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Objective: To compare a modified fixed meal dosing strategy to flexible meal dosing in hospitalized patients with type 2 diabetes., Research Design and Methods: Patients (N = 126) with refractory hyperglycemia or requiring at least 20 units of insulin per day were randomly assigned to fixed meal dosing (including withholding the dose if less than half of the meal tray was consumed) or flexible meal dosing based upon carbohydrate intake. The inpatient diabetes management team made all treatment adjustments. Outcomes included day 3 mean glucose, 72-h glucose trend analysis, hypoglycemia (<3.9 mmol/L), and inpatient diabetes treatment satisfaction., Results: The mean glucose on day 3 was 9.5 and 8.8 mmol/L in the fixed and flexible meal groups, respectively (P = 0.26). The frequency of hypoglycemia was 23 and 39% overall in the fixed and flexible meal groups (P = 0.08), with half of events occurring in the morning. There was a wide range of carbohydrate intake (median 51 g/meal, 10-90% range 26-72 g on day 3). The fixed dose group required significantly more prandial insulin overall and more correction insulin over time. There was no difference in composite treatment satisfaction or dosing miscalculations between groups., Conclusions: A fixed meal dosing strategy provided similar glucose control as flexible meal dosing, when managed by an inpatient diabetes treatment team. However, a larger sample size would be needed to definitively evaluate a treatment effect of flexible meal dosing in the hospital. Further study is needed to improve the delivery of bolus insulin in hospitalized patients.

Objective: To explore the relationship between inpatient diabetes education (IDE) and hospital readmissions in patients with poorly controlled diabetes., Research Design and Methods: Patients with a discharge diagnosis of diabetes (ICD-9 code 250.x) and HbA1c>9% who were hospitalized between 2008 and 2010 were retrospectively identified. All-cause first readmissions were determined within 30 days and 180 days after discharge. IDE was conducted by a certified diabetes educator or trainee. Relationships between IDE and hospital readmission were analyzed with stepwise backward logistic regression models., Results: In all, 2,265 patients were included in the 30-day analysis and 2,069 patients were included in the 180-day analysis. Patients who received IDE had a lower frequency of readmission within 30 days than did those who did not (11 vs. 16%; P=0.0001). This relationship persisted after adjustment for sociodemographic and illness-related factors (odds ratio 0.66 [95% CI 0.51-0.85]; P=0.001). Medicaid insurance and longer stay were also independent predictors in this model. IDE was also associated with reduced readmissions within 180 days, although the relationship was attenuated. In the final 180-day model, no IDE, African American race, Medicaid or Medicare insurance, longer stay, and lower HbA1c were independently associated with increased hospital readmission. Further analysis determined that higher HbA1c was associated with lower frequency of readmission only among patients who received a diabetes education consult., Conclusions: Formal IDE was independently associated with a lower frequency of all-cause hospital readmission within 30 days; this relationship was attenuated by 180 days. Prospective studies are needed to confirm this association.