1
|
Gysling S, Lewis-Lloyd CA, Lobo DN, Crooks CJ, Humes DJ. The effect of diabetes mellitus on perioperative outcomes after colorectal resection: a national cohort study. Br J Anaesth 2024; 133:67-76. [PMID: 38760264 PMCID: PMC11213983 DOI: 10.1016/j.bja.2024.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 04/02/2024] [Accepted: 04/02/2024] [Indexed: 05/19/2024] Open
Abstract
BACKGROUND Diabetes mellitus is a significant modulator of postoperative outcomes and is an important risk factor in the patient selection process. We aimed to investigate the effect of diabetes mellitus and use of insulin on outcomes after colorectal resection using a national cohort. METHODS Adults with a recorded colorectal resection in England between 2010 and 2020 were identified from Hospital Episode Statistics data linked to the Clinical Practice Research Database. The primary outcome was 90-day mortality. Secondary outcomes included hospital length of stay (LOS) and readmission within 90 days. RESULTS Of the 106 139 (52 875, 49.8% male) patients included, diabetes mellitus was prevalent in 10 931 (10.3%), 2145 (19.6%) of whom had a record of use of insulin. Unadjusted 90-day mortality risk was 5.7%, with an increased adjusted hazard ratio (aHR) for people with diabetes mellitus (aHR 1.28, 95% confidence interval [CI] 1.19-1.37, P<0.001). This risk was higher in both people with diabetes using insulin (aHR 1.51, 95% CI 1.31-1.74, P<0.001) and not using insulin (aHR 1.22, 95% CI 1.13-1.33, P<0.001), compared with those without diabetes. Ninety-day readmission occurred in 20 542 (19.4%) patients and this was more likely in those with diabetes mellitus (aHR 1.23, 95% CI 1.18-1.29, P<0.001). Median (inter-quartile range) LOS was 8 (5-15) days and was higher in people with diabetes mellitus (adjusted time ratio 1.10, 95% CI 1.08-1.11, P<0.001). CONCLUSIONS People with diabetes mellitus undergoing colorectal resection are at a higher risk of 90-day mortality, prolonged LOS, and 90-day readmission, with use of insulin associated with additional risk.
Collapse
Affiliation(s)
- Savannah Gysling
- Nottingham Digestive Diseases Centre, Division of Translation Medical Sciences, School of Medicine, University of Nottingham, Queen's Medical Centre, Nottingham, UK; National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Christopher A Lewis-Lloyd
- Nottingham Digestive Diseases Centre, Division of Translation Medical Sciences, School of Medicine, University of Nottingham, Queen's Medical Centre, Nottingham, UK; National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Dileep N Lobo
- Nottingham Digestive Diseases Centre, Division of Translation Medical Sciences, School of Medicine, University of Nottingham, Queen's Medical Centre, Nottingham, UK; National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK; MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, UK; Division of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Colin J Crooks
- Nottingham Digestive Diseases Centre, Division of Translation Medical Sciences, School of Medicine, University of Nottingham, Queen's Medical Centre, Nottingham, UK; National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - David J Humes
- Nottingham Digestive Diseases Centre, Division of Translation Medical Sciences, School of Medicine, University of Nottingham, Queen's Medical Centre, Nottingham, UK; National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK
| |
Collapse
|
2
|
Rayman G. Enhancing Perioperative Diabetes Care: Strategies and Challenges. Diabetes Care 2024; 47:921-923. [PMID: 38768332 DOI: 10.2337/dci24-0010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Accepted: 03/07/2024] [Indexed: 05/22/2024]
Affiliation(s)
- Gerry Rayman
- Diabetes Centre, Ipswich Hospital, East Suffolk and North East Essex Foundation Trust, Ipswich, Suffolk, U.K
| |
Collapse
|
3
|
Sarriyah JF, Alghamdi AS, Al-Otaibi NM, Abdulrahman BB, Aljaed KM. Prevalence of Steroid-Induced Hyperglycemia in King Abdulaziz Specialist Hospital, Taif City, Saudi Arabia. Cureus 2024; 16:e54430. [PMID: 38510914 PMCID: PMC10951554 DOI: 10.7759/cureus.54430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/18/2024] [Indexed: 03/22/2024] Open
Abstract
Background Hyperglycemia is a common side effect of high-dose steroid therapy in hospitalized patients. Objectives To assess the prevalence of hyperglycemia among hospitalized patients receiving steroid therapy. Methods A retrospective study was conducted among 245 patients. The inclusion criteria were patients undergoing steroid therapy and admitted to a single tertiary care hospital due to medical complications or exacerbation of the diseases they were suffering from. Data encompassing patient demographics, admission, discharge dates, comorbidities, medication histories, laboratory results (including blood glucose levels), and documented corticosteroid administrations were meticulously gathered from electronic health records (EHRs). A logistic regression model analysis was done to predict the risk factors of poor glycemic control among hospitalized patients. Results The prevalence of hyperglycemia among the patients who were on steroid therapy was 34.2%. About 70.7% of the patients who required insulin at the time of admission required >17 units, and the insulin requirement was significantly higher among patients who received dexamethasone compared to other steroids (p<0.05). Older age (>65 years) was found to be independently associated with poor glycemic control (p<0.05). Conclusion The study revealed that almost one-third of patients on steroid therapy had hyperglycemia. Monitoring of patients for hyperglycemia after beginning high-dose steroid therapy should be done.
Collapse
Affiliation(s)
- Jehan F Sarriyah
- Internal Medicine, King Abdulaziz Specialist Hospital, Taif, SAU
| | - Adel S Alghamdi
- Endocrinology, King Abdulaziz Specialist Hospital, Taif, SAU
| | | | | | - Kholoud M Aljaed
- Internal Medicine, King Abdulaziz Specialist Hospital, Taif, SAU
| |
Collapse
|
4
|
Irace C, Coluzzi S, Di Cianni G, Forte E, Landi F, Rizzo MR, Sesti G, Succurro E, Consoli A. Continuous glucose monitoring (CGM) in a non-Icu hospital setting: The patient's journey. Nutr Metab Cardiovasc Dis 2023; 33:2107-2118. [PMID: 37574433 DOI: 10.1016/j.numecd.2023.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 06/28/2023] [Indexed: 08/15/2023]
Abstract
AIMS Although consistent data support the outpatient use of continuous glucose monitoring (CGM) to improve glycemic control and reduce hypoglycemic burden, and clinical outcomes, there are limited data regarding its use in the hospital setting, particularly in the non-intensive care unit (non-ICU) setting. The emerging use of CGM in the non-critical care setting may be useful in increasing the efficiency of hospital care and reducing the length of stay for patients with diabetes while improving glycemic control. DATA SYNTHESIS The purpose of this Expert Opinion paper was to evaluate the state of the art and provide a practical model of how CGM can be implemented in the hospital. SETTING A patient's CGM journey from admission to the ward to the application of the sensor, from patient education on the device during hospitalization until discharge of the patient to maintain remote control. CONCLUSIONS This practical approach for the implementation and management of CGM in patients with diabetes admitted to non-ICUs could guide hospitals in their diabetes management initiatives using CGM, helping to identify patients most likely to benefit and suggesting how this technology can be implemented to maximize clinical benefits.
Collapse
Affiliation(s)
- Concetta Irace
- Department of Health Science, University Magna Graecia of Catanzaro, Catanzaro, Italy.
| | - Sara Coluzzi
- Endocrinology and Metabolism Unit, ASL, Pescara, Italy
| | - Graziano Di Cianni
- ASL Tuscany Northwest, Diabetes and Metabolic Disease, Livorno Hospital, Livorno, Italy
| | | | - Francesco Landi
- Department of Geriatrics and Orthopedics, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Maria Rosaria Rizzo
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Giorgio Sesti
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Elena Succurro
- Department of Medical and Surgical Sciences, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Agostino Consoli
- Endocrinology and Metabolism Unit, ASL, Pescara, Italy; Department of Medicine and Aging Sciences DMSI and Center for Advanced Studies and Technology CAST, "G. D'Annunzio" University of Chieti-Pescara, Chieti, Italy
| |
Collapse
|
5
|
Coldwell C, Craig W. How should anaesthetic skills best be deployed for quality, safety and efficiency of care? Anaesthesia 2023; 78:279-281. [PMID: 36410053 DOI: 10.1111/anae.15921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/08/2022] [Indexed: 11/22/2022]
Affiliation(s)
- C Coldwell
- Department of Anaesthesia, Royal Lancaster Infirmary, Lancaster, UK
| | - W Craig
- Department of Surgery, Royal Lancaster Infirmary, Lancaster, UK
| |
Collapse
|
6
|
Dhatariya KK, Umpierrez G. Gaps in our knowledge of managing inpatient dysglycaemia and diabetes in non-critically ill adults: A call for further research. Diabet Med 2023; 40:e14980. [PMID: 36256494 PMCID: PMC10100017 DOI: 10.1111/dme.14980] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 10/11/2022] [Accepted: 10/17/2022] [Indexed: 11/28/2022]
Abstract
AIMS To describe the gaps in knowledge for the care of people in the hospital who have dysglycaemia or diabetes. METHODS A review of the current literature and the authors' knowledge of the subject. RESULTS Recent data has suggested that the prevalence of hospitalised people with diabetes is approximately three times the prevalence in the general population and is growing annually. A wealth of observational data over the last 4 decades has shown that people with hyperglycaemia, severe hypoglycaemia or diabetes, all experience more harm whilst in the hospital than those who do not have the condition. This often equates to a longer length of stay and thus higher costs. To date, the proportion of federal funding aimed at addressing the harms that people with dysglycaemia experience in hospitals has been very small compared to outpatient studies. National organisations, such as the Joint British Diabetes Societies for Inpatient Care, the American Diabetes Association and the Endocrine Society have produced guidelines or consensus statements on the management of various aspects of inpatient care. However, whilst a lot of these have been based on evidence, much remains based on expert opinion and thus low-quality evidence. CONCLUSIONS This review highlights that inpatient diabetes is an underfunded and under-researched area.
Collapse
Affiliation(s)
- Ketan K Dhatariya
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norfolk, UK
- Norwich Medicine School, University of East Anglia, Norfolk, UK
| | - Guillermo Umpierrez
- Department of Medicine, Division of Endocrinology, Emory University School of Medicine, Atlanta, Georgia, USA
| |
Collapse
|
7
|
Cai J, Islam MS. Interventions incorporating a multi-disciplinary team approach and a dedicated care team can help reduce preventable hospital readmissions of people with type 2 diabetes mellitus: A scoping review of current literature. Diabet Med 2023; 40:e14957. [PMID: 36082498 PMCID: PMC10087324 DOI: 10.1111/dme.14957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 08/31/2022] [Accepted: 09/07/2022] [Indexed: 11/28/2022]
Abstract
AIMS This review aimed to identify interventions that hospitals can implement to reduce preventable hospital readmissions of people with type 2 diabetes mellitus (T2DM). METHODS A scoping review framework was utilised to inform the overall process. The electronic databases Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline, the University of New England (UNE) library search engine and Google Scholar were utilised to search for relevant literature. RESULTS The results from this review demonstrate that interventions started at index admission for people diagnosed with T2DM can result in reductions in hospital readmissions. Common strategies which attributed to the success of interventions in reducing hospital readmissions of people with T2DM included a multidisciplinary team approach, a dedicated care team, certified diabetes educator appointments, basic survival skills education and influencing hospital protocol development and implementation. CONCLUSION This scoping review is an attempt at exploring and synthesising current research on interventions that hospitals can implement to reduce preventable hospital readmissions of people with T2DM.
Collapse
Affiliation(s)
- James Cai
- Tamworth Rural Referral Hospital, Tamworth, New South Wales, Australia
| | - Md Shahidul Islam
- Faculty of Medicine and Health, School of Health, University of New England, Armidale, New South Wales, Australia
| |
Collapse
|
8
|
Matthews L, Levett DZH, Grocott MPW. Perioperative Risk Stratification and Modification. Anesthesiol Clin 2022; 40:e1-e23. [PMID: 35595387 DOI: 10.1016/j.anclin.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
This article discusses the important topic of perioperative risk stratification and the interventions that can be used in the perioperative period for risk modification. It begins with a brief overview of the commonly used scoring systems, risk-prediction models, and assessments of functional capacity and discusses some of the evidence behind each. It then moves on to examine how perioperative risk can be modified through the use of shared decision making, management of multimorbidity, and prehabilitation programs, before considering what the future of risk stratification and modification may hold.
Collapse
Affiliation(s)
- Lewis Matthews
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton/University of Southampton, Tremona Road, Southampton SO16 6YD, United Kingdom; Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom; Shackleton Department of Anaesthesia, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton SO16 6YD, United Kingdom.
| | - Denny Z H Levett
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton/University of Southampton, Tremona Road, Southampton SO16 6YD, United Kingdom; Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Michael P W Grocott
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton/University of Southampton, Tremona Road, Southampton SO16 6YD, United Kingdom; Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| |
Collapse
|
9
|
Delivering Value Based Care: The UK Perspective. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00046-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
|
10
|
Sadhu AR, Patham B, Vadhariya A, Chikermane SG, Johnson ML. Outcomes of "Real-World" Insulin Strategies in the Management of Hospital Hyperglycemia. J Endocr Soc 2021; 5:bvab101. [PMID: 34235360 PMCID: PMC8252645 DOI: 10.1210/jendso/bvab101] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Indexed: 11/28/2022] Open
Abstract
Context Guidelines recommend scheduled long-acting basal and short-acting bolus insulin several times daily to manage inpatient hyperglycemia. In the “real world,” insulin therapy is complicated, with limited data on the comparative effectiveness of different insulin strategies. Objective This work aimed to evaluate the association of different insulin strategies with glucose control and hospital outcomes after adjustment for patient and physician factors that influence choice of therapy. Methods This retrospective, observational study took place at an academic hospital. Participants included noncritically ill hospitalized medical/surgical patients (n = 4558) receiving subcutaneous insulin for 75% or longer during admission. Insulin therapy was grouped into 3 strategies within the first 48 hours: basal bolus (BB: scheduled long and short/rapid n = 2358), sliding scale (SS: short/rapid acting n = 1855), or basal only (BO: long only: n = 345). Main outcome measures included glucose control: hypoglycemic days, hyperglycemic days, euglycemic days, mean glucose; and hospitalization: in-hospital mortality, length of stay (LOS), and readmissions. Results Initial therapy with BB was associated with more hypoglycemic (2.40; CI, 2.04 to 2.82) (P < .001) and fewer euglycemic days (0.90; CI, 0.85 to 0.97) (P = .003) than SS, whereas BO was associated with fewer hyperglycemic days (0.70; CI, 0.62 to 0.79) (P < .001), lower mean glucose (–18.03; CI, –22.46 to –12.61) (P < .001), and more euglycemic days (1.22; CI, 1.09 to 1.37) (P < .001) compared to SS. No difference in mortality, LOS, and readmissions was found. However, decreased LOS was observed in the BB subgroup with a medical diagnostic related group (0.93; CI, 0.89 to 0.97) (P < .001). Conclusion BO had a more favorable hyperglycemia profile than SS. BB, on the other hand, showed worse glycemic control as compared to SS. In the real-world hospital, BO may be a simpler and more effective insulin strategy.
Collapse
Affiliation(s)
| | | | - Aisha Vadhariya
- University of Houston, College of Pharmacy, Houston, Texas 77204, USA
| | | | - Michael L Johnson
- University of Houston, College of Pharmacy, Houston, Texas 77204, USA
| |
Collapse
|
11
|
A Practical Guide for the Management of Steroid Induced Hyperglycaemia in the Hospital. J Clin Med 2021; 10:jcm10102154. [PMID: 34065762 PMCID: PMC8157052 DOI: 10.3390/jcm10102154] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 05/05/2021] [Accepted: 05/10/2021] [Indexed: 01/08/2023] Open
Abstract
Glucocorticoids represent frequently recommended and often indispensable immunosuppressant and anti-inflammatory agents prescribed in various medical conditions. Despite their proven efficacy, glucocorticoids bear a wide variety of side effects among which steroid induced hyperglycaemia (SIHG) is among the most important ones. SIHG, potentially causes new-onset hyperglycaemia or exacerbation of glucose control in patients with previously known diabetes. Retrospective data showed that similar to general hyperglycaemia in diabetes, SIHG in the hospital and in outpatient settings detrimentally impacts patient outcomes, including mortality. However, recommendations for treatment targets and guidelines for in-hospital as well as outpatient therapeutic management are lacking, partially due to missing evidence from clinical studies. Still, SIHG caused by various types of glucocorticoids is a common challenge in daily routine and clinical guidance is needed. In this review, we aimed to summarize clinical evidence of SIHG in inpatient care impacting clinical outcome, establishment of diagnosis, diagnostic procedures and therapeutic recommendations.
Collapse
|
12
|
Dhatariya K, Mustafa OG, Rayman G. Safe care for people with diabetes in hospital. Clin Med (Lond) 2021; 20:21-27. [PMID: 31941727 DOI: 10.7861/clinmed.2019-0255] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Diabetes is the most prevalent long-term condition, occurring in approximately 6.5% of the UK population. However, an average of 18% of all acute hospital beds are occupied by someone with diabetes. Having diabetes in hospital is associated with increased harm - however that may be defined. Over the last few years the groups such as the Joint British Diabetes Societies for Inpatient Care have produced guidelines to help medical and nursing staff manage inpatients with diabetes. These guidelines have been rapidly adopted across the UK. The National Diabetes Inpatient Audit has shown that over the last few years the care for people with diabetes has slowly improved, but there remain challenges in terms of providing appropriate staffing and education. Patient safety is paramount, and thus there remains a lot to do to ensure this vulnerable group of people are not at increased risk of harm.
Collapse
Affiliation(s)
- Ketan Dhatariya
- Elsie Bertram Diabetes Centre, Norwich, UK and Norwich Medical School, Norwich, UK
| | - Omar G Mustafa
- King's College Hospital NHS Foundation Trust, London, UK
| | - Gerry Rayman
- Norwich Medical School, Norwich, UK and Ipswich Hospital, Ipswich, UK
| |
Collapse
|
13
|
Foo CD, Surendran S, Tam CH, Ho E, Matchar DB, Car J, Koh GCH. Perceived facilitators and barriers to chronic disease management in primary care networks of Singapore: a qualitative study. BMJ Open 2021; 11:e046010. [PMID: 33947737 PMCID: PMC8098912 DOI: 10.1136/bmjopen-2020-046010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
OBJECTIVE The increasing chronic disease burden has placed tremendous strain on tertiary healthcare resources in most countries, necessitating a shift in chronic disease management from tertiary to primary care providers. The Primary Care Network (PCN) policy was promulgated as a model of care to organise private general practitioners (GPs) into groups to provide GPs with resources to anchor patients with chronic conditions with them in the community. As PCN is still in its embryonic stages, there is a void in research regarding its ability to empower GPs to manage patients with chronic conditions effectively. This qualitative study aims to explore the facilitators and barriers for the management of patients with chronic conditions by GPs enrolled in PCN. DESIGN We conducted 30 semistructured interviews with GPs enrolled in a PCN followed by a thematic analysis of audio transcripts until data saturation was achieved. SETTING Singapore. RESULTS Our results suggest that PCNs facilitated GPs to more effectively manage patients through (1) provision of ancillary services such as diabetic foot screening, diabetic retinal photography and nurse counselling to permit a 'one-stop-shop', (2) systematic monitoring of process and clinical outcome indicators through a chronic disease registry (CDR) to promote accountability for patients' health outcomes and (3) funding streams for PCNs to hire additional manpower to oversee operations and to reimburse GPs for extended consultations. Barriers include high administrative load in maintaining the CDR due to the lack of a smart electronic clinic management system and financial gradient faced by patients seeking services from private GPs which incur higher out-of-pocket expenses than public primary healthcare institutions. CONCLUSION PCNs demonstrate great promise in empowering enrolled GPs to manage patients with chronic conditions. However, barriers will need to be addressed to ensure the viability of PCNs in managing more patients in the face of an ageing population.
Collapse
Affiliation(s)
- Chuan De Foo
- Health Systems and Behavioural Sciences Domain, Saw Swee Hock School of Public Health, National University Singapore, Singapore
| | - Shilpa Surendran
- Health Systems and Behavioural Sciences Domain, Saw Swee Hock School of Public Health, National University Singapore, Singapore
| | - Chen Hee Tam
- Health Systems and Behavioural Sciences Domain, Saw Swee Hock School of Public Health, National University Singapore, Singapore
| | - Elaine Ho
- Health Systems and Behavioural Sciences Domain, Saw Swee Hock School of Public Health, National University Singapore, Singapore
| | - David Bruce Matchar
- Internal Medicine, Duke University, Durham, North Carolina, USA
- Health Services and Systems Research, Duke-NUS Medical School, Singapore
| | - Josip Car
- Centre for Population Health Sciences, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Gerald Choon Huat Koh
- Health Systems and Behavioural Sciences Domain, Saw Swee Hock School of Public Health, National University Singapore, Singapore
| |
Collapse
|
14
|
Michelson KA, Dart AH, Bachur RG, Mahajan P, Finkelstein JA. Measuring complications of serious pediatric emergencies using ICD-10. Health Serv Res 2020; 56:225-234. [PMID: 33374034 DOI: 10.1111/1475-6773.13615] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE To create definitions for complications for 16 serious pediatric conditions using the International Classification of Diseases, 10th Revision, Clinical Modification or Procedure Coding System (ICD-10-CM/PCS), and to assess whether complication rates are similar to those measured with ICD-9-CM/PCS. DATA SOURCES The Healthcare Cost and Utilization Project State Emergency Department and Inpatient Databases from five states between 2014 and 2017 were used to identify cases and assess complication rates. Incidences were calculated using population counts from the 5-year American Community Survey. DATA COLLECTION/EXTRACTION METHODS Patients were identified by the presence of a diagnosis code for one of the 16 serious conditions. Only the first encounter for a given condition by a patient was included. Encounters resulting in transfer were excluded as the presence of complications was unknown. STUDY DESIGN We defined complications using data elements routinely available in administrative databases including ICD-10-CM/PCS codes. The definitions were adapted from ICD-9-CM/PCS using general equivalence mappings and refined using consensus opinion. We included 16 serious conditions: appendicitis, bacterial meningitis, compartment syndrome, new-onset diabetic ketoacidosis (DKA), ectopic pregnancy, empyema, encephalitis, intussusception, mastoiditis, myocarditis, orbital cellulitis, ovarian torsion, sepsis, septic arthritis, stroke, and testicular torsion. Using data from children under 18 years, we compared incidences and complication rates across the ICD-10-CM/PCS transition for each condition using interrupted time series. PRINCIPAL FINDINGS There were 61 314 ED visits for a serious condition; the most common was appendicitis (n = 37 493). Incidence rates for each condition were not significantly different across the ICD-10-CM/PCS transition for 13/16 conditions. Three differed: empyema (increased 42%), orbital cellulitis (increased 60%), and sepsis (increased 26%). Complication rates were not significantly different for each condition across the ICD-10-CM/PCS transition, except appendicitis (odds ratio 0.62, 95% CI 0.57-0.68), DKA (OR 3.79, 95% CI 1.92-7.50), and orbital cellulitis (OR 0.53, 95% CI 0.30-0.95). CONCLUSIONS For most conditions, incidences and complication rates were similar before and after the transition to ICD-10-CM/PCS codes, suggesting our system identifies complications of conditions in administrative data similarly using ICD-9-CM/PCS and ICD-10-CM/PCS codes. This system may be applied to screen for cases with complications and in health services research.
Collapse
Affiliation(s)
- Kenneth A Michelson
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Arianna H Dart
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Richard G Bachur
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Prashant Mahajan
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA.,Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | | |
Collapse
|
15
|
Singh R, Thilagawathi T, Mansoor S, Verma M. Diabetes education and basic insulin related knowledge assessment in nursing staff in a tertiary care hospital in India. Int J Diabetes Dev Ctries 2020. [DOI: 10.1007/s13410-020-00815-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
|
16
|
Yu D, Cai Y, Graffy J, Holman D, Zhao Z, Simmons D. Association Between Systolic Blood Pressure and Cardiovascular Inpatient Cost Moderated by Peer-Support Intervention Among Adult Patients With Type 2 Diabetes: A 2-Cohort Study. Can J Diabetes 2020; 45:179-185.e1. [PMID: 33046400 DOI: 10.1016/j.jcjd.2020.07.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 06/08/2020] [Accepted: 07/31/2020] [Indexed: 11/24/2022]
Abstract
OBJECTIVES People with type 2 diabetes and increased systolic blood pressure (SBP) are at high risk of cardiovascular disease (CVD). In this study, we aimed to investigate the association between CVD-related hospital payments and SBP and tested whether this association is influenced by diabetes peer support. METHODS Two cohorts comprising people with type 2 diabetes were included in the study. The first cohort comprised 4,704 patients with type 2 diabetes assessed between 2008 and 2009 from 18 general practices in Cambridgeshire and followed up to 2009-2011. The second cohort comprised 1,121 patients with type 2 diabetes from post-trial follow-up data, recruited between 2011 and 2012 and followed up to 2015. SBP was measured at baseline. Inpatient payments for CVD hospitalization within 2 years since baseline was the main outcome. The impact of 1:1, group or combined diabetes peer support and usual care were investigated in the second cohort. Adjusted mean CVD inpatient payments per person were estimated using a 2-part model after adjusting for baseline characteristics. RESULTS A "hockey-stick" relationship between baseline SBP and estimated CVD inpatient payment was identified in both cohorts, with a threshold at 133 to 141 mmHg, suggesting increased payments for patients with SBP below and above the threshold. The combined peer-support intervention altered the aforementioned association, with no increased payment with SBP above the threshold, and payment slightly decreased with SBP beyond the threshold. CONCLUSIONS SBP maintained between 133 and 141 mmHg is associated with the lowest CVD disease management costs for patients with type 2 diabetes. Combined peer-support intervention could significantly decrease CVD-related hospital payments.
Collapse
Affiliation(s)
- Dahai Yu
- Department of Nephrology, The First Affiliated Hospital, Zhengzhou University, Zhengzhou, China; Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele, United Kingdom
| | - Yamei Cai
- Department of Nephrology, The First Affiliated Hospital, Zhengzhou University, Zhengzhou, China
| | - Jonathan Graffy
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, Cambridgeshire, United Kingdom
| | - Daniel Holman
- Department of Sociological Studies, University of Sheffield, Sheffield, United Kingdom
| | - Zhanzheng Zhao
- Department of Nephrology, The First Affiliated Hospital, Zhengzhou University, Zhengzhou, China.
| | - David Simmons
- Department of Nephrology, The First Affiliated Hospital, Zhengzhou University, Zhengzhou, China; Western Sydney University, Campbelltown, Sydney New South Wales, Australia.
| |
Collapse
|
17
|
Akiboye F, Adderley NJ, Martin J, Gokhale K, Rudge GM, Marshall TP, Rajendran R, Nirantharakumar K, Rayman G. Impact of the Diabetes Inpatient Care and Education (DICE) project on length of stay and mortality. Diabet Med 2020; 37:277-285. [PMID: 31265148 DOI: 10.1111/dme.14062] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/01/2019] [Indexed: 01/09/2023]
Abstract
AIM To determine whether the Diabetes Inpatient Care and Education (DICE) programme, a whole-systems approach to managing inpatient diabetes, reduces length of stay, in-hospital mortality and readmissions. RESEARCH DESIGN AND METHODS Diabetes Inpatient Care and Education initiatives included identification of all diabetes admissions, a novel DICE care-pathway, an online system for prioritizing referrals, use of web-linked glucose meters, an enhanced diabetes team, and novel diabetes training for doctors. Patient administration system data were extracted for people admitted to Ipswich Hospital from January 2008 to June 2016. Logistic regression was used to compare binary outcomes (mortality, 30-day readmissions) 6 months before and after the intervention; generalized estimating equations were used to compare lengths of stay. Interrupted time series analysis was performed over the full 7.5-year period to account for secular trends. RESULTS Before-and-after analysis revealed a significant reduction in lengths of stay for people with and without diabetes: relative ratios 0.89 (95% CI 0.83, 0.97) and 0.93 (95% CI 0.90, 0.96), respectively; however, in interrupted time series analysis the change in long-term trend for length of stay following the intervention was significant only for people with diabetes (P=0.017 vs P=0.48). Odds ratios for mortality were 0.63 (0.48, 0.82) and 0.81 (0.70, 0.93) in people with and without diabetes, respectively; however, the change in trend was not significant in people with diabetes, while there was an apparent increase in those without diabetes. There was no significant change in 30-day readmissions, but interrupted time series analysis showed a rising trend in both groups. CONCLUSION The DICE programme was associated with a shorter length of stay in inpatients with diabetes beyond that observed in people without diabetes.
Collapse
Affiliation(s)
- F Akiboye
- Diabetes Research Unit, Ipswich Hospital NHS Trust, Ipswich, UK
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - N J Adderley
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - J Martin
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - K Gokhale
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - G M Rudge
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - T P Marshall
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - R Rajendran
- Diabetes Research Unit, Ipswich Hospital NHS Trust, Ipswich, UK
| | - K Nirantharakumar
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - G Rayman
- Diabetes Research Unit, Ipswich Hospital NHS Trust, Ipswich, UK
| |
Collapse
|
18
|
Abstract
AIM Diabetes impairs the quality of life of people living with the condition and is a major public health concern. The aim of this paper is to create a state of the nation report of diabetes in the UK. METHODS Diabetes UK collates information about diabetes from diverse sources. This paper synthesizes these data to create a national report. RESULTS Some 7% of the UK population are now living with diabetes; approximately one million people have undiagnosed type 2 diabetes, 40 000 children have diabetes and more than 3000 children are diagnosed every year. Forty-nine per cent of people with type 1 diabetes were offered structured education, but only 7.6% attended; the corresponding figures for type 2 diabetes were 90% and 10.4%, respectively. Among people with diabetes, 28% reported having issues obtaining medication or equipment for self-management. Fifty-seven per cent of people with type 1 diabetes and 42% with type 2 diabetes do not receive all eight annual health checks. Around 40% of people with diabetes have diminished psychological well-being. One-third of people have a microvascular complication at the time of diagnosis of type 2 diabetes. Diabetes is responsible for 530 myocardial infarctions and 175 amputations every week. The National Health Service spends at least £10 billion a year on diabetes, equivalent to 10% of its budget; 80% is spent treating complications. One in six hospital inpatients has diabetes. CONCLUSION Diabetes continues to place a significant burden on the individual with diabetes and wider UK society. This report will be updated annually to understand how diabetes is changing across the UK.
Collapse
Affiliation(s)
- C A Whicher
- Southern Health NHS Foundation Trust, Research & Development Department, Moorgreen Hospital, University of Southampton, Southampton, UK
| | | | - R I G Holt
- Human Development and Health, University of Southampton, Southampton, UK
| |
Collapse
|
19
|
Levy N, Dhatariya K. Pre-operative optimisation of the surgical patient with diagnosed and undiagnosed diabetes: a practical review. Anaesthesia 2019; 74 Suppl 1:58-66. [PMID: 30604420 DOI: 10.1111/anae.14510] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/12/2018] [Indexed: 01/08/2023]
Abstract
Peri-operative hyperglycaemia, whether the cause is known diabetes, undiagnosed diabetes or stress hyperglycaemia, is a risk factor for harm, increased length of stay and death. There is increasing evidence that peri-operative hyperglycaemia is a modifiable risk factor, and many of the interventions required to improve the outcome of surgery must be instituted before the actual surgical admission. These interventions depend on communication and collaboration within the multidisciplinary team along each stage of the patient journey to ensure that integration of care occurs across the whole of the patient-centred care pathway.
Collapse
Affiliation(s)
- N Levy
- Department of Anaesthesia and Peri-operative Medicine, West Suffolk NHS Foundation Trust, Bury St Edmunds, Suffolk, UK
| | - K Dhatariya
- Diabetes and Endocrinology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich Medical School, University of East Anglia, Norwich, UK
| |
Collapse
|
20
|
Ferreira L, Moniz AC, Carneiro AS, Miranda AS, Fangueiro C, Fernandes D, Silva I, Palhinhas I, Lemos J, Antunes J, Leal M, Sampaio N, Faria S. The impact of glycemic variability on length of stay and mortality in diabetic patients admitted with community-acquired pneumonia or chronic obstructive pulmonary disease. Diabetes Metab Syndr 2019; 13:149-153. [PMID: 30641688 DOI: 10.1016/j.dsx.2018.08.028] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 08/27/2018] [Indexed: 01/07/2023]
Abstract
AIM To investigate the influence of glycemic variability (GV) on length of stay and in-hospital mortality in non-critical diabetic patients. METHODS A observation retrospective study was performed. Diabetic patients admitted between January and June 2016 with the diagnosis of community-acquire pneumonia (CAP) and/or acute exacerbation of chronic obstructive pulmonary disease (COPD) were enrolled and glycemic control (persistent hyperglycemia, hypoglycemia, mean glucose level (MGL) and respective standard deviation (SD) and coefficient of variation (CV)) were evaluated. Primary outcomes were length of stay and in-hospital mortality. RESULTS Data from 242 patients were analyzed. Fifty-eight percent of the patients were male, with a median age of 77 years (min-max, 29-98). Patients had on average 2.1 glucose readings-day and the MGL was 193.3 mg/dl (min-max, 84.3-436.6). Hypoglycemia was documented in 13.4% of the patients and 55.4% had persistent hyperglycemia. The median length of hospital stay was 10 days (min-max, 1-66) and in-hospital mortality was 7.4%. We found a significant higher in-hospital mortality in older patients, with history of cancer and with nosocomial infections. We did not find any correlation between MGL, SD, CV, hypoglycemia or persist hyperglycemia and in-hospital mortality. A longer length of stay was observed in patients with heavy alcohol consumption and nosocomial infections. The length of stay was negatively correlated with the mean glucose level (r2-0.147; p < 0.05) and positively correlated with the coefficient of variation (p 0.162; p < 0.05). CONCLUSION This study confirmed the negative impact of the glycemic variability in the outcomes of diabetic patients admitted with CAP or acute exacerbation of COPD.
Collapse
Affiliation(s)
- L Ferreira
- Department of Endocrinology, Centro Hospitalar do Porto, Porto, Portugal.
| | - A C Moniz
- Instituto Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
| | - A S Carneiro
- Instituto Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
| | - A S Miranda
- Instituto Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
| | - C Fangueiro
- Instituto Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
| | - D Fernandes
- Instituto Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
| | - I Silva
- Instituto Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
| | - I Palhinhas
- Instituto Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
| | - J Lemos
- Instituto Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
| | - J Antunes
- Instituto Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
| | - M Leal
- Instituto Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
| | - N Sampaio
- Instituto Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
| | - S Faria
- Instituto Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
| |
Collapse
|
21
|
Yu D, Cai Y, Graffy J, Holman D, Zhao Z, Simmons D. Derivation and external validation of risk algorithms for cerebrovascular (re)hospitalisation in patients with type 2 diabetes: Two cohorts study. Diabetes Res Clin Pract 2018; 144:74-81. [PMID: 30114459 DOI: 10.1016/j.diabres.2018.08.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 07/25/2018] [Accepted: 08/09/2018] [Indexed: 11/26/2022]
Abstract
AIMS Cerebrovascular disease is one of more typical reasons for hospitalisation and re-hospitalisation in people with type 2 diabetes. We aimed to derive and externally validate two risk prediction algorithms for cerebrovascular hospitalisation and re-hospitalisation. METHODS Two independent cohorts were used to derive and externally validate the two risk scores. The development cohort comprises 4704 patients with type 2 diabetes registered in 18 general practices across Cambridgeshire. The validation cohort includes 1121 type 2 patients from a post-trial cohort data. Outcomes were cerebrovascular hospitalisation within two years and cerebrovascular re-hospitalisation within ninety days of the previous cerebrovascular hospitalisation. Logistic regression was applied to derive the two risk scores for cerebrovascular hospitalisation and re-hospitalisation from development cohort, which were externally validated in the validation cohort. RESULTS The incidence of cerebrovascular hospitalisation and re-hospitalisation was 3.76% and 1.46% in the development cohort, and 4.99% and 1.87% in the external validation cohort. Age, gender, body mass index, blood pressures, and lipid profiles were included in the final model. Model discrimination was similar in both cohorts, with all C-statistics > 0.70, and very good calibration of observed and predicted individual risks. CONCLUSION Two new risk scores that quantify individual risks of cerebrovascular hospitalisation and re-hospitalisation have been well derived and externally validated. Both scores are on the basis of a few of clinical measurements that are commonly available for patients with type 2 diabetes in primary care settings and could work as tools to identify individuals at high risk of cerebrovascular hospitalisation and re-hospitalisation.
Collapse
Affiliation(s)
- Dahai Yu
- Department of Nephrology, The First Affiliated Hospital, Zhengzhou University, Zhengzhou 450052, China; Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele ST5 5BG, United Kingdom
| | - Yamei Cai
- Department of Nephrology, The First Affiliated Hospital, Zhengzhou University, Zhengzhou 450052, China
| | - Jonathan Graffy
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, Cambridgeshire CB2 0SR, United Kingdom
| | - Daniel Holman
- Department of Sociological Studies, University of Sheffield, Sheffield S10 2TU, United Kingdom
| | - Zhanzheng Zhao
- Department of Nephrology, The First Affiliated Hospital, Zhengzhou University, Zhengzhou 450052, China.
| | - David Simmons
- Western Sydney University, Campbelltown, Sydney, NSW 2760, Australia.
| |
Collapse
|
22
|
Yu D, Cai Y, Qin R, Graffy J, Holman D, Zhao Z, Simmons D. Total/high density lipoprotein cholesterol and cardiovascular disease (re)hospitalization nadir in type 2 diabetes. J Lipid Res 2018; 59:1745-1750. [PMID: 29959181 DOI: 10.1194/jlr.p084269] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 05/26/2018] [Indexed: 11/20/2022] Open
Abstract
Total cholesterol to HDL cholesterol ratio (TC/HDL) is an important prognostic factor for CVD. This study used restricted cubic spline modeling to investigate the dose-response associations between TC/HDL and both CVD hospitalization and CVD rehospitalization in two independent prospective cohorts. The East Cambridgeshire and Fenland cohort includes 4,704 patients with T2D from 18 general practices in Cambridgeshire. The Randomized controlled trial of Peer Support In type 2 Diabetes cohort comprises 1,121 patients with T2D with posttrial follow-up data. TC/HDL and other demographic and clinical measurements were measured at baseline. Outcomes were CVD hospitalization over 2 years and CVD rehospitalization after 90 days of the prior CVD hospitalization. Modeling showed nonlinear relationships between TC/HDL and risks of CVD hospitalization and rehospitalization consistently in both cohorts (all P < 0.001 for linear tests). The lowest risks of CVD hospitalization and rehospitalization were consistently found for TC/HDL at 2.8 (95% CI: 2.6-3.0) in both cohorts and both overall and by gender. This is lower than the current lipid control target, 4.0 of TC/HDL. Reducing the TC/HDL target to 2.8 would include a further 33-44% patients with TC/HDL in the 2.8-4.0 range. Studies are required to assess the effectiveness and cost-effectiveness of the earlier introduction of, and more intensive, lipid-lowering treatment needed to achieve this new lower TC/HDL target.
Collapse
Affiliation(s)
- Dahai Yu
- Department of Nephrology, the First Affiliated Hospital, Zhengzhou University, Zhengzhou 450052, China; Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele ST5 5BG, United Kingdom
| | - Yamei Cai
- Department of Nephrology, the First Affiliated Hospital, Zhengzhou University, Zhengzhou 450052, China
| | - Rui Qin
- Department of Nephrology, the First Affiliated Hospital, Zhengzhou University, Zhengzhou 450052, China
| | - Jonathan Graffy
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, Cambridgeshire CB2 0SR, United Kingdom
| | - Daniel Holman
- Department of Sociological Studies, University of Sheffield, Sheffield S10 2TU, United Kingdom
| | - Zhanzheng Zhao
- Department of Nephrology, the First Affiliated Hospital, Zhengzhou University, Zhengzhou 450052, China.
| | - David Simmons
- Western Sydney University, Campbelltown, Sydney NSW 2751, Australia.
| |
Collapse
|
23
|
Adderley NJ, Mallett S, Marshall T, Ghosh S, Rayman G, Bellary S, Coleman J, Akiboye F, Toulis KA, Nirantharakumar K. Temporal and external validation of a prediction model for adverse outcomes among inpatients with diabetes. Diabet Med 2018; 35:798-806. [PMID: 29485723 DOI: 10.1111/dme.13612] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/22/2018] [Indexed: 02/06/2023]
Abstract
AIM To temporally and externally validate our previously developed prediction model, which used data from University Hospitals Birmingham to identify inpatients with diabetes at high risk of adverse outcome (mortality or excessive length of stay), in order to demonstrate its applicability to other hospital populations within the UK. METHODS Temporal validation was performed using data from University Hospitals Birmingham and external validation was performed using data from both the Heart of England NHS Foundation Trust and Ipswich Hospital. All adult inpatients with diabetes were included. Variables included in the model were age, gender, ethnicity, admission type, intensive therapy unit admission, insulin therapy, albumin, sodium, potassium, haemoglobin, C-reactive protein, estimated GFR and neutrophil count. Adverse outcome was defined as excessive length of stay or death. RESULTS Model discrimination in the temporal and external validation datasets was good. In temporal validation using data from University Hospitals Birmingham, the area under the curve was 0.797 (95% CI 0.785-0.810), sensitivity was 70% (95% CI 67-72) and specificity was 75% (95% CI 74-76). In external validation using data from Heart of England NHS Foundation Trust, the area under the curve was 0.758 (95% CI 0.747-0.768), sensitivity was 73% (95% CI 71-74) and specificity was 66% (95% CI 65-67). In external validation using data from Ipswich, the area under the curve was 0.736 (95% CI 0.711-0.761), sensitivity was 63% (95% CI 59-68) and specificity was 69% (95% CI 67-72). These results were similar to those for the internally validated model derived from University Hospitals Birmingham. CONCLUSIONS The prediction model to identify patients with diabetes at high risk of developing an adverse event while in hospital performed well in temporal and external validation. The externally validated prediction model is a novel tool that can be used to improve care pathways for inpatients with diabetes. Further research to assess clinical utility is needed.
Collapse
Affiliation(s)
- N J Adderley
- Institute of Applied Health Research, University of Birmingham, Birmingham
| | - S Mallett
- Institute of Applied Health Research, University of Birmingham, Birmingham
| | - T Marshall
- Institute of Applied Health Research, University of Birmingham, Birmingham
| | - S Ghosh
- Diabetes Department, University Hospitals Birmingham NHS Foundation Trust, Birmingham
| | - G Rayman
- Ipswich Hospital NHS Trust, Ipswich
| | - S Bellary
- Heart of England Foundation Trust, Birmingham, UK
| | - J Coleman
- Institute of Applied Health Research, University of Birmingham, Birmingham
| | | | - K A Toulis
- Institute of Applied Health Research, University of Birmingham, Birmingham
- 424 General Military Hospital, Thessaloniki, Greece
| | - K Nirantharakumar
- Institute of Applied Health Research, University of Birmingham, Birmingham
- Diabetes Department, University Hospitals Birmingham NHS Foundation Trust, Birmingham
| |
Collapse
|
24
|
Yu D, Cai Y, Graffy J, Holman D, Zhao Z, Simmons D. Development and External Validation of Risk Scores for Cardiovascular Hospitalization and Rehospitalization in Patients With Diabetes. J Clin Endocrinol Metab 2018; 103:1122-1129. [PMID: 29319819 DOI: 10.1210/jc.2017-02293] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Accepted: 01/03/2018] [Indexed: 02/12/2023]
Abstract
CONTEXT Cardiovascular disease (CVD) is a common and costly reason for hospitalization and rehospitalization among patients with type 2 diabetes. OBJECTIVE This study aimed to develop and externally validate two risk-prediction models for cardiovascular hospitalization and cardiovascular rehospitalization. DESIGN Two independent prospective cohorts. SETTING The derivation cohort includes 4704 patients with type 2 diabetes from 18 general practices in Cambridgeshire. The validation cohort comprises 1121 patients with type 2 diabetes from post-trial follow-up data. MAIN OUTCOME MEASURE Cardiovascular hospitalization over 2 years and cardiovascular rehospitalization after 90 days of the prior CVD hospitalization. RESULTS The absolute rate of cardiovascular hospitalization and rehospitalization was 12.5% and 6.7% in the derivation cohort and 16.3% and 7.0% in the validation cohort. Discrimination of the models was similar in both cohorts, with C statistics above 0.70 and excellent calibration of observed and predicted risks. CONCLUSION Two prediction models that quantify risks of cardiovascular hospitalization and rehospitalization have been developed and externally validated. They are based on a small number of clinical measurements that are available for patients with type 2 diabetes in many developed countries in primary care settings and could serve as the tools to screen the population at high risk of cardiovascular hospitalization and rehospitalization.
Collapse
Affiliation(s)
- Dahai Yu
- Department of Nephrology, The First Affiliated Hospital, Zhengzhou University, Zhengzhou, China
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele, United Kingdom
| | - Yamei Cai
- Department of Nephrology, The First Affiliated Hospital, Zhengzhou University, Zhengzhou, China
| | - Jonathan Graffy
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, Cambridgeshire0SR, United Kingdom
| | - Daniel Holman
- Department of Sociological Studies, University of Sheffield, Sheffield, United Kingdom
| | - Zhanzheng Zhao
- Department of Nephrology, The First Affiliated Hospital, Zhengzhou University, Zhengzhou, China
| | - David Simmons
- Western Sydney University, Campbelltown, Sydney, New South Wales, Australia
| |
Collapse
|
25
|
Abstract
PURPOSE OF REVIEW Diabetes is the most prevalent long-term metabolic condition and its incidence continues to increase unabated. Patients with diabetes are overrepresented in the surgical population. It has been well recognized that poor perioperative diabetes control is associated with poor surgical outcomes. The outcomes are worst for those people who were not recognized as having hyperglycaemia. RECENT FINDINGS Recent work has shown that preoperative recognition of diabetes and good communication between the clinical teams at all stages of the patient pathway help to minimize the potential for errors, and improve glycaemic control. The stages of the patient journey start in primary care and end when the patient goes home. The early involvement of the diabetes specialist team is important if the glycated haemoglobin is more than 8.5%, and advice sought if the preoperative assessment team is not familiar with the drug regimens. To date the glycaemic targets for the perioperative period have remained uncertain, but recently a consensus is being reached to ensure glucose levels remain between 108 and180 mg/dl (6.0 and 10.0 mmol/l). There have been a number of ways to achieve these - primarily by manipulating the patients' usual diabetes medications, to also allow day of surgery admission. SUMMARY glycaemic control remains an important consideration in the surgical patient.
Collapse
|
26
|
Stuart K, Adderley NJ, Marshall T, Rayman G, Sitch A, Manley S, Ghosh S, Toulis KA, Nirantharakumar K. Predicting inpatient hypoglycaemia in hospitalized patients with diabetes: a retrospective analysis of 9584 admissions with diabetes. Diabet Med 2017. [PMID: 28632918 DOI: 10.1111/dme.13409] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
AIMS To explore whether a quantitative approach to identifying hospitalized patients with diabetes at risk of hypoglycaemia would be feasible through incorporation of routine biochemical, haematological and prescription data. METHODS A retrospective cross-sectional analysis of all diabetic admissions (n=9584) from 1 January 2014 to 31 December 2014 was performed. Hypoglycaemia was defined as a blood glucose level of <4 mmol/l. The prediction model was constructed using multivariable logistic regression, populated by clinically important variables and routine laboratory data. RESULTS Using a prespecified variable selection strategy, it was shown that the occurrence of inpatient hypoglycaemia could be predicted by a combined model taking into account background medication (type of insulin, use of sulfonylureas), ethnicity (black and Asian), age (≥75 years), type of admission (emergency) and laboratory measurements (estimated GFR, C-reactive protein, sodium and albumin). Receiver-operating curve analysis showed that the area under the curve was 0.733 (95% CI 0.719 to 0.747). The threshold chosen to maximize both sensitivity and specificity was 0.15. The area under the curve obtained from internal validation did not differ from the primary model [0.731 (95% CI 0.717 to 0.746)]. CONCLUSIONS The inclusion of routine biochemical data, available at the time of admission, can add prognostic value to demographic and medication history. The predictive performance of the constructed model indicates potential clinical utility for the identification of patients at risk of hypoglycaemia during their inpatient stay.
Collapse
Affiliation(s)
- K Stuart
- Institute of Applied Health Research, University of Birmingham, Birmingham
- West Hertfordshire NHS Trust, Hertfordshire
| | - N J Adderley
- Institute of Applied Health Research, University of Birmingham, Birmingham
| | - T Marshall
- Institute of Applied Health Research, University of Birmingham, Birmingham
| | - G Rayman
- Ipswich Hospital NHS Trust, Ipswich
| | - A Sitch
- Institute of Applied Health Research, University of Birmingham, Birmingham
| | - S Manley
- Diabetes Department, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - S Ghosh
- Diabetes Department, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - K A Toulis
- Institute of Applied Health Research, University of Birmingham, Birmingham
- 424 General Military Hospital, Thessaloniki, Greece
| | - K Nirantharakumar
- Institute of Applied Health Research, University of Birmingham, Birmingham
- Diabetes Department, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| |
Collapse
|
27
|
Pournaras DJ, Photi ES, Barnett N, Challand CP, Chatzizacharias NA, Dlamini NP, Doulias T, Foley A, Hernon J, Kumar B, Martin J, Nunney I, Oglesby F, Panagiotopoulou I, Sengupta N, Shivakumar O, Sinclair P, Stather P, Than MM, Wells AC, Xanthis A, Dhatariya K. Assessing the quality of primary care referrals to surgery of patients with diabetes in the East of England: A multi-centre cross-sectional cohort study. Int J Clin Pract 2017; 71. [PMID: 28618177 DOI: 10.1111/ijcp.12971] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 05/10/2017] [Indexed: 01/10/2023] Open
Abstract
AIM Peri-operative hyperglycaemia is associated with an increased incidence of adverse outcomes. Communication between primary and secondary care is paramount to minimise these harms. National guidance in the UK recommends that the glycated haemoglobin (HbA1c) should be measured within 3 months prior to surgery and that the concentration should be less that 69 mmol/mol (8.5%). In addition, national guidance outlines the minimum dataset that should be included in any letter at the time of referral to the surgeons. Currently, it is unclear how well this process is being carried out. This study investigated the quality of information being handed over during the referral from primary care to surgical outpatients within the East of England. METHODS Primary care referrals to nine different NHS hospital Trusts were gathered over a 1-week period. All age groups were included from 11 different surgical specialties. Referral letters were analysed using a standardised data collection tool based on the national guidelines. RESULTS A total of 1919 referrals were received, of whom 169 (8.8%) had previously diagnosed diabetes mellitus (DM). However, of these, 38 made no mention of DM in the referral letter but were on glucose-lowering agents. Only 13 (7.7%) referrals for patients with DM contained a recent HbA1c, and 20 (11.8%) contained no documentation of glucose-lowering medication. CONCLUSION This study has shown that the quality of referral letters to surgical specialties for patients with DM in the East of England remain inadequate. There is a clear need for improving the quality of clinical data contained within referral letters from primary care. In addition, we have shown that the rate of referral for surgery for people with diabetes is almost 50% higher than the background population with diabetes.
Collapse
Affiliation(s)
- Dimitri J Pournaras
- Norfolk and Norwich University Hospitals, Norwich, UK
- Addenbrookes Hospital, Cambridge, UK
| | | | - Nicholas Barnett
- Mid Essex Hospital Services NHS Trust, Broomfield Hospital, Essex, UK
| | | | | | | | | | | | - James Hernon
- Norfolk and Norwich University Hospitals, Norwich, UK
| | - Bhaskar Kumar
- Norfolk and Norwich University Hospitals, Norwich, UK
| | - Jack Martin
- Peterborough City Hospital, Peterborough, UK
| | | | | | | | | | | | | | - Phil Stather
- Queen Elizabeth Hospital Kings Lynn, Norwich, UK
| | | | - Antonia C Wells
- Mid Essex Hospital Services NHS Trust, Broomfield Hospital, Essex, UK
| | | | - Ketan Dhatariya
- Norfolk and Norwich University Hospitals, Norwich, UK
- University of East Anglia, Norwich, UK
| |
Collapse
|
28
|
Mesenchymal stem cells and differentiated insulin producing cells are new horizons for pancreatic regeneration in type I diabetes mellitus. Int J Biochem Cell Biol 2017; 87:77-85. [PMID: 28385600 DOI: 10.1016/j.biocel.2017.03.018] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2016] [Revised: 03/24/2017] [Accepted: 03/28/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Diabetes mellitus has become the third human killer following cancer and cardiovascular disease. Millions of patients, often children, suffer from type 1 diabetes (T1D). Stem cells created hopes to regenerate damaged body tissues and restore their function. AIM This work aimed at clarifying and comparing the therapeutic potential of differentiated and non-differentiated mesenchymal stem cells (MSCs) as a new line of therapy for T1D. METHODS 40 Female albino rats divided into group I (control): 10 rats and group II (diabetic), III and IV, 10 rats in each, were injected with streptozotocin (50mg/kg body weight). Group III (MSCs) were transplanted with bone marrow derived MSCs from male rats and group IV (IPCs) with differentiated insulin producing cells. Blood and pancreatic tissue samples were taken from all rats for biochemical and histological studies. RESULTS MSCs reduced hyperglycemia in diabetic rats on day 15 while IPCs normalizes blood glucose level on day 7. Histological and morphometric analysis of pancreas of experimental diabetic rats showed improvement in MSCs-treated group but in IPCs-treated group, β-cells insulin immunoreactions were obviously returned to normal, with normal distribution of β-cells in the center and other cells at the periphery. Meanwhile, most of the pathological lesions were still detected in diabetic rats. CONCLUSION MSCs transplantation can reduce blood glucose level in recipient diabetic rats. IPCs initiate endogenous pancreatic regeneration by neogenesis of islets. IPCs are better than MSCs in regeneration of β-cells. So, IPCs therapy can be considered clinically to offer a hope for patients suffering from T1D.
Collapse
|
29
|
Yang MH, Jaeger M, Baxter M, VanDenKerkhof E, van Vlymen J. Postoperative dysglycemia in elective non-diabetic surgical patients: a prospective observational study. Can J Anaesth 2016; 63:1319-1334. [DOI: 10.1007/s12630-016-0742-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 06/14/2016] [Accepted: 09/14/2016] [Indexed: 10/20/2022] Open
|
30
|
Akirov A, Dicker D, Shochat T, Shimon I. Mortality risk in admitted patients with diabetes mellitus according to treatment. J Diabetes Complications 2016; 30:1025-31. [PMID: 27138870 DOI: 10.1016/j.jdiacomp.2016.04.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Revised: 04/11/2016] [Accepted: 04/12/2016] [Indexed: 01/04/2023]
Abstract
AIMS Investigate the importance of treating diabetes by evaluating mortality risk of untreated and medically-treated diabetic patients. METHODS Historical prospectively collected observational data of hospitalized patient ≥18years, admitted for any-cause to medical wards, between January 2011 and December 2013. Main outcome was all-cause mortality at end of follow-up. RESULTS Cohort included 35,340 patients (51% male, median age 70years); 24,159 without diabetes and 11,181 with diabetes. Within the diabetic group, 2,188 patients (20%) were not receiving medical treatment for diabetes and 8993 were being treated as follows: 4550 (41%) non-insulin monotherapy; 1550 (14%) non-insulin combination therapy; 2,893 (26%) insulin. Hazard ratios were compared for the entire follow-up, indicating a significant difference in overall survival between medically untreated DM and all groups, except insulin-treated. Subset analysis with adjustment for age, gender, BMI, alcohol and smoking indicated a significant survival difference between untreated DM and all groups. Rates of hypertension, ischemic heart disease, renal failure, and congestive heart disease were higher in the untreated and insulin-treated diabetic patients than in the nondiabetic and diabetic patients on non-insulin treatment. CONCLUSIONS Lack of treatment for diabetes might have serious consequences. Further studies are needed to see if targeted treatment approach may decrease mortality.
Collapse
Affiliation(s)
- Amit Akirov
- Institute of Endocrinology, Rabin Medical Center - Beilinson Hospital, Petach Tikva 49100; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Dror Dicker
- Department of Internal Medicine D, Rabin Medical Center - Beilinson Hospital, Petach Tikva 49100; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tzipora Shochat
- Statistical Consulting Unit, Rabin Medical Center, Beilinson Hospital
| | - Ilan Shimon
- Institute of Endocrinology, Rabin Medical Center - Beilinson Hospital, Petach Tikva 49100; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| |
Collapse
|
31
|
Aldam P, Levy N, Hall GM. Perioperative management of diabetic patients: new controversies. Br J Anaesth 2014; 113:906-9. [PMID: 25080432 DOI: 10.1093/bja/aeu259] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Affiliation(s)
- P Aldam
- Division of Anaesthesia, Addenbrookes Hospital, Cambridge CB2 0QQ, UK
| | - N Levy
- Department of Anaesthesia, West Suffolk Hospital, Bury St Edmunds IP33 2QZ, UK
| | - G M Hall
- Department of Anaesthesia, St George's Hospital Medical School, London SW17 0RE, UK
| |
Collapse
|
32
|
Dhatariya K. Admissions avoidance in diabetes: guidance from the Joint British Diabetes Societies Inpatient Care Group. PRACTICAL DIABETES 2014. [DOI: 10.1002/pdi.1819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
|
33
|
Yu D, Simmons D. Relationship between HbA1c and risk of all-cause hospital admissions among people with Type 2 diabetes. Diabet Med 2013; 30:1407-11. [PMID: 23692400 DOI: 10.1111/dme.12235] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2013] [Revised: 04/15/2013] [Accepted: 05/15/2013] [Indexed: 11/30/2022]
Abstract
AIM To investigate the relationship between HbA(1c) and the 2-year risk of hospitalization among people with Type 2 diabetes. METHODS In total, 4704 patients from 18 general practices in Cambridgeshire were included. Glycaemic exposure was assessed in 2008-2009. The primary outcome was all-cause hospital admissions in 2010-2011. Adjusted relative risks for each HbA(1c) quintile were estimated using Cox models. Further relationships between HbA(1c) and risks were explored using spline models. RESULTS There was a non-linear relationship between HbA(1c) and the risk of all-cause, diabetes and vascular admissions (all P < 0.001 for linearity test) with an HbA(1c) threshold of 61 (95% CI 55-66) mmol/mol [7.7 (95% CI 7.2-8.2)%]. For every 11 mmol/mol (1%) HbA(1c) above the threshold, the risks increased by 6.3% for all-cause admission, 6.4% for a diabetes admission and 15.9% for a cardiovascular admission (all P < 0.001). The overall hospitalization risks of having an HbA(1c) above, rather than at, the threshold, were 19.1 16.3 and 54.3% greater, respectively. There were non-significantly greater risks of hospital admission below the threshold. CONCLUSION In people with Type 2 diabetes, a non-linear relationship exists between HbA(1c) and the risk of hospitalization. A threshold of 61 mmol/mol (7.7%) was associated with the lowest rate of all-cause hospital admissions. Further research should investigate the causes of admissions below and above this threshold, with a view to developing strategies to reduce the excess hospitalization among patients with diabetes.
Collapse
Affiliation(s)
- D Yu
- Institute of Metabolic Science, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | |
Collapse
|
34
|
Dhatariya K, Sampson M, Walton C, Rayman G, Walden E, Kelly T. Comment on: Draznin et al. Pathways to quality inpatient management of hyperglycemia and diabetes: a call to action. Diabetes Care 2013;36:1807-1814. Diabetes Care 2013; 36:e219. [PMID: 24265388 PMCID: PMC3836115 DOI: 10.2337/dc13-1721] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
|
35
|
Gooday C, Hallam C, Sieber C, Mtariswa L, Turner J, Schelenz S, Murchison R, Messenger G, Morrow D, Hutchinson R, Williams H, Dhatariya K. An antibiotic formulary for a tertiary care foot clinic: admission avoidance using intramuscular antibiotics for borderline foot infections in people with diabetes. Diabet Med 2013; 30:581-9. [PMID: 23210933 DOI: 10.1111/dme.12074] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2012] [Revised: 10/08/2012] [Accepted: 11/16/2012] [Indexed: 11/28/2022]
Abstract
AIMS To develop an antibiotic foot formulary for the empirical treatment of diabetes-related foot infections presenting to our service. Subsequently, to asses costs associated with the introduction of our protocol, in particular to assess the effect on admissions avoidance and any cost savings achieved. METHODS We reviewed several existing antibiotic protocols. We analysed data on costs related to treatment and admission rates prior to and after the introduction of the protocol. RESULTS We rationalized our antibiotic protocol and adapted the Infectious Disease Society of America guideline by introducing a category of 'moderate infection-borderline admission' to our classification. This enabled the administration of outpatient intramuscular antibiotics. After introducing the rationalized protocol, our average antibiotic prescribing costs for a 3-week course of treatment fell from £17.12 to £16.42. Over 22 months of follow-up, 26 episodes were eligible for treatment with intramuscular antibiotics. Over the same time period, 121 people were admitted directly from the foot clinic. The costs saved as a result of avoided or delayed admission for those 26 episodes was over £76 000. For 12 people who required subsequent admission, their length of hospital stay was significantly shorter than those admitted directly [9.25 days (range 2-25) vs. 16.11 (2-64), P = 0.045]. CONCLUSIONS By modifying the Infectious Disease Society of America classification and adopting a protocol to administer outpatient oral and intramuscular antibiotics, we have led to substantial cost savings, shorter hospital admissions and also have developed a successful admissions avoidance strategy.
Collapse
Affiliation(s)
- C Gooday
- Diabetic Foot Clinic, Norfolk and Norwich University Hospitals NHS Foundation Trust, Colney Lane, Norwich, UK
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
36
|
Tan HK, Flanagan D. The impact of hypoglycaemia on patients admitted to hospital with medical emergencies. Diabet Med 2013; 30:574-80. [PMID: 23323805 DOI: 10.1111/dme.12123] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2012] [Revised: 11/19/2012] [Accepted: 01/09/2013] [Indexed: 01/01/2023]
Abstract
AIMS To quantify the frequency of biochemical hypoglycaemia in acutely unwell patients in the medical assessment unit and relate this to their subsequent outcomes. METHODS A retrospective audit was conducted on all emergency medical patients attending the medical assessment unit between November 2010 and April 2011. Capillary blood glucose measurements were obtained and electronically stored for all patients. Admission details, presence of diabetes, type of diabetes and treatment, length of stay in hospital and death in hospital were obtained from the hospital clinical coding data and electronic discharge summary. The incidence of hypoglycaemia in patients with and without diabetes was quantified. The mean age, length of stay and percentage of death in hospital were compared between groups with and without hypoglycaemia. RESULTS One hundred and thirty-eight (9.5%) patients with diabetes and 70 (2.7%) patients without diabetes had an episode of hypoglycaemia in the medical assessment unit. Patients with diabetes and hypoglycaemia on admission had a significantly longer length of stay (mean ± sd) (10.3 ± 11.2 vs. 7.3 ± 9.5 days, P = 0.001) and higher rate of hospital mortality (14.5 vs. 5.2%, P < 0.001) compared with those without hypoglycaemia. Patients without diabetes with hypoglycaemia had a longer length of stay (mean ± sd) (9.1 ± 10.5 vs. 6.7 ± 9.9 days, P = 0.05) and a higher rate of hospital mortality (24.3 vs. 5.4%, P < 0.001) compared with those without hypoglycaemia. CONCLUSION Hypoglycaemia is associated with an increased length of stay in hospital and an increased in-hospital mortality rate. Hypoglycaemia may have contributed to the poorer outcome, but would also appear to be a marker of disease severity in unwell patients, especially patients with sepsis.
Collapse
Affiliation(s)
- H K Tan
- Department of Endocrinology, Derriford Hospital, Plymouth, UK
| | | |
Collapse
|
37
|
Herring R, Russell-Jones DL, Pengilley C, Hopkins H, Tuthill B, Wright J, Hordern SV, Davidson S. Management of raised glucose, a clinical decision tool to reduce length of stay of patients with hyperglycaemia. Diabet Med 2013; 30:81-7. [PMID: 22950637 DOI: 10.1111/dme.12006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To assess whether the introduction of a management of raised glucose clinical decision tool could improve assessment of patients with hyperglycaemia by non-specialist physicians, leading to early discharge and improved quality of inpatient care. METHODS Participants were adults aged 18 years or over presenting to the Medical Assessment Unit with a capillary blood glucose level > 11.1 mmol/l. Phase 1 of the study (phase 1) evaluated current clinical practice and potential impact of the clinical decision tool. Phase 2 evaluated the effectiveness of the management of raised glucose tool in clinical practice. Primary outcome measures were inpatient length of stay and same-calendar-day discharges. Secondary outcome measures were diabetes specialist input, patient assessment, intravenous insulin infusion use and patient satisfaction. RESULTS Implementation of the management of raised glucose clinical decision tool allowed safe, same-calendar-day discharges of 40% of patients with hyperglycaemia as their primary reason for attendance. Median length of stay was lower in the phase 1 than in phase 2 (1.0 vs. 3.5 days, P < 0.01). Early discharge did not result in an increase in readmissions. There was improvement in hyperglycaemia assessment for all patients (P < 0.01), a reduction in the use of intravenous insulin infusions (P < 0.01) and high level of patient satisfaction. CONCLUSION The management of raised glucose clinical decision tool resulted in a significant increase in the number of same-calendar-day discharges and reduction in hospital length of stay without adverse impact on readmission rates. Additionally, the tool was associated with improvements in inpatient diabetes care and patient satisfaction.
Collapse
Affiliation(s)
- R Herring
- Centre for Endocrinology, Diabetes and Research, Royal Surrey County Hospital, Guildford, UK
| | | | | | | | | | | | | | | |
Collapse
|
38
|
Rudd B, Patel K, Levy N, Dhatariya K. A Survey of the Implementation of the NHS Diabetes Guidelines for Management of Diabetic Ketoacidosis in the Intensive Care Units of the East of England. J Intensive Care Soc 2013. [DOI: 10.1177/175114371301400112] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
For patients with insulin-treated diabetes, diabetic ketoacidosis (DKA) is a serious acute complication that often leads to intensive care admission. To overcome perceived shortcomings in care, the Joint British Diabetes Societies (JBDS) published national guidelines for the management of DKA in adults in March 2010. A telephone survey of the 13 general adult intensive care units in the East of England during November 2011 examined how widely four key steps of the guidelines had been adopted in the region. The survey demonstrated that while most units had guidelines for the management of DKA, the majority had not adopted the JBDS guidelines. We recommend that future national guidelines for DKA are developed with the participation of the intensive care community and are disseminated to all intensivists.
Collapse
Affiliation(s)
- Bryony Rudd
- Core Trainee Year 2, Acute Care Common Stem, West Suffolk Hospital
| | - Krishna Patel
- Statistical Research Assistant, Intensive Care National Audit & Research Centre, London
| | - Nicholas Levy
- Consultant in Anaesthesia and Critical Care Medicine, West Suffolk Hospital, Bury St Edmonds
| | | |
Collapse
|
39
|
Dhatariya K. Perioperative management of adults with diabetes: why do we need guidance? Br J Hosp Med (Lond) 2012; 73:366-7. [PMID: 22875428 DOI: 10.12968/hmed.2012.73.7.366] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
40
|
Kimani KN, Potluri R, Natalwala A, Ghosh S, Heun R, Narendran P. Length of hospital stay is shorter in black and ethnic minority patients with diabetes. Diabet Med 2012; 29:830-1. [PMID: 22050447 DOI: 10.1111/j.1464-5491.2011.03512.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
41
|
Anwar H, Fischbacher CM, Leese GP, Lindsay RS, McKnight JA, Wild SH. Assessment of the under-reporting of diabetes in hospital admission data: a study from the Scottish Diabetes Research Network Epidemiology Group. Diabet Med 2011; 28:1514-9. [PMID: 21883441 PMCID: PMC4215191 DOI: 10.1111/j.1464-5491.2011.03432.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIMS Good quality data are required to plan and evaluate diabetes services and to assess progress against targets for reducing hospital admissions and bed days. The aim of this study was to assess the completeness of recording of diabetes in hospital admissions using recent national data for Scotland. METHODS Data derived from linkage of the Scottish National Diabetes Register and hospital admissions data were analysed to assess the completeness of coding of diabetes in hospital inpatient admissions between 2000 and 2007 for patients identified with diabetes prior to hospital admission. RESULTS In 2007, only 59% of hospital inpatient admissions for people previously diagnosed with diabetes mentioned diabetes, whereas over 99% of people with a mention of diabetes on hospital records were included in the diabetes register. The completeness of diabetes recording varied from 44 to 82% among mainland National Health Service Boards and from 34 to 89% among large general hospitals. Completeness of recording of diabetes as a co-morbidity also varied by primary diagnosis: 70 and 41% of admissions with coronary heart disease and cancer as the primary diagnosis mentioned co-existing diabetes, respectively. CONCLUSIONS There is wide variation in the completeness of recording of diabetes in hospital admission data. Hospital data alone considerably underestimate the number of admissions and bed days but overestimate length of stay for people with diabetes. Linkage of diabetes register data to hospital admissions data provides a more accurate source for measuring hospital admissions among people diagnosed with diabetes than hospital admissions data.
Collapse
Affiliation(s)
- H Anwar
- Information Services Division, NHS National Services Scotland, Edinburgh, UK.
| | | | | | | | | | | |
Collapse
|
42
|
Daultrey H, Gooday C, Dhatariya K. Increased length of inpatient stay and poor clinical coding: audit of patients with diabetes. JRSM SHORT REPORTS 2011; 2:83. [PMID: 22140609 PMCID: PMC3227384 DOI: 10.1258/shorts.2011.011100] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Objectives People with diabetes stay in hospital for longer than those without diabetes for similar conditions. Clinical coding is poor across all specialties. Inpatients with diabetes often have unrecognized foot problems. We wanted to look at the relationships between these factors. Design A single day audit, looking at the prevalence of diabetes in all adult inpatients. Also looking at their feet to find out how many were high-risk or had existing problems. Setting A 998-bed university teaching hospital. Participants All adult inpatients. Main outcome measures (a) To see if patients with diabetes and foot problems were in hospital for longer than the national average length of stay compared with national data; (b) to see if there were people in hospital with acute foot problems who were not known to the specialist diabetic foot team; and (c) to assess the accuracy of clinical coding. Results We identified 110 people with diabetes. However, discharge coding data for inpatients on that day showed 119 people with diabetes. Length of stay (LOS) was substantially higher for those with diabetes compared to those without (± SD) at 22.39 (22.26) days, vs. 11.68 (6.46) (P < 0.001). Finally, clinical coding was poor with some people who had been identified as having diabetes on the audit, who were not coded as such on discharge. Conclusion Clinical coding – which is dependent on discharge summaries – poorly reflects diagnoses. Additionally, length of stay is significantly longer than previous estimates. The discrepancy between coding and diagnosis needs addressing by increasing the levels of awareness and education of coders and physicians. We suggest that our data be used by healthcare planners when deciding on future tariffs.
Collapse
Affiliation(s)
- Harriet Daultrey
- Norwich Medical School, University of East Anglia , Norwich, Norfolk , UK
| | | | | |
Collapse
|
43
|
Simmons D, Wenzel H. Diabetes inpatients: a case of lose, lose, lose. Is it time to use a 'diabetes-attributable hospitalization cost' to assess the impact of diabetes? Diabet Med 2011; 28:1123-30. [PMID: 21418095 DOI: 10.1111/j.1464-5491.2011.03295.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIMS The UK National Health Service in England pays for inpatients using a formula ('tariff'). The appropriateness of the tariff for people with diabetes is unknown. We have compared the tariff paid and costs for inpatients with/without diabetes and tested the concept of a 'diabetes-attributable hospitalization cost'. METHODS This was a cross-sectional, retrospective 12-month audit in a single teaching hospital assessing mortality, bed days per annum and 'diabetes-attributable hospitalization cost' (i.e. the proportion of costs for all patients with diabetes in excess of that paid for comparable patients without diabetes). RESULTS There were 64 829 inpatient admissions, with 4864 of those coded as having diabetes; 12.9% was estimated to be the number of patients having diabetes but not coded. People with diabetes occupied 13.9% of all bed days and were 18.1% (1.3-37.8%) more likely to die (age adjusted). The mean bed days per annum were greatest among those with (vs. without) diabetes (men 10.9 ± 17.0 vs. 6.3 ± 12.8; women 11.4 ± 19.4 vs. 5.9 ± 11.6; P < 0.001). The greatest excess admission rates were among those aged 25-64 years. The annual mean tariff was greater for those with diabetes (5380 ± 8740) than those without diabetes (3706 ± 6221) (P < 0.001). The overall cost was even higher among those with diabetes: 5835 ± 11 246 vs. 3567 ± 7238 (P < 0.001). The diabetes-attributable hospitalization cost was 46.5% (9 125 085). An HbA(1c) > 10.0% (> 86 mmol/mol) was associated with excess hospitalization. CONCLUSIONS Those with diabetes cost more and are more likely to die when inpatients. The tariff paid for diabetes is high, but in this centre less than the actual costs. Approaches known to reduce hospitalization are urgently required.
Collapse
Affiliation(s)
- D Simmons
- Institute of Metabolic Science, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.
| | | |
Collapse
|
44
|
Abstract
The prevalence of diabetes mellitus (DM) is increasing rapidly in the 21st century as a result of obesity, an ageing population, lack of exercise, and increased migration of susceptible patients. This costly and chronic disease has been likened recently to the 'Black Death' of the 14th century. Type 2 DM is the more common form and the primary aim of management is to delay the micro- and macrovascular complications by achieving good glycaemic control. This involves changes in lifestyle, such as weight loss and exercise, and drug therapy. Increased knowledge of the pathophysiology of diabetes has contributed to the development of novel treatments: glucagon-like peptide-1 (GLP-1) mimetics, dipeptidyl peptidase-4 (DPP-4) inhibitors, thiazolidinediones (TZDs), and insulin analogues. GLP-1 agonists mimic the effect of this incretin, whereas DPP-4 inhibitors prevent the inactivation of the endogenously released hormone. Both agents offer an effective alternative to the currently available hypoglycaemic drugs but further evaluation is needed to confirm their safety and clinical role. The past decade has seen the rise and fall in the use of the TZDs (glitazones), such that the only glitazone recommended is pioglitazone as a third-line treatment. The association between the use of rosiglitazone and adverse cardiac outcomes is still disputed by some authorities. The advent of new insulin analogues, fast-acting, and basal release formulations, has enabled the adoption of a basal-bolus regimen for the management of blood glucose. This regimen aims to provide a continuous, low basal insulin release between meals with bolus fast-acting insulin to limit hyperglycaemia after meals. Insulin therapy is increasingly used in type 2 DM to enhance glycaemic control. Recently, it has been suggested that the use of the basal-release insulins, particularly insulin glargine may be associated with an increased risk of cancer. Although attention is focused increasingly on newer agents in the treatment of diabetes, metformin and the sulphonylureas are still used in many patients. Metformin, in particular, remains of great value and may have novel anti-cancer properties.
Collapse
Affiliation(s)
- G Nicholson
- Department of Anaesthesia and Intensive Care Medicine, St George's University of London, Cranmer Terrace, London SW17 0RE, UK
| | | |
Collapse
|
45
|
Abstract
AIMS At any given time, people with diabetes occupy approximately 10-20% of acute hospital beds. In addition, diabetes is associated with a greater length of stay. Patients undergoing elective procedures occupy approximately 50% of hospital beds. The aim of this 12-month project was to improve the quality of diabetes care for elective inpatients. The primary outcome measure was length of stay. METHODS A team was established to improve the quality of care and reduce the length of stay of all patients admitted electively with diabetes. Specific areas of focus were surgical pre-assessment, planning the admission, post-operative care and planning a safe discharge. A retrospective audit of all elective patients with a coded diagnosis of diabetes admitted between June 2008 and June 2009 was performed. RESULTS Comparing the year of the project with the preceding year day-case rates for patients with diabetes increased by 34.8% for diabetes vs. 13.7% for the total hospital population (P for difference=0.048). There was a significant fall in diabetes length of stay of 0.34 days comparing 2008 and 2009 (P=0.040). Over the same period, we have shown a smaller reduction in length of stay for all other admissions of 0.08 days (p=0.039). CONCLUSION A team specifically employed to focus on elective inpatient diabetes care have a significant impact on length of stay of this patient group with potential cost savings.
Collapse
Affiliation(s)
- D Flanagan
- Department of Endocrinology, Plymouth Diabetes Service, Derriford Hospital, Plymouth.
| | | | | | | | | |
Collapse
|
46
|
Abstract
AIMS We analysed the in-hospital costs of diabetic patients admitted to English hospitals and aimed to assess what proportions of cost variation are explained by patient and hospital characteristics. METHODS We used Hospital Episode Statistics and reference costs for all patients admitted to diabetes care for all English hospitals for the financial year 2005/2006. Our sample included 31 371 patients admitted to 148 hospitals. We applied a multi-level approach. We analysed the relationship between patient costs and patient characteristics. We estimated the average cost of being treated in each hospital after controlling for patient characteristics. In addition, we explored why these average costs vary across hospitals. RESULTS Much of the variation in the costs of controlling diabetes was driven by the Healthcare Resource Group to which the patient was allocated, but costs were also higher for patients who were transferred between hospitals, suffered infections and other complications, or for those who died in hospital. Even so, approximately 8-9% of the variation in costs was related to the hospital in which the patient was treated, with geographical variation in factor prices being the prime reason for this variation. The volume of patients, and the number and diversity of specialties involved in caring for diabetic patients did not explain the variation in the cost of treating diabetic patients across hospitals. CONCLUSIONS Healthcare Resource Groups and diagnostic markers are significant patient-related cost drivers in diabetes care. Costs are not lower in hospitals with a high volume of patients and where diabetes care is concentrated in few specialties.
Collapse
Affiliation(s)
- T Kristensen
- Department of Health Economics, Faculty of Social Sciences, Institute of Public Health, University of Southern Denmark, Odense, Denmark.
| | | | | | | |
Collapse
|
47
|
Pehmøller C, Treebak JT, Birk JB, Chen S, Mackintosh C, Hardie DG, Richter EA, Wojtaszewski JFP. Genetic disruption of AMPK signaling abolishes both contraction- and insulin-stimulated TBC1D1 phosphorylation and 14-3-3 binding in mouse skeletal muscle. Am J Physiol Endocrinol Metab 2009; 297:E665-75. [PMID: 19531644 PMCID: PMC2739697 DOI: 10.1152/ajpendo.00115.2009] [Citation(s) in RCA: 120] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
TBC1D1 is a Rab-GTPase-activating protein (GAP) known to be phosphorylated in response to insulin, growth factors, pharmacological agonists that activate 5'-AMP-activated protein kinase (AMPK), and muscle contraction. Silencing TBC1D1 in L6 muscle cells by siRNA increases insulin-stimulated GLUT4 translocation, and overexpression of TBC1D1 in 3T3-L1 adipocytes with low endogenous TBC1D1 expression inhibits insulin-stimulated GLUT4 translocation, suggesting a role of TBC1D1 in regulating GLUT4 translocation. Aiming to unravel the regulation of TBC1D1 during contraction and the potential role of AMPK in intact skeletal muscle, we used EDL muscles from wild-type (WT) and AMPK kinase dead (KD) mice. We explored the site-specific phosphorylation of TBC1D1 Ser(237) and Thr(596) and their relation to 14-3-3 binding, a proposed mechanism for regulation of GAP function of TBC1D1. We show that muscle contraction increases 14-3-3 binding to TBC1D1 as well as phosphorylation of Ser(237) and Thr(596) in an AMPK-dependent manner. AMPK activation by AICAR induced similar Ser(237) and Thr(596) phosphorylation of, and 14-3-3 binding to, TBC1D1 as muscle contraction. Insulin did not increase Ser(237) phosphorylation or 14-3-3 binding to TBC1D1. However, insulin increased Thr(596) phosphorylation, and intriguingly this response was fully abolished in the AMPK KD mice. Thus, TBC1D1 is differentially regulated in response to insulin and contraction. This study provides genetic evidence to support an important role for AMPK in regulating TBC1D1 in response to both of these physiological stimuli.
Collapse
Affiliation(s)
- Christian Pehmøller
- Molecular Physiology Group, Copenhagen Muscle Research Centre, Dept. of Exercise and Sport Sciences, Univ. of Copenhagen, DK-2100, Copenhagen, Denmark
| | | | | | | | | | | | | | | |
Collapse
|
48
|
Sampson MJ, Singh H, Dhatariya KK, Jones C, Walden E, Bradley C. Psychometric validation and use of a novel diabetes in-patient treatment satisfaction questionnaire. Diabet Med 2009; 26:729-35. [PMID: 19573123 DOI: 10.1111/j.1464-5491.2009.02754.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
AIMS To develop the first psychometrically validated Diabetes Treatment Satisfaction Questionnaire for in-patients (DTSQ-IP) and examine determinants of in-patient diabetes treatment satisfaction. METHODS We studied 366 in-patients with insulin-treated diabetes at a single UK centre. We developed a 19-item DTSQ-IP to assess in-patient diabetes treatment satisfaction, and collected data on in-patient length of stay (LOS) and in-patient care at the same time. RESULTS Psychometric analyses including Principal Components Analysis and Cronbach's alpha reliability coefficient showed that a single satisfaction score (excluding two items scored individually) can be computed for the entire DTSQ-IP, indicating very good internal consistency reliability (0.92). The DTSQ-IP detected considerable dissatisfaction with meal choice and timing (13.7% of in-patients would never have chosen similar meals at home), and with in-patient hypoglycaemia (35.3% felt that their blood glucose was too low most of the time). In-patients on surgical wards, women, and those long established on insulin were significantly more dissatisfied, particularly with competence of hospital staff. Patients who administered their own insulin were not significantly less dissatisfied overall, but were so with the choice of meals (P = 0.005). Multiple regression analysis produced a model accounting for 8.2% of variability in DTSQ-IP (r = 0.29; P = 0.0058) and 21.7% of variability in LOS (r = 0.46; P = 0.0001). CONCLUSIONS The DTSQ-IP is a novel, psychometrically validated and sensitive tool that adds to the DTSQ portfolio. The DTSQ-IP facilitates efforts to assess and improve treatment satisfaction in in-patients with diabetes.
Collapse
Affiliation(s)
- M J Sampson
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospital NHS Trust, Norwich, UK.
| | | | | | | | | | | |
Collapse
|
49
|
Abstract
AIMS At any given time, people with diabetes occupy approximately 5-10% of acute hospital beds. In addition, diabetes is associated with a greater length of stay (LOS). This is partially because of increased complexity of the cases but also because of unfamiliarity of dealing with the condition by other specialist teams. METHODS In 2002, with increasing pressure on acute hospital beds, a team was established to improve the care of inpatients with diabetes admitted to Derriford Hospital. The team consisted of five diabetes specialist nurses dedicated to inpatient care, supported by a consultant and specialist registrar diabetologist. A link nurse responsible for diabetes was appointed on every ward and each individual with a diagnosis of diabetes was identified on admission. We have compared LOS of all patients with diabetes admitted between January 2002 and December 2006. RESULTS LOS fell from a mean +/- se of 8.3 +/- 0.18 days in 2002 to 7.7 +/- 0.10 days in 2006 (P = 0.002). Significant falls were seen for emergency admissions (9.7 +/- 0.23 vs. 9.2 +/- 0.20, P < 0.001) but not elective admissions. The data show significant reductions in LOS for medical admissions (9.2 +/- 0.24 vs. 8.4 +/- 0.20, P < 0.001) but not surgical admissions. Over the same period, LOS for the total hospital population fell by 0.3 days (P < 0.001). CONCLUSION In conclusion, a team specifically employed to focus on inpatient diabetes care has a significant impact on LOS of this patient group.
Collapse
Affiliation(s)
- D Flanagan
- Plymouth Diabetes Service, Derriford Hospital, Plymouth, UK.
| | | | | | | | | |
Collapse
|