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"textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Approximately 1 of every 5 patients admitted to internal medicine departments present diabetes mellitus as a secondary diagnosis.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">1</span></a> The most common causes for the hospitalization of patients with diabetes are decompensations of cardiovascular and respiratory diseases, as well as the presence of infectious processes. Currently, hospitalizations directly related to defects in glycemic control represent less than 5%. Most patients with diabetes hospitalized in internal medicine departments are adequately treated by internal medicine specialists who follow the recommendations of the clinical practice guidelines.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">2</span></a> These guidelines recommend measuring HbA1c in all patients with diabetes or with blood glucose values at admission >140<span class="elsevierStyleHsp" style=""></span>mg/dL, administering insulin to treat hyperglycemia (glucose levels >180<span class="elsevierStyleHsp" style=""></span>mg/dL), setting a glucose control objective of 140–180<span class="elsevierStyleHsp" style=""></span>mg/dL, using insulin in a basal-bolus regimen, avoiding the administration of insulin in a sliding-scale regimen, employing a hypoglycemia treatment protocol (blood glucose level ≤70<span class="elsevierStyleHsp" style=""></span>mg/dL) and properly planning for the patient at the time of discharge.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The transition of the hospitalized patient with diabetes mellitus at discharge is a key aspect that should be individualized. Depending on the patient's circumstances, they may be discharged to their home, to a home hospitalization unit or to a nursing home. In all cases, the patient's transition should consider the type and severity of the diabetes, the effects of the current disease on blood glucose levels and the patient's abilities and wishes. The American Diabetes Association recommends that patients have an appointment with primary care 30 days after the discharge. If there have been changes in the medication or if the glycemic control is not as desired, the appointment should be conducted 10–15 days after the discharge. In the United States, the Agency for Healthcare Research and Quality recommends that the discharge report should at least contain a reconciliation of the medication and a structured communication plan.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a> A consensus document was developed in Spain by 4 scientific societies (Spanish Society of Diabetes, Spanish Society of Internal Medicine, Spanish Society of Family and Community Medicine and Spanish Society of Primary Care Physicians) that includes recommendations on the transition from hospitalization to discharge (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">5</span></a> The document lists 9 directives directed at reducing the risks of hypoglycemia, hospital readmission and complications, especially for polypathological and polymedicated patients, as usually occurs for many patients with diabetes. To date, no study has evaluated the degree of adherence to the recommendations and their impact on clinically relevant outcomes.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The quasi-experimental (preintervention and postintervention) study conducted by Pérez et al. showed the results of an intervention aimed at improving basic aspects in the care and treatment of patients with diabetes during hospitalization and at discharge.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">6</span></a> The intervention was based on the recommendations of the multidisciplinary consensus document.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">5</span></a> The study's main objective was to demonstrate that adherence to the recommendations was associated with a reduction in HbA1c values at 3 months of follow-up. The patients included in the study had a mean age of 68 years, approximately 50% had cardiovascular disease, and 33% had chronic kidney disease. Upon entering the study, the mean HbA1c level preintervention and postintervention was 8.2% and 8.3%, respectively, for the 2 groups. The study showed greater adherence to the recommendations in the postintervention group regarding diet, exercise, diabetes education, self-monitoring of glucose levels and the description of the specifications for the follow-up visit. Among the evaluated outcomes, there was a significant reduction in HbA1c values by the end of the study, with final values similar in the 2 groups (7.3 vs. 7.2%) preintervention and postintervention. In terms of the other outcomes, there were no differences in the incidence of insulin use, hypoglycemia or hospital readmission between the two groups. The authors recognized that the study limitations included the participation of the same researchers in the groups preintervention and postintervention, the short follow-up and the presence of a Hawthorne effect due to the mere act of observation.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">7</span></a> The benefits of the intervention might have been observed if the study had included a population with a higher risk. It is well known that patients aged 80 or more years, who are undergoing insulin therapy have a 5-fold greater risk of hospitalization for hypoglycemia than patients between 45 and 64 years of age. The proportion of patients who used insulin after the discharge in the study by Pérez et al. was approximately 55–60%. It is also apparent that the number of comorbidities and polypharmacy increase with age, thereby making medication reconciliation more complex. Medication reconciliation is a process that takes 15–20<span class="elsevierStyleHsp" style=""></span>min per patient and therefore is a significant barrier in complying with the objectives.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">8</span></a> An important area of study would be determining the impact on emergency department visits and hospitalization of the reconciliation of other risk drugs (such as anticoagulants and opioids) that are frequently administered to patients with diabetes.</p></span>"
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"leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Abbreviations: HbA1c, glycated hemoglobin; MDRD, Modification of Diet in Renal Disease.</p>"
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\t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1. HbA1c reading during the hospitalization \t\t\t\t\t\t\n
\t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2. Includes the renal function at discharge (MDRD) \t\t\t\t\t\t\n
\t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3. Patient's clinical situation at discharge and predicted outcome \t\t\t\t\t\t\n
\t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4. Sets the objectives for blood glucose (HbA1c and glycemia) and for other risk factors (lipids, blood pressure, tobacco use and weight reduction) \t\t\t\t\t\t\n
\t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5. Specifies the level of diabetes education and the needs that still need covering \t\t\t\t\t\t\n
\t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">6. Includes individual recommendations on diet and exercise \t\t\t\t\t\t\n
\t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">7. Indicates the changes made in the treatment and their rationale \t\t\t\t\t\t\n
\t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">8. Specifies the indication and frequency of blood glucose checks \t\t\t\t\t\t\n
\t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">9. Defines the follow-up needs: review period and care level (primary, specialized) \t\t\t\t\t\t\n
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