Indicator performance after the implementation of the Spanish Consensus Document for the control of hyperglycemia in the hospital and at discharge

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"apellidos" => "Gómez-Huelgas" "email" => array:1 [ 0 => "ricardogomezhuelgas@hotmail.com" ] "referencia" => array:4 [ 0 => array:2 [ "etiqueta" => "f" "identificador" => "aff0030" ] 1 => array:2 [ "etiqueta" => "g" "identificador" => "aff0035" ] 2 => array:2 [ "etiqueta" => "h" "identificador" => "aff0040" ] 3 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 5 => array:1 [ "colaborador" => "on behalf of Grupo de estudio AL ALTA" ] ] "afiliaciones" => array:8 [ 0 => array:3 [ "entidad" => "Servicio de Endocrinología y Nutrición, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Medicina, Universitat Autònoma de Barcelona (UAB), Campus de la UAB, Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Diabetes y Enfermedades Metabólicas CIBER (CIBERDEM), Barcelona, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital Gutiérrez Ortega, Valdepeñas, Ciudad Real, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital Clínico San Carlos, Madrid, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital Regional Universitario de Málaga, Málaga, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] 6 => array:3 [ "entidad" => "Instituto de Investigación Biomédica de Málaga (IBIMA)" "etiqueta" => "g" "identificador" => "aff0035" ] 7 => array:3 [ "entidad" => "CIBER Fisiopatología de la Obesidad y Nutrición (CIBEROBN), Instituto Carlos III, Madrid, Spain" "etiqueta" => "h" "identificador" => "aff0040" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Rendimiento de los indicadores tras la implementación del Documento de consenso español para el control de la hiperglucemia en el hospital y al alta" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2094 "Ancho" => 1203 "Tamanyo" => 192142 ] ] "descripcion" => array:1 [ "en" => "Progression of antidiabetic therapy from hospital discharge to the third month after discharge in the prospective and retrospective groups. Patients discharged with insulin with or without ODDs (A), only with ODDs (B), and with insulin plus ODDs (C). Abbreviation: ODDs, oral diabetes drugs." ] ] ] "textoCompleto" => "BackgroundPatients with diabetes have a considerably high rate of hospitalization due to causes related to the disease itself.<a class="elsevierStyleCrossRefs" href="#bib0125">1–3</a> The most common problems among hospitalized patients are hyperglycemia due to decompensated diabetes mellitus, undiagnosed diabetes and hospital hyperglycemia,<a class="elsevierStyleCrossRef" href="#bib0140">4</a> which are often linked to mediocre results.<a class="elsevierStyleCrossRefs" href="#bib0145">5–7</a> Improved glycemic control, however, translates into reduced morbidity and mortality.<a class="elsevierStyleCrossRefs" href="#bib0160">8–10</a>The patient's transition from hospital to outpatient is a vulnerable period, especially for patients with diabetes, during which there is the risk of treatment abandonment and adverse events.<a class="elsevierStyleCrossRef" href="#bib0175">11</a> Accordingly, proper planning of the hospital discharge should be part of these patients’ comprehensive management<a class="elsevierStyleCrossRefs" href="#bib0180">12–14</a>; however, the available information on strategies for hospital discharges in diabetes is scarce.<a class="elsevierStyleCrossRefs" href="#bib0195">15,16</a>In 2012, Spain adapted the general recommendations of 12 national scientific societies, supported by the National Patients Forum of Spain,<a class="elsevierStyleCrossRef" href="#bib0180">12</a> to the specific needs of hospitalized patients with diabetes.<a class="elsevierStyleCrossRef" href="#bib0205">17</a> This document provided individual guidelines directed at therapeutic reconciliation, taking into account the etiology of hyperglycemia, the previous antidiabetic treatments, the patient's clinical condition and degree of glycemic control, glucose monitoring, diabetes education and follow-up after the hospital discharge. The aim of the AL ALTA (Spanish for “at discharge”) study was to assess the impact of implementing the recommendations of the Spanish consensus document for managing the hospital discharge of patients with type 2 diabetes (DM2) or hyperglycemia during hospitalization.Materials and methodsStudy designAL ALTA is a prospective, observational and multicenter study conducted by the internal medicine departments of 19 hospitals in Spain. Following an initial training session (October 2013) on the Spanish consensus document,<a class="elsevierStyleCrossRef" href="#bib0205">17</a> we proceeded to prospectively collect data for the following events: hospital admission, hospital discharge and 3 months after the discharge. For the retrospective group, the data collection was performed retrospectively based on prior medical records from the same hospitals and from the same events. To ensure the study's observational nature, the data was collected before the diagnosis or treatment, provided the data was included in the patient's medical history or when the data could be obtained during the interview visit.The study was conducted in accordance with the Declaration of Helsinki, including all of its amendments, and was approved by the pertinent independent research ethics committee. All patients gave their written informed consent for use of their data prior to admission to the study.Study populationThe design of this study included 2patient groups (prospective and retrospective), with a ratio of 2:1. The prospective group included men and women with noncritical disease, between the ages of 18 and 80 years, with DM2 or hyperglycemia (blood glucose levels>140mg/dL) undergoing treatment in a basal-bolus-correction insulin or basal-correction insulin regimen during the hospitalization period. We predicted a hospital stay of at least 5 days in a hemodynamically stable condition and planned a follow-up of 3 months after the discharge. The main exclusion criteria were other types of diabetes (e.g., type 1 diabetes, latent autoimmune diabetes in adults and pancreatic diabetes), drug addiction, alcoholism, hospitalization for diabetic ketoacidosis or hyperosmolar hyperglycemic syndrome, critical disease and any psychiatric or neurological disorder that could interfere with the follow-up. For the retrospective group, the selection criteria were the same as for the prospective group, with the addition of having been hospital discharged before the start of the study.Study proceduresThe primary objective of the AL ALTA study was to assess the effect of applying the recommendations of the Spanish consensus document<a class="elsevierStyleCrossRef" href="#bib0205">17</a> for managing the hospital discharge of patients with DM2 or hyperglycemia during the hospitalization in terms of changes experienced in HbA1c levels, from hospital admission (start) to 3 months after the discharge. The study also analyzed the change during this period in the number of hypoglycemic (<70mg/dL), severe hypoglycemic (<40mg/dL) and hyperglycemic (>250mg/dL) events, as well as the number of emergency department and hospital readmissions and the number of complications that occurred during the 3-month follow-up period after the discharge.Other secondary endpoints were (1) changes in the antidiabetic therapy occurring during the admission-to-discharge and discharge-to-3 months (of follow-up) periods, considering the proportion of patients undergoing therapy with insulin, oral diabetes drugs (ODDs) and insulin plus ODDs and (2) quality indicators in the discharge report, including diet and exercise recommendations, patient condition at discharge, expected clinical progress, diabetes education, frequency of glucose monitoring and other specifications to consider for the next follow-up visit.Statistical analysisBased on the HOSMIDIA study,<a class="elsevierStyleCrossRef" href="#bib0195">15</a> the sample size needed to achieve an expected reduction of 0.7% in HbA1c levels is 200 individuals for the prospective group and 100 for the control group, for a ratio of 2:1, plus 10% for incomplete or inconsistent data.In the descriptive statistical analysis of the quantitative variables, we employed measures of central tendency and dispersion (mean, median, standard deviation [SD] and 95% confidence interval [CI]). For the qualitative variables, we used valid frequencies and percentages.The study of the statistically significant differences between the quantitative variables was conducted using the Mann–Whitney-Wilcoxon test for the continuous variables and with the chi-squared test (or Fischer's exact test) for the discrete variables.For the endpoints directed at assessing changes in therapy, from the moment prior to hospitalization to the follow-up visit in month 3, we created contingency tables and employed McNemar's test. For this analysis, we created 2groups: patients with an HbA1c level>7.5% and patients with an HbA1c level<7.5%. In the analysis, we did not consider the lost data and set the level of significance to a p-value<.05. All statistical analyses were conducted using the Statistical Package for the Social Sciences (SPSS) version 22.0.ResultsStudy participantsThe study included 276 individuals between November 2013 and February 2015, 2 of whom were excluded for screening failures. The study population therefore consisted of 274 patients with diabetes (199 in the prospective group and 75 in the retrospective group). The initial clinical characteristics are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. There were no significant differences between the groups in terms of sex, age, body mass index, HbA1c or duration of hospital stay.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Quality indicators in the discharge reportThe degree of adherence to the recommendations of the Spanish consensus document, measured by means of the quality indicators in the hospital discharge reports, was greater in the prospective group (p<.001), except in terms of the expected clinical progression after discharge (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Treatment of diabetesThere was a significant change in the prospective group in the antidiabetic therapy between the hospital admission and discharge between the patients with HbA1c levels<7.5% (p<.005) and the patients with HbA1c levels≥7.5% (p<.001). In the retrospective group, in contrast, this change was only significant in the patients with HbA1c levels≥7.5% (p<.001) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The changes in antidiabetic therapy during the period from hospital discharge to month 3 of the follow-up were only significant in the prospective group (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).<elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia>At discharge, 197 patients (71.9%) were treated with insulin (72.9% vs. 69.3% for the prospective and retrospective groups, respectively; p=.651) and 203 (74.1%) were treated with ODDs (74.4% vs. 73.3%, respectively; p=.878). The most commonly prescribed ODDs were metformin (77% vs. 72.7% for the prospective and retrospective groups, respectively; p=.525), dipeptidyl peptidase-4 inhibitors (53.4% vs. 45.5%, respectively; p=.315) and sulfonylureas (10.1% vs. 9.1%, respectively; p=.824). At month 3 after discharge, 175 individuals (67.8%) were treated with insulin (66.7% vs. 70.7% for the prospective and retrospective groups, respectively; p=.561), and 208 (80.6%) were treated with ODDs, mainly metformin (76.5% vs. 78%, respectively; p=.822) and dipeptidyl peptidase-4 inhibitors (55.7% vs. 49.2%, respectively; p=.393).Glycemic controlThree months after the hospital discharge, there was a statistically significant reduction in the mean HbA1c levels, both in the prospective group (8.2±1.9% to 7.3±0.2%; p<.001) and retrospective group (8.3±1.5% to 7.2±1.2%; p<.001) (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).<elsevierMultimedia ident="fig0015"></elsevierMultimedia>In terms of mean blood glucose levels, there was a reduction from discharge to month 3 of follow-up in the prospective cohort (174.3±49.3 vs. 147.3±33.8mg/dL; p=.028) but not in the retrospective group (153.8±32.8 vs. 153.8±25.9mg/dL; p=.119).SafetyA total of 65 patients (25.2%) experienced hypoglycemic crises during the 3 months after discharge, with no differences between the 2study cohorts (26.2% vs. 22.7% for the prospective and retrospective groups, respectively; p=.637). The mean number of hypoglycemic crises for the entire study population during the 3-month follow-up period was 3.0±3.0. Severe hypoglycemic events were reported in 2.2% of the prospective group and 4.0% of the retrospective group (p=.418). There were no differences in the mean number of severe cases between the groups (1.0±0.0 vs. 1.7±0.6 for the prospective and retrospective groups, respectively; p=.229). The frequency of hyperglycemic crises was similar in the 2 groups (28.4% vs. 31.1% for the prospective and retrospective groups, respectively; p=.762).In all, 49 patients (19.0%) were readmitted, mainly in the emergency departments (71.8%), with no differences between the groups (p=.729). The main cause for emergency department readmission was respiratory infection; only 2patients were treated for hypoglycemia, and 1 was treated for hyperglycemia. These 3patients were part of the retrospective group.DiscussionThis observational prospective multicenter study sought to assess the impact of implementing the recommendations of the Spanish consensus document for managing the hospital discharge of individuals with DM2 or hyperglycemia during hospitalization. Our study shows that implementing these recommendations significantly improved the registration of the quality indicators in the discharge report and in the therapeutic reconciliation at the time of discharge. The implementation also improved glycemic control at 3 months after the hospital discharge, if we consider the previous antidiabetic therapy, clinical condition and degree of glycemic control. This improvement appears to be independent of the quality indicators included in the discharge report.A systematic Cochrane review revealed that a structured discharge plan adapted to the patient can reduce the length of the hospital stay and readmission rates and can increase patient satisfaction.<a class="elsevierStyleCrossRef" href="#bib0210">18</a> However, the hospital discharge procedure is not generic and should consider all aspects related to the patient's social and health needs. The Spanish consensus document for managing the hospital discharge of patients with DM2 or hyperglycemia focuses specifically on those aspects of diabetes care that should be considered in the discharge and include therapeutic reconciliation, patient education, follow-up assessments and the range of quality indicators of the discharge.<a class="elsevierStyleCrossRef" href="#bib0205">17</a> In this study, we assessed the impact of implementing these recommendations and their efficacy in terms of glycemic control and readmission after the discharge. Providing information on the cause of the hyperglycemia, the expected progression and recommended antidiabetic therapies can help those responsible for primary care to understand the continuity of care after the hospital discharge. Conversely, a lack of communication in the discharge process can lead to medical errors and deficient glycemic control.<a class="elsevierStyleCrossRef" href="#bib0215">19</a> The discharge report is the main form of communication between the hospital care team and those responsible for post-treatment care; thus, the importance of this document. In our study, the key information in the discharge report (quality indicators) related to the therapy (diet, exercise, education and glucose monitoring) and the subsequent follow-up after discharge were improved. However, based on a previous study,<a class="elsevierStyleCrossRef" href="#bib0220">20</a> the influence of this improvement in the discharge report values in our study appears to be limited. We found a similar improvement in the data regarding glycemic control, episodes of hypoglycemia/hyperglycemia and hospital readmission rates among the prospective and retrospective groups. Nevertheless, our findings are consistent with the lack of correlation observed between the readmission rates and the quality of the directives on the discharge report for patients with heart failure.<a class="elsevierStyleCrossRef" href="#bib0210">18</a>Accurate therapeutic reconciliation is a critical element in the success of the transition after the discharge; most studies have shown that its efficacy reduces the adverse effects of the drugs.<a class="elsevierStyleCrossRef" href="#bib0145">5</a> In terms of the reconciliation's influence on emergency department visits and readmissions after discharge, the evidence is still inconclusive.<a class="elsevierStyleCrossRef" href="#bib0225">21</a> There is evidence that patients with diabetes have clinical inertia toward intensifying the treatments at the time of discharge. In a retrospective study of 1359 elderly patients with diabetes and HbA1c levels >8.0% (median, 8.7%), only 22.4% of the patients changed their diabetes medication at discharge, and almost a third did not change the treatment or the subsequent follow-up regimen.<a class="elsevierStyleCrossRef" href="#bib0225">21</a> As with previous studies,<a class="elsevierStyleCrossRefs" href="#bib0195">15,16</a> the most common change in our study (in both groups) in treatment from admission to discharge was the addition of basal insulin, especially in patients with an HbA1c level >7.5%. The changes in antidiabetic therapy performed in the retrospective group suggest that the therapy had already been reconciled adequately before the first training session. Although maintaining the treatment established at the discharge during the 3-month follow-up reinforces the therapeutic reconciliation strategy, an interesting aspect of our study on the follow-up after the discharge was that the proportion of patients in the prospective group treated with insulin was reduced, while the proportion of patients with insulin plus ODD showed no significant changes. This temporary insulinization agrees with the strategy established in the Spanish consensus document for selecting the treatment at discharge, in the need for considering the patients’ clinical condition.<a class="elsevierStyleCrossRef" href="#bib0205">17</a> By implementing these therapeutic changes at discharge, glycemic control could be optimized in both groups, a result that would be confirmed and broadened by the findings of the few studies that have been interested in the hospital discharge of patients with diabetes.<a class="elsevierStyleCrossRefs" href="#bib0170">10,15,16</a> Umpierrez et al.<a class="elsevierStyleCrossRef" href="#bib0200">16</a> used a discharge algorithm based on HbA1c levels during hospitalization to adjust the treatment and observed that the mean HbA1c level decreased from 8.7% at admission to 7.3% 3 months after the discharge. In a prospective observational study conducted in 15 Spanish hospitals that also applied a simple therapeutic algorithm based on HbA1c levels during hospitalization, the mean HbA1c level decreased from 8.7% at admission to 7.6% 3 months after the discharge.<a class="elsevierStyleCrossRef" href="#bib0195">15</a> Lipska et al.<a class="elsevierStyleCrossRef" href="#bib0230">22</a> reported that omitting antidiabetic therapy at discharge was associated with increased mortality in the first year, more frequent hospitalizations and increased healthcare expenditures. Considering these data, the discharge program would improve adherence and results, as well as represent greater savings for the health system.Our study had a number of limitations when interpreting the results. Since this was an observational study, we cannot completely rule out some biases; however, the patient selection in each center was conducted by the same researcher. All researchers knew the importance of reducing the selection bias, and the patients’ clinical characteristics and inclusion criteria were similar in the 2 groups. Another limitation was the follow-up duration, which might have been too short to determine the long-term efficacy of implementing the Spanish consensus recommendations. We should also consider the Hawthorne effect, in which individuals can change their behavior due to the singular attention provided by the researcher, which could explain the improved results.<a class="elsevierStyleCrossRef" href="#bib0235">23</a> Finally, it is worth recognizing that our study's objective was not to compare the efficacy and safety of various antidiabetic therapies but rather to assess the impact of the general recommendations of the Spanish consensus document for improving glycemic control following hospital discharge. Given that the study was conducted with Spanish populations, these results are applicable to patients treated in internal medicine departments with similar characteristics.ConclusionsOur study indicated that implementing the recommendations of the Spanish consensus document for managing the hospital discharge of patients with DM2 or hyperglycemia dramatically improved the registration of quality indicators in the discharge report. The reconciliation of the antidiabetic medication at hospital discharge (taking into account the previous treatment for hyperglycemia, the patient's clinical condition and degree of glycemic control) improved the glycemic control after the hospital discharge.FundingThis study was financially supported by Sanofi-Aventis. The study sponsor did not participate in the data collection, analysis or interpretation of the results or in the preparation of the manuscript.AuthorshipAll authors collaborated in designing the study, recruiting patients, critically reviewing the content of the manuscript and participating in the final approval of the presented version.Conflicts of interestAPP has participated as a consultant for or has received lecture fees or travel reimbursement from Sanofi-Aventis, Esteve, GSK, Almirall, Novo Nordisk, Eli Lilly, MSD, Boehringer Ingelheim, Novartis, Menarini, Janssen and Astra Zeneca. RGH has participated as a consultant for or has received lecture fees or travel reimbursement from Sanofi-Aventis, Esteve, Novo Nordisk, Eli Lilly, MSD, Boehringer Ingelheim, Novartis, Menarini, Janssen and Astra Zeneca. APP and RGH, as study coordinators, were remunerated by Sanofi-Aventis. The other authors declare that they have no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:14 [ 0 => array:3 [ "identificador" => "xres1142538" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background and aims" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1073204" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1142539" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Antecedentes y objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1073203" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Background" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Materials and methods" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Study design" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Study population" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Study procedures" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Statistical analysis" ] ] ] 6 => array:3 [ "identificador" => "sec0035" "titulo" => "Results" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0040" "titulo" => "Study participants" ] 1 => array:2 [ "identificador" => "sec0045" "titulo" => "Quality indicators in the discharge report" ] 2 => array:2 [ "identificador" => "sec0050" "titulo" => "Treatment of diabetes" ] 3 => array:2 [ "identificador" => "sec0055" "titulo" => "Glycemic control" ] 4 => array:2 [ "identificador" => "sec0060" "titulo" => "Safety" ] ] ] 7 => array:2 [ "identificador" => "sec0065" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0070" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0075" "titulo" => "Funding" ] 10 => array:2 [ "identificador" => "sec0080" "titulo" => "Authorship" ] 11 => array:2 [ "identificador" => "sec0085" "titulo" => "Conflicts of interest" ] 12 => array:2 [ "identificador" => "xack389298" "titulo" => "Acknowledgements" ] 13 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-01-10" "fechaAceptado" => "2018-05-12" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1073204" "palabras" => array:6 [ 0 => "Hospital discharge" 1 => "Type 2 diabetes" 2 => "Hyperglycemia" 3 => "Medication reconciliation" 4 => "Quality indicators" 5 => "Glycaemic control" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1073203" "palabras" => array:6 [ 0 => "Alta hospitalaria" 1 => "Diabetes tipo 2" 2 => "Hiperglucemia" 3 => "Conciliación de medicamentos" 4 => "Indicadores de calidad" 5 => "Control glucémico" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "Background and aimsInformation for the adequate management of diabetic patients at hospital discharge is limited. We aimed to evaluate the impact of implementation of recommendations of the Spanish consensus for the management hospital discharge in patients with type 2 diabetes or hyperglycaemia during hospitalization. MethodsObservational multicentric study with a prospective and a retrospective colection of patients with type 2 diabetes/hyperglycaemia (>140mg/dl) during hospitalization from 19 Spanish hospitals. Quality indicators in discharge report, antidiabetic therapy, HbA1c and adverse events were gathered at hospital admission, hospital discharge and 3 month post-discharge. Results199 and 75 subjects in the prospective and retrospective group respectively were included. The indicators of quality in the hospital discharge reports was higher in the prospective group (p<.001). The proportion of patients with insulin, oral antidiabetic drugs (OADs), and insulin+OADs was modified at discharge in patients with HbA1c<7.5% (p<.005) and ≥7.5% (p<.001) in the prospective group and in patients with HbA 1c ≥7.5% (p<.001) in the retrospective group. At 3 month post-discharge HbA1c levels decreased from 8.2±1.9% to 7.3±1.2% (p<.001) in the prospective group, and from 8.3±1.5% to 7.2±1.2% (p<.001) in the retrospective group. Hypoglycaemic and hyperglycaemic episodes and hospital readmissions were similar in both groups. ConclusionsImplementation of Spanish consensus recommendations for the management of hospital discharge in patients with diabetes type 2 or hyperglycaemia considerably improved the registration of quality indicators in the discharge report. Reconciliation of antidiabetic medication at the time of hospital discharge, improves glycaemic control after hospital discharge." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background and aims" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "Antecedentes y objetivosLa información sobre el manejo de los pacientes diabéticos en el momento del alta hospitalaria es reducida. El objetivo del estudio fue evaluar el impacto de la implementación de las recomendaciones del Consenso español para el manejo del alta hospitalaria en pacientes con diabetes tipo 2 (DM2) o hiperglucemia durante la hospitalización. MétodosEstudio observacional con un grupo de recogida prospectiva y otra retrospectiva de pacientes con DM2/hiperglucemia (> 140mg/dl) durante la hospitalización de 19 hospitales españoles. Se recopilaron indicadores de calidad en el informe de alta, terapia hipoglucémica, HbA1c y eventos adversos al ingreso, en el momento del alta y a los 3 meses del alta. ResultadosSe incluyó a 199 pacientes en el grupo prospectivo y 75 en el retrospectivo. Los indicadores de calidad del informe de alta hospitalaria fueron mayores en el grupo prospectivo (p<0,001). La proporción de pacientes con tratamiento de insulina, fármacos antidiabéticos orales (ADO) e insulina+ADO sufrió modificaciones en el momento del alta hospitalaria de los pacientes del grupo prospectivo con HbA1c<7,5% (p<0,005) y ≥ 7,5% (p<0,001), y en los pacientes del grupo retrospectivo con HbA1c ≥ 7,5% (p<0,001). En el mes 3 tras el alta, los niveles de HbA1c descendieron de 8,2± 1,9% a 7,3±1,2% (p<0,001) en el grupo prospectivo y desde 8,2±1,9% a 7,3±1,2% (p<0,001) en el retrospectivo. Los episodios de hipoglucemia e hiperglucemia así como los de reingreso fueron semejantes en ambos grupos. ConclusionesLa aplicación del documento español de consenso de las recomendaciones para el manejo del alta hospitalaria en pacientes con DM2 o hiperglucemia mejora de forma considerable el registro de indicadores de calidad en el informe de alta. La conciliación de la medicación antidiabética en el momento del alta hospitalaria mejora el control glucémico después del alta." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Antecedentes y objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Pérez A, Ramos A, Reales P, Tobares N, Gómez-Huelgas R, en nombre del Grupo de estudio AL ALTA. Rendimiento de los indicadores tras la implementación del Documento de consenso español para el control de la hiperglucemia en el hospital y al alta. Rev Clin Esp. 2019;219:18–25." ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "Consenso sobre la diabetes en España." ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1837 "Ancho" => 2911 "Tamanyo" => 337384 ] ] "descripcion" => array:1 [ "en" => "Progression of the antidiabetic therapy from hospital admission to hospital discharge, stratified by groups plus HbA1c at admission: prospective group with HbA1c<7.5% (A), prospective group with HbA1c≥7.5% (B), retrospective group with HbA1c<7.5% (C), retrospective group with HbA1c≥7.5% (D)." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2094 "Ancho" => 1203 "Tamanyo" => 192142 ] ] "descripcion" => array:1 [ "en" => "Progression of antidiabetic therapy from hospital discharge to the third month after discharge in the prospective and retrospective groups. Patients discharged with insulin with or without ODDs (A), only with ODDs (B), and with insulin plus ODDs (C). Abbreviation: ODDs, oral diabetes drugs." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 992 "Ancho" => 2108 "Tamanyo" => 127356 ] ] "descripcion" => array:1 [ "en" => "Progression of the HbA1c values from the hospital admission to month 3 after discharge." ] ] 3 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "The data are presented either as the mean±SD or as the absolute number of individuals in each group and their percentage in parentheses, as necessary.Abbreviations: BMI, body mass index; HbA1c, glycated hemoglobin; SD, standard deviation." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Prospective group (n=199) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Retrospective group (n=75) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p-Value \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age, years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">68.7±9.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">68.3±10.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">.909 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">Sex</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Female \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">78 (39.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">29 (38.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">>.999 \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">Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">121 (60.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">46 (61.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">BMI, kg/m2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30.9±6.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30.7±5.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.933 \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">Previous diagnoses of diabetes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">175 (87.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">68 (90.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.525 \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">HbA1c during hospitalization, % \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.1±1.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.3±1.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.512 \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">HbA1c <7.5% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">79 (40.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">25 (34.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.357 \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">HbA1c ≥7.5% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">114 (59.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">47 (65.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">Medical history</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hypertension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">198 (99.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">63 (84.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">>.999 \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">Dyslipidemia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">135 (67.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">53 (70.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.417 \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">Cardiovascular disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">98 (49.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">37 (49.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">>.999 \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">Renal failure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">68 (34.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19 (25.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.191 \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">Obesity \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">95 (47.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33 (44.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.590 \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">Tobacco use \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30 (15.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 (20) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.345 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top">Reasons for hospital readmission<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a></td><td class="td" title="table-entry " align="char" valign="top">.378 \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">Cardiovascular disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17 (42.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (21.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \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">Infection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (20.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (14.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \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">Exacerbation of the underlying disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (12.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (28.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \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">Others \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 (25.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (35.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Treatment with glucocorticoids \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">63 (31.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">23 (30.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.875 \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">Hospital stay, days \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12.2±9.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15.9±42.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.584 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1949776.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "Total number of hospital readmissions 54 (40 in the prospective cohort and 14 in the control cohort), for a total of 49 patients." ] ] ] "descripcion" => array:1 [ "en" => "Clinical characteristics of the study population." ] ] 4 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "The data are shown as the total number of individuals in each group and their percentage between parentheses." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Indicator \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Prospective group (n=199) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Retrospective group (n=75) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Recommendation for the number of daily meals<a class="elsevierStyleCrossRef" href="#tblfn0010">*</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">173 (86.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">28 (37.3) \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">Exercise recommendation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">122 (61.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">23 (30.7) \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">Was the patient's clinical condition included at discharge?<a class="elsevierStyleCrossRef" href="#tblfn0010">*</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">143 (71.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30 (40.0) \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">Was the expected clinical progression included? \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">61 (30.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17 (22.7) \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">Diabetes education<a class="elsevierStyleCrossRef" href="#tblfn0010">*</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">172 (86.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">29 (38.7) \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">Was the frequency of glucose monitoring included?<a class="elsevierStyleCrossRef" href="#tblfn0010">*</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">165 (82.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">31 (41.3) \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">Were other specifications for the next follow-up visit included?<a class="elsevierStyleCrossRef" href="#tblfn0010">*</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">196 (98.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">51 (68.0) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1949775.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "*" "nota" => "p<.001." ] ] ] "descripcion" => array:1 [ "en" => "Quality indicators in the discharge report." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:23 [ 0 => array:3 [ "identificador" => "bib0125" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Increased hospital morbidity among trauma patients with diabetes mellitus compared with age- and injury severity score-matched control subjects" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "R. Ahmad" 1 => "R.A. Cherry" 2 => "I. Lendel" 3 => "D.T. Mauger" 4 => "S.L. Service" 5 => "L.J. Texter" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1001/archsurg.142.7.613" "Revista" => array:6 [ "tituloSerie" => "Arch Surg" "fecha" => "2007" "volumen" => "142" "paginaInicial" => "613" "paginaFinal" => "618" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17638797" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0130" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Diabetes mellitus and mortality after acute coronary syndrome as a first or recurrent cardiovascular event" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "R.M. Cubbon" 1 => "A. Abbas" 2 => "S.B. Wheatcroft" 3 => "N. Kilcullen" 4 => "R. Das" 5 => "C. Morrell" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1371/journal.pone.0003483" "Revista" => array:5 [ "tituloSerie" => "PLoS ONE" "fecha" => "2008" "volumen" => "3" "paginaInicial" => "e3483" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18941531" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0135" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Rates and risk of hospitalisation among patients with type 2 diabetes: retrospective cohort study using the UK General Practice Research Database linked to English Hospital Episode Statistics" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "J.M. Khalid" 1 => "M. Raluy-Callado" 2 => "B.H. Curtis" 3 => "K.S. Boye" 4 => "A. Maguire" 5 => "M. Reaney" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/ijcp.12265" "Revista" => array:6 [ "tituloSerie" => "Int J Clin Pract" "fecha" => "2014" "volumen" => "68" "paginaInicial" => "40" "paginaFinal" => "48" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24112108" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0140" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Insulin therapy for the management of hyperglycemia in hospitalized patients" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "M.E. McDonnell" 1 => "G.E. 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Suriñach (University Hospital Vall d’Hebrón, Barcelona, Spain), Rafael Castillo (University Hospital Arnau de Vilanova, Valencia, Spain), Emilio Casariego (University Hospital Lucus Augusti, Lugo, Spain), Cristina Ligorria (District Hospital Sant Jaume de Calella, Barcelona, Spain), Emilio Uriarte (Hospital San Eloy, Vizcaya, Spain), Javier Ena (Hospital Marina Baixa, Alicante, Spain), Mónica Romero (University General Hospital of Elda, Alicante, Spain), José Arribas (University General Hospital Morales Meseguer, Murcia, Spain), Joaquín Morís (University Hospital of Cabueñes, Gijón, Spain), Fermín Jiménez (Hospital Complex of Navarra, Navarra, Spain), Albert Lecube (University Hospital Arnau de Vilanova, Lérida, Spain), Iria Pinal (Hospital of Verín, Ourense, Spain). We are very grateful to Cristina Romera-López of Dynamic Science for her assistance in collecting and managing the data and extend our thanks to Ana López-Ballesteros and Antonio Torres-Ruiz of Dynamic Science for their support in the medical editing and editorial assistance. The responsibility for the opinions, conclusions and interpretation falls entirely upon the authors of the article." "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/22548874/0000021900000001/v1_201901300620/S2254887418301309/v1_201901300620/en/main.assets" "Apartado" => array:4 [ "identificador" => "1901" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Original Articles" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/22548874/0000021900000001/v1_201901300620/S2254887418301309/v1_201901300620/en/main.pdf?idApp=WRCEE&text.app=https://www.revclinesp.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2254887418301309?idApp=WRCEE"]

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Indicator performance after the implementation of the Spanish Consensus Document for the control of hyperglycemia in the hospital and at discharge

Rendimiento de los indicadores tras la implementación del Documento de consenso español para el control de la hiperglucemia en el hospital y al alta

A. Péreza,b,c,

Corresponding author

aperez@santpau.cat

Corresponding author.

, A. Ramosa,b, P. Realesd, N. Tobarese, R. Gómez-Huelgasf,g,h,

Corresponding author

ricardogomezhuelgas@hotmail.com

Corresponding author.

, on behalf of Grupo de estudio AL ALTA

a Servicio de Endocrinología y Nutrición, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain

b Departamento de Medicina, Universitat Autònoma de Barcelona (UAB), Campus de la UAB, Barcelona, Spain

c Diabetes y Enfermedades Metabólicas CIBER (CIBERDEM), Barcelona, Spain

d Servicio de Medicina Interna, Hospital Gutiérrez Ortega, Valdepeñas, Ciudad Real, Spain

e Servicio de Medicina Interna, Hospital Clínico San Carlos, Madrid, Spain

f Servicio de Medicina Interna, Hospital Regional Universitario de Málaga, Málaga, Spain

g Instituto de Investigación Biomédica de Málaga (IBIMA)

h CIBER Fisiopatología de la Obesidad y Nutrición (CIBEROBN), Instituto Carlos III, Madrid, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Background</span><p id="par0005" class="elsevierStylePara elsevierViewall">Patients with diabetes have a considerably high rate of hospitalization due to causes related to the disease itself&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">1&#8211;3</span></a> The most common problems among hospitalized patients are hyperglycemia due to decompensated diabetes mellitus&#44; undiagnosed diabetes and hospital hyperglycemia&#44;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">4</span></a> which are often linked to mediocre results&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">5&#8211;7</span></a> Improved glycemic control&#44; however&#44; translates into reduced morbidity and mortality&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">8&#8211;10</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The patient&#39;s transition from hospital to outpatient is a vulnerable period&#44; especially for patients with diabetes&#44; during which there is the risk of treatment abandonment and adverse events&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">11</span></a> Accordingly&#44; proper planning of the hospital discharge should be part of these patients&#8217; comprehensive management<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">12&#8211;14</span></a>&#59; however&#44; the available information on strategies for hospital discharges in diabetes is scarce&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">15&#44;16</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In 2012&#44; Spain adapted the general recommendations of 12 national scientific societies&#44; supported by the National Patients Forum of Spain&#44;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">12</span></a> to the specific needs of hospitalized patients with diabetes&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">17</span></a> This document provided individual guidelines directed at therapeutic reconciliation&#44; taking into account the etiology of hyperglycemia&#44; the previous antidiabetic treatments&#44; the patient&#39;s clinical condition and degree of glycemic control&#44; glucose monitoring&#44; diabetes education and follow-up after the hospital discharge&#46; The aim of the AL ALTA &#40;Spanish for &#8220;at discharge&#8221;&#41; study was to assess the impact of implementing the recommendations of the Spanish consensus document for managing the hospital discharge of patients with type 2 diabetes &#40;DM2&#41; or hyperglycemia during hospitalization&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materials and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Study design</span><p id="par0020" class="elsevierStylePara elsevierViewall">AL ALTA is a prospective&#44; observational and multicenter study conducted by the internal medicine departments of 19 hospitals in Spain&#46; Following an initial training session &#40;October 2013&#41; on the Spanish consensus document&#44;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">17</span></a> we proceeded to prospectively collect data for the following events&#58; hospital admission&#44; hospital discharge and 3 months after the discharge&#46; For the retrospective group&#44; the data collection was performed retrospectively based on prior medical records from the same hospitals and from the same events&#46; To ensure the study&#39;s observational nature&#44; the data was collected before the diagnosis or treatment&#44; provided the data was included in the patient&#39;s medical history or when the data could be obtained during the interview visit&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The study was conducted in accordance with the Declaration of Helsinki&#44; including all of its amendments&#44; and was approved by the pertinent independent research ethics committee&#46; All patients gave their written informed consent for use of their data prior to admission to the study&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Study population</span><p id="par0030" class="elsevierStylePara elsevierViewall">The design of this study included 2<span class="elsevierStyleHsp" style=""></span>patient groups &#40;prospective and retrospective&#41;&#44; with a ratio of 2&#58;1&#46; The prospective group included men and women with noncritical disease&#44; between the ages of 18 and 80 years&#44; with DM2 or hyperglycemia &#40;blood glucose levels<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>140<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#41; undergoing treatment in a basal-bolus-correction insulin or basal-correction insulin regimen during the hospitalization period&#46; We predicted a hospital stay of at least 5 days in a hemodynamically stable condition and planned a follow-up of 3 months after the discharge&#46; The main exclusion criteria were other types of diabetes &#40;e&#46;g&#46;&#44; type 1 diabetes&#44; latent autoimmune diabetes in adults and pancreatic diabetes&#41;&#44; drug addiction&#44; alcoholism&#44; hospitalization for diabetic ketoacidosis or hyperosmolar hyperglycemic syndrome&#44; critical disease and any psychiatric or neurological disorder that could interfere with the follow-up&#46; For the retrospective group&#44; the selection criteria were the same as for the prospective group&#44; with the addition of having been hospital discharged before the start of the study&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Study procedures</span><p id="par0035" class="elsevierStylePara elsevierViewall">The primary objective of the AL ALTA study was to assess the effect of applying the recommendations of the Spanish consensus document<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">17</span></a> for managing the hospital discharge of patients with DM2 or hyperglycemia during the hospitalization in terms of changes experienced in HbA1c levels&#44; from hospital admission &#40;start&#41; to 3 months after the discharge&#46; The study also analyzed the change during this period in the number of hypoglycemic &#40;&#60;70<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#41;&#44; severe hypoglycemic &#40;&#60;40<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#41; and hyperglycemic &#40;&#62;250<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#41; events&#44; as well as the number of emergency department and hospital readmissions and the number of complications that occurred during the 3-month follow-up period after the discharge&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Other secondary endpoints were &#40;1&#41; changes in the antidiabetic therapy occurring during the admission-to-discharge and discharge-to-3 months &#40;of follow-up&#41; periods&#44; considering the proportion of patients undergoing therapy with insulin&#44; oral diabetes drugs &#40;ODDs&#41; and insulin plus ODDs and &#40;2&#41; quality indicators in the discharge report&#44; including diet and exercise recommendations&#44; patient condition at discharge&#44; expected clinical progress&#44; diabetes education&#44; frequency of glucose monitoring and other specifications to consider for the next follow-up visit&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Statistical analysis</span><p id="par0045" class="elsevierStylePara elsevierViewall">Based on the HOSMIDIA study&#44;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">15</span></a> the sample size needed to achieve an expected reduction of 0&#46;7&#37; in HbA1c levels is 200 individuals for the prospective group and 100 for the control group&#44; for a ratio of 2&#58;1&#44; plus 10&#37; for incomplete or inconsistent data&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">In the descriptive statistical analysis of the quantitative variables&#44; we employed measures of central tendency and dispersion &#40;mean&#44; median&#44; standard deviation &#91;SD&#93; and 95&#37; confidence interval &#91;CI&#93;&#41;&#46; For the qualitative variables&#44; we used valid frequencies and percentages&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The study of the statistically significant differences between the quantitative variables was conducted using the Mann&#8211;Whitney-Wilcoxon test for the continuous variables and with the chi-squared test &#40;or Fischer&#39;s exact test&#41; for the discrete variables&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">For the endpoints directed at assessing changes in therapy&#44; from the moment prior to hospitalization to the follow-up visit in month 3&#44; we created contingency tables and employed McNemar&#39;s test&#46; For this analysis&#44; we created 2<span class="elsevierStyleHsp" style=""></span>groups&#58; patients with an HbA1c level<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>7&#46;5&#37; and patients with an HbA1c level<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>7&#46;5&#37;&#46; In the analysis&#44; we did not consider the lost data and set the level of significance to a <span class="elsevierStyleItalic">p</span>-value<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;05&#46; All statistical analyses were conducted using the Statistical Package for the Social Sciences &#40;SPSS&#41; version 22&#46;0&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Results</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Study participants</span><p id="par0065" class="elsevierStylePara elsevierViewall">The study included 276 individuals between November 2013 and February 2015&#44; 2 of whom were excluded for screening failures&#46; The study population therefore consisted of 274 patients with diabetes &#40;199 in the prospective group and 75 in the retrospective group&#41;&#46; The initial clinical characteristics are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; There were no significant differences between the groups in terms of sex&#44; age&#44; body mass index&#44; HbA1c or duration of hospital stay&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Quality indicators in the discharge report</span><p id="par0070" class="elsevierStylePara elsevierViewall">The degree of adherence to the recommendations of the Spanish consensus document&#44; measured by means of the quality indicators in the hospital discharge reports&#44; was greater in the prospective group &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#44; except in terms of the expected clinical progression after discharge &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Treatment of diabetes</span><p id="par0075" class="elsevierStylePara elsevierViewall">There was a significant change in the prospective group in the antidiabetic therapy between the hospital admission and discharge between the patients with HbA1c levels<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>7&#46;5&#37; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;005&#41; and the patients with HbA1c levels<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>7&#46;5&#37; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#46; In the retrospective group&#44; in contrast&#44; this change was only significant in the patients with HbA1c levels<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>7&#46;5&#37; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; The changes in antidiabetic therapy during the period from hospital discharge to month 3 of the follow-up were only significant in the prospective group &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">At discharge&#44; 197 patients &#40;71&#46;9&#37;&#41; were treated with insulin &#40;72&#46;9&#37; vs&#46; 69&#46;3&#37; for the prospective and retrospective groups&#44; respectively&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;651&#41; and 203 &#40;74&#46;1&#37;&#41; were treated with ODDs &#40;74&#46;4&#37; vs&#46; 73&#46;3&#37;&#44; respectively&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;878&#41;&#46; The most commonly prescribed ODDs were metformin &#40;77&#37; vs&#46; 72&#46;7&#37; for the prospective and retrospective groups&#44; respectively&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;525&#41;&#44; dipeptidyl peptidase-4 inhibitors &#40;53&#46;4&#37; vs&#46; 45&#46;5&#37;&#44; respectively&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;315&#41; and sulfonylureas &#40;10&#46;1&#37; vs&#46; 9&#46;1&#37;&#44; respectively&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;824&#41;&#46; At month 3 after discharge&#44; 175 individuals &#40;67&#46;8&#37;&#41; were treated with insulin &#40;66&#46;7&#37; vs&#46; 70&#46;7&#37; for the prospective and retrospective groups&#44; respectively&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;561&#41;&#44; and 208 &#40;80&#46;6&#37;&#41; were treated with ODDs&#44; mainly metformin &#40;76&#46;5&#37; vs&#46; 78&#37;&#44; respectively&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;822&#41; and dipeptidyl peptidase-4 inhibitors &#40;55&#46;7&#37; vs&#46; 49&#46;2&#37;&#44; respectively&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;393&#41;&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Glycemic control</span><p id="par0085" class="elsevierStylePara elsevierViewall">Three months after the hospital discharge&#44; there was a statistically significant reduction in the mean HbA1c levels&#44; both in the prospective group &#40;8&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;9&#37; to 7&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;2&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41; and retrospective group &#40;8&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;5&#37; to 7&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;2&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">In terms of mean blood glucose levels&#44; there was a reduction from discharge to month 3 of follow-up in the prospective cohort &#40;174&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>49&#46;3 vs&#46; 147&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>33&#46;8<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;028&#41; but not in the retrospective group &#40;153&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>32&#46;8 vs&#46; 153&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>25&#46;9<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;119&#41;&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Safety</span><p id="par0095" class="elsevierStylePara elsevierViewall">A total of 65 patients &#40;25&#46;2&#37;&#41; experienced hypoglycemic crises during the 3 months after discharge&#44; with no differences between the 2<span class="elsevierStyleHsp" style=""></span>study cohorts &#40;26&#46;2&#37; vs&#46; 22&#46;7&#37; for the prospective and retrospective groups&#44; respectively&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;637&#41;&#46; The mean number of hypoglycemic crises for the entire study population during the 3-month follow-up period was 3&#46;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;0&#46; Severe hypoglycemic events were reported in 2&#46;2&#37; of the prospective group and 4&#46;0&#37; of the retrospective group &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;418&#41;&#46; There were no differences in the mean number of severe cases between the groups &#40;1&#46;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;0 vs&#46; 1&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;6 for the prospective and retrospective groups&#44; respectively&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;229&#41;&#46; The frequency of hyperglycemic crises was similar in the 2 groups &#40;28&#46;4&#37; vs&#46; 31&#46;1&#37; for the prospective and retrospective groups&#44; respectively&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;762&#41;&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">In all&#44; 49 patients &#40;19&#46;0&#37;&#41; were readmitted&#44; mainly in the emergency departments &#40;71&#46;8&#37;&#41;&#44; with no differences between the groups &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;729&#41;&#46; The main cause for emergency department readmission was respiratory infection&#59; only 2<span class="elsevierStyleHsp" style=""></span>patients were treated for hypoglycemia&#44; and 1 was treated for hyperglycemia&#46; These 3<span class="elsevierStyleHsp" style=""></span>patients were part of the retrospective group&#46;</p></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Discussion</span><p id="par0105" class="elsevierStylePara elsevierViewall">This observational prospective multicenter study sought to assess the impact of implementing the recommendations of the Spanish consensus document for managing the hospital discharge of individuals with DM2 or hyperglycemia during hospitalization&#46; Our study shows that implementing these recommendations significantly improved the registration of the quality indicators in the discharge report and in the therapeutic reconciliation at the time of discharge&#46; The implementation also improved glycemic control at 3 months after the hospital discharge&#44; if we consider the previous antidiabetic therapy&#44; clinical condition and degree of glycemic control&#46; This improvement appears to be independent of the quality indicators included in the discharge report&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">A systematic Cochrane review revealed that a structured discharge plan adapted to the patient can reduce the length of the hospital stay and readmission rates and can increase patient satisfaction&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">18</span></a> However&#44; the hospital discharge procedure is not generic and should consider all aspects related to the patient&#39;s social and health needs&#46; The Spanish consensus document for managing the hospital discharge of patients with DM2 or hyperglycemia focuses specifically on those aspects of diabetes care that should be considered in the discharge and include therapeutic reconciliation&#44; patient education&#44; follow-up assessments and the range of quality indicators of the discharge&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">17</span></a> In this study&#44; we assessed the impact of implementing these recommendations and their efficacy in terms of glycemic control and readmission after the discharge&#46; Providing information on the cause of the hyperglycemia&#44; the expected progression and recommended antidiabetic therapies can help those responsible for primary care to understand the continuity of care after the hospital discharge&#46; Conversely&#44; a lack of communication in the discharge process can lead to medical errors and deficient glycemic control&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">19</span></a> The discharge report is the main form of communication between the hospital care team and those responsible for post-treatment care&#59; thus&#44; the importance of this document&#46; In our study&#44; the key information in the discharge report &#40;quality indicators&#41; related to the therapy &#40;diet&#44; exercise&#44; education and glucose monitoring&#41; and the subsequent follow-up after discharge were improved&#46; However&#44; based on a previous study&#44;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">20</span></a> the influence of this improvement in the discharge report values in our study appears to be limited&#46; We found a similar improvement in the data regarding glycemic control&#44; episodes of hypoglycemia&#47;hyperglycemia and hospital readmission rates among the prospective and retrospective groups&#46; Nevertheless&#44; our findings are consistent with the lack of correlation observed between the readmission rates and the quality of the directives on the discharge report for patients with heart failure&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">18</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Accurate therapeutic reconciliation is a critical element in the success of the transition after the discharge&#59; most studies have shown that its efficacy reduces the adverse effects of the drugs&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">5</span></a> In terms of the reconciliation&#39;s influence on emergency department visits and readmissions after discharge&#44; the evidence is still inconclusive&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">21</span></a> There is evidence that patients with diabetes have clinical inertia toward intensifying the treatments at the time of discharge&#46; In a retrospective study of 1359 elderly patients with diabetes and HbA1c levels &#62;8&#46;0&#37; &#40;median&#44; 8&#46;7&#37;&#41;&#44; only 22&#46;4&#37; of the patients changed their diabetes medication at discharge&#44; and almost a third did not change the treatment or the subsequent follow-up regimen&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">21</span></a> As with previous studies&#44;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">15&#44;16</span></a> the most common change in our study &#40;in both groups&#41; in treatment from admission to discharge was the addition of basal insulin&#44; especially in patients with an HbA1c level &#62;7&#46;5&#37;&#46; The changes in antidiabetic therapy performed in the retrospective group suggest that the therapy had already been reconciled adequately before the first training session&#46; Although maintaining the treatment established at the discharge during the 3-month follow-up reinforces the therapeutic reconciliation strategy&#44; an interesting aspect of our study on the follow-up after the discharge was that the proportion of patients in the prospective group treated with insulin was reduced&#44; while the proportion of patients with insulin plus ODD showed no significant changes&#46; This temporary insulinization agrees with the strategy established in the Spanish consensus document for selecting the treatment at discharge&#44; in the need for considering the patients&#8217; clinical condition&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">17</span></a> By implementing these therapeutic changes at discharge&#44; glycemic control could be optimized in both groups&#44; a result that would be confirmed and broadened by the findings of the few studies that have been interested in the hospital discharge of patients with diabetes&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">10&#44;15&#44;16</span></a> Umpierrez et al&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">16</span></a> used a discharge algorithm based on HbA1c levels during hospitalization to adjust the treatment and observed that the mean HbA1c level decreased from 8&#46;7&#37; at admission to 7&#46;3&#37; 3 months after the discharge&#46; In a prospective observational study conducted in 15 Spanish hospitals that also applied a simple therapeutic algorithm based on HbA1c levels during hospitalization&#44; the mean HbA1c level decreased from 8&#46;7&#37; at admission to 7&#46;6&#37; 3 months after the discharge&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">15</span></a> Lipska et al&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">22</span></a> reported that omitting antidiabetic therapy at discharge was associated with increased mortality in the first year&#44; more frequent hospitalizations and increased healthcare expenditures&#46; Considering these data&#44; the discharge program would improve adherence and results&#44; as well as represent greater savings for the health system&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Our study had a number of limitations when interpreting the results&#46; Since this was an observational study&#44; we cannot completely rule out some biases&#59; however&#44; the patient selection in each center was conducted by the same researcher&#46; All researchers knew the importance of reducing the selection bias&#44; and the patients&#8217; clinical characteristics and inclusion criteria were similar in the 2 groups&#46; Another limitation was the follow-up duration&#44; which might have been too short to determine the long-term efficacy of implementing the Spanish consensus recommendations&#46; We should also consider the Hawthorne effect&#44; in which individuals can change their behavior due to the singular attention provided by the researcher&#44; which could explain the improved results&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">23</span></a> Finally&#44; it is worth recognizing that our study&#39;s objective was not to compare the efficacy and safety of various antidiabetic therapies but rather to assess the impact of the general recommendations of the Spanish consensus document for improving glycemic control following hospital discharge&#46; Given that the study was conducted with Spanish populations&#44; these results are applicable to patients treated in internal medicine departments with similar characteristics&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Conclusions</span><p id="par0125" class="elsevierStylePara elsevierViewall">Our study indicated that implementing the recommendations of the Spanish consensus document for managing the hospital discharge of patients with DM2 or hyperglycemia dramatically improved the registration of quality indicators in the discharge report&#46; The reconciliation of the antidiabetic medication at hospital discharge &#40;taking into account the previous treatment for hyperglycemia&#44; the patient&#39;s clinical condition and degree of glycemic control&#41; improved the glycemic control after the hospital discharge&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Funding</span><p id="par0130" class="elsevierStylePara elsevierViewall">This study was financially supported by Sanofi-Aventis&#46; The study sponsor did not participate in the data collection&#44; analysis or interpretation of the results or in the preparation of the manuscript&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Authorship</span><p id="par0135" class="elsevierStylePara elsevierViewall">All authors collaborated in designing the study&#44; recruiting patients&#44; critically reviewing the content of the manuscript and participating in the final approval of the presented version&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Conflicts of interest</span><p id="par0140" class="elsevierStylePara elsevierViewall">APP has participated as a consultant for or has received lecture fees or travel reimbursement from Sanofi-Aventis&#44; Esteve&#44; GSK&#44; Almirall&#44; Novo Nordisk&#44; Eli Lilly&#44; MSD&#44; Boehringer Ingelheim&#44; Novartis&#44; Menarini&#44; Janssen and Astra Zeneca&#46; RGH has participated as a consultant for or has received lecture fees or travel reimbursement from Sanofi-Aventis&#44; Esteve&#44; Novo Nordisk&#44; Eli Lilly&#44; MSD&#44; Boehringer Ingelheim&#44; Novartis&#44; Menarini&#44; Janssen and Astra Zeneca&#46; APP and RGH&#44; as study coordinators&#44; were remunerated by Sanofi-Aventis&#46; The other authors declare that they have no conflicts of interest&#46;</p></span></span>"
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    "fechaRecibido" => "2018-01-10"
    "fechaAceptado" => "2018-05-12"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background and aims</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Information for the adequate management of diabetic patients at hospital discharge is limited&#46; We aimed to evaluate the impact of implementation of recommendations of the Spanish consensus for the management hospital discharge in patients with type 2 diabetes or hyperglycaemia during hospitalization&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Observational multicentric study with a prospective and a retrospective colection of patients with type 2 diabetes&#47;hyperglycaemia &#40;&#62;140<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#41; during hospitalization from 19 Spanish hospitals&#46; Quality indicators in discharge report&#44; antidiabetic therapy&#44; HbA<span class="elsevierStyleInf">1c</span> and adverse events were gathered at hospital admission&#44; hospital discharge and 3 month post-discharge&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">199 and 75 subjects in the prospective and retrospective group respectively were included&#46; The indicators of quality in the hospital discharge reports was higher in the prospective group &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#46; The proportion of patients with insulin&#44; oral antidiabetic drugs &#40;OADs&#41;&#44; and insulin<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>OADs was modified at discharge in patients with HbA<span class="elsevierStyleInf">1c</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>7&#46;5&#37; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;005&#41; and &#8805;7&#46;5&#37; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41; in the prospective group and in patients with HbA 1<span class="elsevierStyleHsp" style=""></span>c &#8805;7&#46;5&#37; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41; in the retrospective group&#46; At 3 month post-discharge HbA<span class="elsevierStyleInf">1c</span> levels decreased from 8&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;9&#37; to 7&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;2&#37; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41; in the prospective group&#44; and from 8&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;5&#37; to 7&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;2&#37; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41; in the retrospective group&#46; Hypoglycaemic and hyperglycaemic episodes and hospital readmissions were similar in both groups&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Implementation of Spanish consensus recommendations for the management of hospital discharge in patients with diabetes type 2 or hyperglycaemia considerably improved the registration of quality indicators in the discharge report&#46; Reconciliation of antidiabetic medication at the time of hospital discharge&#44; improves glycaemic control after hospital discharge&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Antecedentes y objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La informaci&#243;n sobre el manejo de los pacientes diab&#233;ticos en el momento del alta hospitalaria es reducida&#46; El objetivo del estudio fue evaluar el impacto de la implementaci&#243;n de las recomendaciones del Consenso espa&#241;ol para el manejo del alta hospitalaria en pacientes con diabetes tipo 2 &#40;DM2&#41; o hiperglucemia durante la hospitalizaci&#243;n&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio observacional con un grupo de recogida prospectiva y otra retrospectiva de pacientes con DM2&#47;hiperglucemia &#40;&#62; 140<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#41; durante la hospitalizaci&#243;n de 19 hospitales espa&#241;oles&#46; Se recopilaron indicadores de calidad en el informe de alta&#44; terapia hipogluc&#233;mica&#44; HbA<span class="elsevierStyleInf">1c</span> y eventos adversos al ingreso&#44; en el momento del alta y a los 3 meses del alta&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se incluy&#243; a 199 pacientes en el grupo prospectivo y 75 en el retrospectivo&#46; Los indicadores de calidad del informe de alta hospitalaria fueron mayores en el grupo prospectivo &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46; La proporci&#243;n de pacientes con tratamiento de insulina&#44; f&#225;rmacos antidiab&#233;ticos orales &#40;ADO&#41; e insulina<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>ADO sufri&#243; modificaciones en el momento del alta hospitalaria de los pacientes del grupo prospectivo con HbA<span class="elsevierStyleInf">1c</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>7&#44;5&#37; &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;005&#41; y &#8805; 7&#44;5&#37; &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; y en los pacientes del grupo retrospectivo con HbA<span class="elsevierStyleInf">1c</span> &#8805; 7&#44;5&#37; &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46; En el mes 3 tras el alta&#44; los niveles de HbA<span class="elsevierStyleInf">1c</span> descendieron de 8&#44;2<span class="elsevierStyleHsp" style=""></span>&#177; 1&#44;9&#37; a 7&#44;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;2&#37; &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; en el grupo prospectivo y desde 8&#44;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;9&#37; a 7&#44;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;2&#37; &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; en el retrospectivo&#46; Los episodios de hipoglucemia e hiperglucemia as&#237; como los de reingreso fueron semejantes en ambos grupos&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La aplicaci&#243;n del documento espa&#241;ol de consenso de las recomendaciones para el manejo del alta hospitalaria en pacientes con DM2 o hiperglucemia mejora de forma considerable el registro de indicadores de calidad en el informe de alta&#46; La conciliaci&#243;n de la medicaci&#243;n antidiab&#233;tica en el momento del alta hospitalaria mejora el control gluc&#233;mico despu&#233;s del alta&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Please cite this article as&#58; P&#233;rez A&#44; Ramos A&#44; Reales P&#44; Tobares N&#44; G&#243;mez-Huelgas R&#44; en nombre del Grupo de estudio AL ALTA&#46; Rendimiento de los indicadores tras la implementaci&#243;n del Documento de consenso espa&#241;ol para el control de la hiperglucemia en el hospital y al alta&#46; Rev Clin Esp&#46; 2019&#59;219&#58;18&#8211;25&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0020">Consenso sobre la diabetes en Espa&#241;a&#46;</p>"
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#46;909&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Sex</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Female&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">78 &#40;39&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">29 &#40;38&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#62;&#46;999&nbsp;\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"><span class="elsevierStyleHsp" style=""></span>Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">121 &#40;60&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">46 &#40;61&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">BMI&#44; kg&#47;m</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">2</span></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;933&nbsp;\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"><span class="elsevierStyleItalic">Previous diagnoses of diabetes</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">175 &#40;87&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">68 &#40;90&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;525&nbsp;\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"><span class="elsevierStyleItalic">HbA1c during hospitalization&#44; &#37;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;512&nbsp;\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"><span class="elsevierStyleHsp" style=""></span>HbA<span class="elsevierStyleInf">1c</span> &#60;7&#46;5&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">79 &#40;40&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25 &#40;34&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;357&nbsp;\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"><span class="elsevierStyleHsp" style=""></span>HbA1c &#8805;7&#46;5&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">114 &#40;59&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">47 &#40;65&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Medical history</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Hypertension&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">198 &#40;99&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">63 &#40;84&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#62;&#46;999&nbsp;\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"><span class="elsevierStyleHsp" style=""></span>Dyslipidemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">135 &#40;67&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">53 &#40;70&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;417&nbsp;\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"><span class="elsevierStyleHsp" style=""></span>Cardiovascular disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">98 &#40;49&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">37 &#40;49&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#62;&#46;999&nbsp;\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"><span class="elsevierStyleHsp" style=""></span>Renal failure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">68 &#40;34&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">19 &#40;25&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;191&nbsp;\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"><span class="elsevierStyleHsp" style=""></span>Obesity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">95 &#40;47&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">33 &#40;44&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;590&nbsp;\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"><span class="elsevierStyleHsp" style=""></span>Tobacco use&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30 &#40;15&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15 &#40;20&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;345&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">Reasons for hospital readmission</span><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a></td><td class="td" title="table-entry  " align="char" valign="top">&#46;378&nbsp;\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"><span class="elsevierStyleHsp" style=""></span>Cardiovascular disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">17 &#40;42&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;21&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\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"><span class="elsevierStyleHsp" style=""></span>Infection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8 &#40;20&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;14&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\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"><span class="elsevierStyleHsp" style=""></span>Exacerbation of the underlying disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;12&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;28&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\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"><span class="elsevierStyleHsp" style=""></span>Others&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10 &#40;25&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;35&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Treatment with glucocorticoids</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">63 &#40;31&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23 &#40;30&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;875&nbsp;\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"><span class="elsevierStyleItalic">Hospital stay&#44; days</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>42&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;584&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Indicator&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Recommendation for the number of daily meals<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">173 &#40;86&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">28 &#40;37&#46;3&#41;&nbsp;\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">Exercise recommendation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">122 &#40;61&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23 &#40;30&#46;7&#41;&nbsp;\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">Was the patient&#39;s clinical condition included at discharge&#63;<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">143 &#40;71&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30 &#40;40&#46;0&#41;&nbsp;\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">Was the expected clinical progression included&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">61 &#40;30&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">17 &#40;22&#46;7&#41;&nbsp;\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">Diabetes education<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">172 &#40;86&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">29 &#40;38&#46;7&#41;&nbsp;\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">Was the frequency of glucose monitoring included&#63;<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">165 &#40;82&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">31 &#40;41&#46;3&#41;&nbsp;\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">Were other specifications for the next follow-up visit included&#63;<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">196 &#40;98&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">51 &#40;68&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
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        "texto" => "<p id="par0150" class="elsevierStylePara elsevierViewall">The authors would like to thank the other researchers of the AL ALTA Study Group for their valuable contributions&#58; Jos&#233; M&#46; Suri&#241;ach &#40;University Hospital Vall d&#8217;Hebr&#243;n&#44; Barcelona&#44; Spain&#41;&#44; Rafael Castillo &#40;University Hospital Arnau de Vilanova&#44; Valencia&#44; Spain&#41;&#44; Emilio Casariego &#40;University Hospital Lucus Augusti&#44; Lugo&#44; Spain&#41;&#44; Cristina Ligorria &#40;District Hospital Sant Jaume de Calella&#44; Barcelona&#44; Spain&#41;&#44; Emilio Uriarte &#40;Hospital San Eloy&#44; Vizcaya&#44; Spain&#41;&#44; Javier Ena &#40;Hospital Marina Baixa&#44; Alicante&#44; Spain&#41;&#44; M&#243;nica Romero &#40;University General Hospital of Elda&#44; Alicante&#44; Spain&#41;&#44; Jos&#233; Arribas &#40;University General Hospital Morales Meseguer&#44; Murcia&#44; Spain&#41;&#44; Joaqu&#237;n Mor&#237;s &#40;University Hospital of Cabue&#241;es&#44; Gij&#243;n&#44; Spain&#41;&#44; Ferm&#237;n Jim&#233;nez &#40;Hospital Complex of Navarra&#44; Navarra&#44; Spain&#41;&#44; Albert Lecube &#40;University Hospital Arnau de Vilanova&#44; L&#233;rida&#44; Spain&#41;&#44; Iria Pinal &#40;Hospital of Ver&#237;n&#44; Ourense&#44; Spain&#41;&#46;</p> <p id="par0155" class="elsevierStylePara elsevierViewall">We are very grateful to Cristina Romera-L&#243;pez of Dynamic Science for her assistance in collecting and managing the data and extend our thanks to Ana L&#243;pez-Ballesteros and Antonio Torres-Ruiz of Dynamic Science for their support in the medical editing and editorial assistance&#46; The responsibility for the opinions&#44; conclusions and interpretation falls entirely upon the authors of the article&#46;</p>"
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Article information

ISSN: 22548874
Original language: English

DOI:10.1016/j.rceng.2018.08.001

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