance   Metformin use may protect against the development of age-related macular degeneration (AMD) based on results from observational studies. However, its potential effectiveness among patients without diabetes remains unclear.

Objective   To assess the association between metformin use and the development of AMD in patients without diabetes.

Design, Setting, and Participants   This case-control study used data from 2006 to 2017 in the Merative MarketScan Research Database, a nationwide insurance claims database that includes between 27 and 57 million patients in the US with primary or Medicare supplemental health insurance. Cases with AMD and controls without AMD aged 55 years or older were matched 1:1 by year, age, anemia, hypertension, region, and Charlson Comorbidity Index score. Then, cases and matched controls without a diagnosis of diabetes were selected. In subgroup analyses, cases with dry AMD and their matched controls were identified to explore the association between metformin use and AMD staging in patients without diabetes. Data were analyzed between March and September 2023.

Exposures   Exposure to metformin in the 2 years prior to the index date (ie, date of AMD diagnosis in cases and date of a randomly selected eye examination for controls) was assessed from the claims database and categorized into quartiles based on cumulative dose (1-270, 271-600, 601-1080, and >1080 g/2 y). Exposure to other antidiabetic medications was also noted.

Main Outcomes and Measures   Odds of new-onset AMD development as assessed by multivariable conditional logistic regression after adjusting for known risk factors for AMD, including female sex, hyperlipidemia, smoking, and exposures to other antidiabetic medications. Asymptotic Cochran-Armitage tests for trend were also performed.

Results   We identified 231 142 patients with any AMD (mean [SD] age, 75.1 [10.4] years; 140 172 females [60.6%]) and 232 879 matched controls without AMD (mean [SD] age, 74.9 [10.5] years; 133 670 females [57.4%]), none of whom had a diagnosis of diabetes. The sample included 144 147 cases with dry AMD that were matched to 144 530 controls. In all, 2268 (1.0%) cases and 3087 controls (1.3%) were exposed to metformin in the 2 years before their index visit. After data adjustment, exposure to any metformin was associated with reduced odds of any AMD development (adjusted odds ratio [AOR], 0.83; 95% CI, 0.74-0.87), specifically in the dosing quartiles of 1 to 270, 271 to 600, and 601 to 1080 g/2 y. Any metformin use was also associated with a reduced odds of developing dry AMD (AOR, 0.85; 95% CI, 0.79-0.92), specifically in the dosing quartiles of 1 to 270 and 271 to 600 g/2 y. Adjusted odds ratios for any AMD and dry AMD development did not differ across the dosing quartiles. Asymptotic Cochran-Armitage tests for trend revealed 2-sided P  = .51 and P  = .66 for the any and dry AMD samples, respectively.

Conclusions and Relevance   In this case-control study of a population without a diagnosis of diabetes, metformin use was associated with reduced odds of developing AMD. This association does not appear to be dose dependent. These findings provide further impetus to study metformin’s usefulness in protecting against AMD in prospective clinical trials.

Read More About

Aggarwal S , Moir J , Hyman MJ, et al. Metformin Use and Age-Related Macular Degeneration in Patients Without Diabetes. JAMA Ophthalmol. 2024;142(1):53–57. doi:10.1001/jamaophthalmol.2023.5478

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