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Monteiro Lopes S, Maia A, Melo P, Abreu S, Paiva I, Barros L. [Non-Insulin Antidiabetic Agents in the Management of Hyperglycaemia of Non-Critical Hospitalized Patients]. ACTA MEDICA PORT 2024; 37:207-214. [PMID: 38316163 DOI: 10.20344/amp.20858] [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: 10/24/2023] [Accepted: 01/16/2024] [Indexed: 02/07/2024]
Abstract
Hyperglycaemia affects more than 30% of adults hospitalized for non-critical illness and is associated with an increased risk of adverse clinical outcomes. Insulin therapy is widely used for its safety and efficacy. However, given the growing availability of new drugs and new classes of antidiabetic agents with benefits beyond glycaemic control, challenges arise regarding their use in the hospital setting. This article aims to review and summarize the most recently available evidence and recommendations on the role of non-insulin antidiabetic agents in the management of hyperglycaemia in hospitalized patients. Insulin therapy remains the method of choice. Dipeptidyl peptidase 4 inhibitors can be considered in mild to moderate hyperglycaemia. Glucagon-like peptide 1 receptor agonists have recently shown promising results, with high efficacy in glycaemic control and low risk of hypoglycaemia. There are concerns regarding the increased risk of acidosis with metformin use, especially in cases of acute illness, although there is no evidence to support its suspension in selected patients with relative clinical stability. Sodium-glucose cotransporter-2 inhibitors should be discontinued in clinical situations that may predispose to ketoacidosis, including episodes of acute illness. The hospital use of sulfonylureas and thiazolidinediones is not advised.
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Affiliation(s)
- Sofia Monteiro Lopes
- Grupo de Estudos de Diabetes. Sociedade Portuguesa de Endocrinologia, Diabetes e Metabolismo. Lisboa; Serviço de Endocrinologia, Diabetes e Metabolismo. Centro Hospitalar e Universitário de Coimbra. Coimbra. Portugal
| | - Ariana Maia
- Grupo de Estudos de Diabetes. Sociedade Portuguesa de Endocrinologia, Diabetes e Metabolismo. Lisboa; Serviço de Endocrinologia. Centro Hospitalar Universitário do Porto. Porto. Portugal
| | - Pedro Melo
- Grupo de Estudos de Diabetes. Sociedade Portuguesa de Endocrinologia, Diabetes e Metabolismo. Lisboa; Serviço de Endocrinologia. Unidade Local de Saúde de Matosinhos. Portugal
| | - Silvestre Abreu
- Grupo de Estudos de Diabetes. Sociedade Portuguesa de Endocrinologia, Diabetes e Metabolismo. Lisboa; Serviço Regional de Saúde da Região Autónoma da Madeira. Funchal. Portugal
| | - Isabel Paiva
- Grupo de Estudos de Diabetes. Sociedade Portuguesa de Endocrinologia, Diabetes e Metabolismo. Lisboa; Serviço de Endocrinologia, Diabetes e Metabolismo. Centro Hospitalar e Universitário de Coimbra. Coimbra. Portugal
| | - Luísa Barros
- Grupo de Estudos de Diabetes. Sociedade Portuguesa de Endocrinologia, Diabetes e Metabolismo. Lisboa; Serviço de Endocrinologia, Diabetes e Metabolismo. Centro Hospitalar e Universitário de Coimbra. Coimbra. Portugal
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Dei Cas A, Aldigeri R, Ridolfi V, Vazzana A, Ciardullo AV, Manicardi V, Sforza A, Tomasi F, Zavaroni D, Zavaroni I, Bonadonna RC. Efficacy of a training programme for the management of diabetes mellitus in the hospital: A randomized study (stage 2 of GOVEPAZ healthcare). Diabetes Metab Res Rev 2023; 39:e3708. [PMID: 37574863 DOI: 10.1002/dmrr.3708] [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: 09/22/2021] [Revised: 05/24/2023] [Accepted: 06/25/2023] [Indexed: 08/15/2023]
Abstract
AIMS To assess the efficacy of a structured educational intervention for health professionals on the appropriateness of inpatient diabetes care and on some clinical outcomes in hospitalised subjects. METHODS A multicentre (6 regional hospitals) cluster-randomized (2:1) two parallel-group pragmatic intervention trials, as a part of the GOVEPAZ study, was conducted in three clinical settings, that is, Internal Medicine, Surgery and Intensive Care. Intervention consisted of a 2-month structured education of clinical staff to inpatient diabetes care. Twelve wards - 2 for each hospital - and 6 wards - 1 for each hospital - were randomized to usual care and to the intervention arm, respectively. Consecutively hospitalised diabetic subjects (n = 524, age 74 ± 14 years, 57% males, median HbA1C 57 mmol/mol) were included. The clinical appropriateness of inpatient diabetes management was assessed by a previously validated multi-domain performance score (PS). Clinical outcomes included hypoglycemia, glucose control biomarkers, clinical conditions at discharge and inpatient mortality rate. RESULTS A numerically, but not statistically significant, higher PS (+0.94; 95% C.I.: -0.53 - +2.4) was achieved in the intervention than in the usual care wards. Hypoglycemias (p = 0.32), glucose control (p = 0.89) and survival rates (p = 0.71) were similar in the two experimental arms. Plasma glucose on admission (OR = 1.52 per 1 SD; C.I. 1.07-2.17; p = 0.021) and the number of hypoglycemic events per patient (OR = 1.55 per 1 SD; C.I.:1.11-2.16; p = 0.011) were independently associated with the inpatient mortality rate. CONCLUSIONS Structured education of the clinical staff failed to improve the inpatient appropriateness of diabetes care or clinical outcomes. In-hospital hypoglycemia was confirmed to be an independent indicator of death risk.
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Affiliation(s)
- Alessandra Dei Cas
- Department of Medicine and Surgery, Università di Parma, Parma, Italy
- Division of Endocrinology and Metabolic Diseases, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | | | - Valentina Ridolfi
- Department of Medicine and Surgery, Università di Parma, Parma, Italy
- Division of Endocrinology and Metabolic Diseases, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Angela Vazzana
- Division of Endocrinology and Metabolic Diseases, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | | | | | | | | | | | - Ivana Zavaroni
- Department of Medicine and Surgery, Università di Parma, Parma, Italy
- Division of Endocrinology and Metabolic Diseases, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Riccardo C Bonadonna
- Department of Medicine and Surgery, Università di Parma, Parma, Italy
- Division of Endocrinology and Metabolic Diseases, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
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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.
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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
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Galindo RJ, Dhatariya K, Gomez-Peralta F, Umpierrez GE. Safety and Efficacy of Inpatient Diabetes Management with Non-insulin Agents: an Overview of International Practices. Curr Diab Rep 2022; 22:237-246. [PMID: 35507117 PMCID: PMC9065239 DOI: 10.1007/s11892-022-01464-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/14/2022] [Indexed: 12/25/2022]
Abstract
PURPOSE OF REVIEW The field of inpatient diabetes has advanced significantly over the last 20 years, leading to the development of personalized treatment approaches. However, outdated guidelines still recommend the use of basal-bolus insulin therapy as the preferred treatment approach, and against the use of non-insulin anti-hyperglycemic agents. RECENT FINDINGS Several observational and prospective randomized controlled studies have demonstrated that oral anti-hyperglycemic agents are widely used in the hospital, including studies of DPP-4 agents and GLP-1 agonists. With advances in the field of inpatient diabetes management, a paradigm shift has occurred, from an approach of recommending "basal-bolus regimens" for all patients to a more precision medicine option for hospitalized non-critically ill patients with type 2 diabetes.
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Affiliation(s)
- Rodolfo J Galindo
- Associate Professor of Medicine, Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, USA.
| | - Ketan Dhatariya
- Consultant Diabetes & Endocrinology / Honorary Professor, Norwich Medical School, Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals, NHS Foundation Trust, Norwich, UK
| | | | - Guillermo E Umpierrez
- Professor of Medicine, Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, USA
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Use of antihyperglycaemic therapy with cardiovascular benefit in patients with type 2 diabetes who require hospitalisation: A cross-sectional study. Rev Clin Esp 2021; 221:517-528. [PMID: 34752263 DOI: 10.1016/j.rceng.2019.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Accepted: 12/26/2019] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To evaluate the use of therapy with cardiovascular benefit in patients with type 2 diabetes mellitus admitted to internal medicine departments. METHODS One day, cross-sectional study of patients with type 2 diabetes mellitus hospitalised in internal medicine departments. We recorded demographic and anthropometric variables, laboratory data and use of antihyperglycaemic drugs. The endpoint was the proportion and determinants of the use of sodium-glucose cotransporter-2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP1-RA). RESULTS We included 928 patients belonging to 74 hospitals, with a mean age of 78.9 years (SD, 10.86 years), 50% of whom were men. A total of 557 (60%) patients had ischaemic heart disease, 189 (20.4%) had cerebrovascular disease, 293 (31.6%) had heart failure, 274 (29.5%) had chronic kidney disease, and 129 (13.9%) had peripheral arterial disease. Prior to their hospital admission, the patients were taking sulfonylureas (5.7%), biguanides (49.1%), alpha-glucosidase inhibitors (0.2%), pioglitazone (0%), dipeptidyl peptidase 4 inhibitors (39%), SGLT2i (5.8%), GLP1-RA (2.6%) and basal insulin analogues (24%). An age over 75 years was the main determinant for not taking SGLT2i (adjusted OR, 0.28; 95% CI 0.10-0.74; p = .039) or GLP1-RA (adjusted OR, 0.09; 95% CI 0.02-0.46; p = .006). DISCUSSION A large proportion of elderly patients with type 2 diabetes mellitus at very high cardiovascular risk are not treated with antihyperglycemic drugs with proven cardiovascular benefit. The most commonly used drugs were metformin and DPP4i. There is room for improvement in the treatment of this very high-risk population.
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Russo MP, Fosser SNM, Elizondo CM, Giunta DH, Fuentes NA, Grande-Ratti MF. In-Hospital Mortality and Glycemic Control in Patients with Hospital Hyperglycemia. Rev Diabet Stud 2021; 17:50-56. [PMID: 34852895 PMCID: PMC9380085 DOI: 10.1900/rds.2021.17.50] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Stress-induced hyperglycemia is a phenomenon that occurs typically in patients hospitalized for acute disease and resolves spontaneously after regression of the acute illness. However, it can also occur in diabetes patients, a fact that is sometimes overlooked. It is thus important to make a proper diabetes diagnosis if hospitalized patients with episodes of hyperglycemia with and without diabetes are studied. AIMS To estimate the extent of the association between stress-induced hyperglycemia and in-hospital mortality in patients with hospital hyperglycemia (HH), and to explore potential differences between patients diagnosed with diabetes (HH-DBT) and those with stress-induced hyperglycemia (SH), but not diagnosed with diabetes. METHODS A cohort of adults with hospital hyperglycemia admitted to a tertiary, university hospital in Buenos Aires, Argentina, was analyzed retrospectively. RESULTS In the study, 2,955 patients were included and classified for analysis as 1,579 SH and 1,376 HH-DBT. Significant differences were observed in glycemic goal (35.53% SH versus 25.80% HH-DBT, p < 0.01), insulin use rate (26.66% SH versus 46.58% HH-DBT, p < 0.01), and severe hypoglycemia rate (1.32% SH versus 1.74% HH-DBT, p < 0.01). There were no differences in hypoglycemia rate (8.23% SH versus 10.53% HH-DBT) and hospital mortality. There was no increase in risk of mortality in the SH group adjusted for age, non-scheduled hospitalization, major surgical intervention, critical care, hypoglycemia, oncological disease, cardiovascular comorbidity, and prolonged hospitalization. CONCLUSIONS In this study, we observed better glycemic control in patients with SH than in those with HH-DBT, and there was no difference in hospital mortality.
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Affiliation(s)
- María Paula Russo
- Internal Medicine Research Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Santiago Nicolas Marquez Fosser
- Clinical and Health Informatics Research Group, McGill University, Montr??al, Qu??bec, Canada; Department of Health Informatics, Hospital Italiano de Buenos Aires, Ciudad de Buenos Aires, Argentina
| | | | - Diego Hernán Giunta
- Internal Medicine Research Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | | | - María Florencia Grande-Ratti
- Internal Medicine Research Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina; Department of Health Informatics, Hospital Italiano de Buenos Aires, Ciudad de Buenos Aires, Argentina
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Corrao S, Nobili A, Natoli G, Mannucci PM, Perticone F, Pietrangelo A, Argano C. Hyperglycemia at admission, comorbidities, and in-hospital mortality in elderly patients hospitalized in internal medicine wards: data from the RePoSI Registry. Acta Diabetol 2021; 58:1225-1236. [PMID: 33890176 PMCID: PMC8316168 DOI: 10.1007/s00592-021-01716-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 03/31/2021] [Indexed: 12/22/2022]
Abstract
AIMS The association between hyperglycemia at hospital admission and relevant short- and long-term outcomes in elderly population is known. We assessed the effects on mortality of hyperglycemia, disability, and multimorbidity at admission in internal medicine ward in patients aged ≥ 65 years. METHODS Data were collected from an active register of 102 internal medicine and geriatric wards in Italy (RePoSi project). Patients were recruited during four index weeks of a year. Socio-demographic data, reason for hospitalization, diagnoses, treatment, severity and comorbidity indexes (Cumulative Illness rating Scale CIRS-SI and CIRS-CI), renal function, functional (Barthel Index), and cognitive status (Short Blessed Test) and mood disorders (Geriatric Depression Scale) were recorded. Mortality rates were assessed in hospital 3 and 12 months after discharge. RESULTS Of the 4714 elderly patients hospitalized, 361 had a glycemia level ≥ 250 mg/dL at admission. Compared to subjects with lower glycemia level, patients with glycemia ≥ 250 mg/dL showed higher rates of male sex, smoke and class III obesity. These patients had a significantly lower Barthel Index (p = 0.0249), higher CIRS-SI and CIRS-CI scores (p = 0.0025 and p = 0.0013, respectively), and took more drugs. In-hospital mortality rate was 9.2% and 5.1% in subjects with glycemia ≥ 250 and < 250 mg/dL, respectively (p = 0.0010). Regression analysis showed a strong association between in-hospital death and glycemia ≥ 250 mg/dL (OR 2.07; [95% CI 1.34-3.19]), Barthel Index ≤ 40 (3.28[2.44-4.42]), CIRS-SI (1.87[1.27-2.77]), and male sex (1.54[1.16-2.03]). CONCLUSIONS The stronger predictors of in-hospital mortality for older patients admitted in general wards were glycemia level ≥ 250 mg/dL, Barthel Index ≤ 40, CIRS-SI, and male sex.
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Affiliation(s)
- Salvatore Corrao
- Department of Internal Medicine, UOC Medicina Interna 2 iGR, National Relevance Hospital Trust, ARNAS Civico, Di Cristina e Benfratelli, Piazza Nicola Leotta, 4 - 90127, Palermo, Italy.
- Biomedical Department of Internal Medicine and Medical Specialties (DiBiMIS), University of Palermo, Palermo, Italy.
| | - Alessandro Nobili
- Department of Neuroscience, IRCCS Istituto Di Ricerche Farmacologiche Mario Negri, Milan, Italy
| | - Giuseppe Natoli
- Department of Internal Medicine, UOC Medicina Interna 2 iGR, National Relevance Hospital Trust, ARNAS Civico, Di Cristina e Benfratelli, Piazza Nicola Leotta, 4 - 90127, Palermo, Italy
| | | | - Francesco Perticone
- Department of Medical and Surgical Sciences, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Antonello Pietrangelo
- Department of Internal Medicine II, CenterforHemochromatosis, University of Modena and Reggio Emilia Policlinico, Modena, Italy
| | - Christiano Argano
- Department of Internal Medicine, UOC Medicina Interna 2 iGR, National Relevance Hospital Trust, ARNAS Civico, Di Cristina e Benfratelli, Piazza Nicola Leotta, 4 - 90127, Palermo, Italy
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Carrasco-Sánchez FJ, Fernández-Rodríguez JM, Ena J, Gómez-Huelgas R, Carretero-Gómez J. Medical treatment of type 2 diabetes mellitus: Recommendations of the Diabetes, Obesity and Nutrition Group of the Spanish Society of Internal Medicine. Rev Clin Esp 2021; 221:101-108. [PMID: 32674850 DOI: 10.1016/j.rce.2020.06.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 06/04/2020] [Accepted: 06/05/2020] [Indexed: 02/08/2023]
Abstract
Type 2 diabetes mellitus is a major health problem with high prevalence, morbidity and mortality, and its medical treatment is growing in complexity due to patients' diverse clinical conditions. This article presents a consensus document by the Diabetes, Obesity and Nutrition Group of the Spanish Society of Internal Medicine, with recommendations for the medical treatment of type 2 diabetes mellitus. The main objective of this article is to facilitate the therapeutic decision-making process to improve the care of patients with diabetes. The document prioritises treatments with cardiovascular benefits, especially those that benefit patients with heart and renal failure.
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Affiliation(s)
- F J Carrasco-Sánchez
- Área de Insuficiencia Cardíaca, Diabetes y Riesgo Vascular, Unidad de Gestión Clínica de Medicina Interna y Cuidados Paliativos, Hospital Universitario Juan Ramón Jiménez, Huelva, España.
| | - J M Fernández-Rodríguez
- Servicio de Medicina Interna, Hospital Carmen y Severo Ochoa, Cangas de Narcea, Asturias, España
| | - J Ena
- Servicio de Medicina Interna, Hospital Marina Baixa, Alicante, España
| | - R Gómez-Huelgas
- Centro de Investigación Biomédica en Red de Fisiopatología de la Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III, Servicio de Medicina Interna, Hospital Regional Universitario de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA), Universidad de Málaga, Málaga, España
| | - J Carretero-Gómez
- Servicio de Medicina Interna, Hospital de Zafra, Zafra, Badajoz, España
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Medical treatment of type 2 diabetes mellitus: Recommendations of the Diabetes, Obesity and Nutrition Group of the Spanish Society of Internal Medicine. Rev Clin Esp 2020; 221:101-108. [PMID: 33998485 DOI: 10.1016/j.rceng.2020.06.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 06/05/2020] [Indexed: 11/21/2022]
Abstract
Type 2 diabetes is a big health concern due to its high prevalence and morbi-mortality. Medical treatment has a growing complexity which is focus on patients' clinical situations. This article contains a consensus statement about recommendations on medical treatment of type-2 diabetes from the Working Group of Diabetes, Obesity and Nutrition of Spanish Society of Internal Medicine. The aim of this consensus is to facilitate therapeutic decision-making to improve the diabetes patients care. The document prioritizes treatments with cardiovascular, especially heart failure, and real benefits.
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Dei Cas A, Aldigeri R, Ridolfi V, Vazzana A, Ciardullo AV, Manicardi V, Sforza A, Tomasi F, Zavaroni D, Zavaroni I, Bonadonna RC. A performance score of the quality of inpatient diabetes care is a marker of clinical outcomes and suggests a cause-effect relationship between hypoglycaemia and the risk of in-hospital mortality. Diabetes Metab Res Rev 2020; 36:e3347. [PMID: 32445284 DOI: 10.1002/dmrr.3347] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 05/04/2020] [Accepted: 05/10/2020] [Indexed: 12/17/2022]
Abstract
AIMS To build a tool to assess the management of inpatients with diabetes mellitus and to investigate its relationship, if any, with clinical outcomes. MATERIALS AND METHODS A total of 678 patients from different settings, Internal Medicine (IMU, n = 255), General Surgery (GSU, n = 230) and Intensive Care (ICU, n = 193) Units, were enrolled. A work-flow of clinical care of diabetes was created according to guidelines. The workflow was divided into five different domains: (a) initial assessment; (b) glucose monitoring; (c) medical therapy; (d) consultancies; (e) discharge. Each domain was assessed by a performance score (PS), computed as the sum of the scores achieved in a set of indicators of clinical appropriateness, management and patient empowerment. Appropriate glucose goals were included as intermediate phenotypes. Clinical outcomes included: hypoglycaemia, survival rate and clinical conditions at discharge. RESULTS The total PS and those of initial assessment and glucose monitoring were significantly lower in GSU with respect to IMU and ICU (P < .0001). The glucose monitoring PS was associated with lower risk of hypoglycaemia (OR = 0.55; P < .0001), whereas both the PSs of glucose monitoring and medical therapy resulted associated with higher in-hospital survival only in the IMU ward (OR = 6.67 P = .001 and OR = 2.38 P = .03, respectively). Instrumental variable analysis with the aid of PS of glucose monitoring showed that hypoglycaemia may play a causal role in in-hospital mortality (P = .04). CONCLUSIONS The quality of in-hospital care of diabetes may affect patient outcomes, including glucose control and the risk of hypoglycaemia, and through the latter it may influence the risk of in-hospital mortality.
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Affiliation(s)
- Alessandra Dei Cas
- Department of Medicine and Surgery, Università di Parma, Parma, Italy
- Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | | | - Valentina Ridolfi
- Department of Medicine and Surgery, Università di Parma, Parma, Italy
- Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Angela Vazzana
- Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | | | | | | | | | | | - Ivana Zavaroni
- Department of Medicine and Surgery, Università di Parma, Parma, Italy
- Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Riccardo C Bonadonna
- Department of Medicine and Surgery, Università di Parma, Parma, Italy
- Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
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Ena J, Carretero-Gómez J, Zapatero-Gaviria A, Carrasco Sánchez FJ, Del Romero-Sánchez M, González-Becerra C, Blazquez-Encinar JC, Iguzquiza-Pellejero MJ, de Escalante Yangüela B, Gómez-Huelgas R. Use of antihyperglycaemic therapy with cardiovascular benefit in patients with type 2 diabetes who require hospitalisation: A cross-sectional study. Rev Clin Esp 2020; 221:S0014-2565(20)30059-X. [PMID: 32279949 DOI: 10.1016/j.rce.2019.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Revised: 12/18/2019] [Accepted: 12/26/2019] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To evaluate the use of therapy with cardiovascular benefit in patients with type 2 diabetes mellitus admitted to internal medicine departments. METHODS One day, cross-sectional study of patients with type 2 diabetes mellitus hospitalised in internal medicine departments. We recorded demographic and anthropometric variables, laboratory data and use of antihyperglycaemic drugs. The endpoint was the proportion and determinants of the use of sodium-glucose cotransporter-2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP1-RA). RESULTS We included 928 patients belonging to 74 hospitals, with a mean age of 78.9 years (SD, 10.86 years), 50% of whom were men. A total of 557 (60%) patients had ischaemic heart disease, 189 (20.4%) had cerebrovascular disease, 293 (31.6%) had heart failure, 274 (29.5%) had chronic kidney disease, and 129 (13.9%) had peripheral arterial disease. Prior to their hospital admission, the patients were taking sulfonylureas (5.7%), biguanides (49.1%), alpha-glucosidase inhibitors (0.2%), pioglitazone (0%), dipeptidyl peptidase 4 inhibitors (39%), SGLT2i (5.8%), GLP1-RA (2.6%) and basal insulin analogues (24%). An age over 75 years was the main determinant for not taking SGLT2i (adjusted OR, 0.28; 95% CI 0.10-0.74; P=.039) or GLP1-RA (adjusted OR, 0.09; 95% CI 0.02-0.46; P=.006). DISCUSSION A large proportion of elderly patients with type 2 diabetes mellitus at very high cardiovascular risk are not treated with antihyperglycemic drugs with proven cardiovascular benefit. The most commonly used drugs were metformin and DPP4i. There is room for improvement in the treatment of this very high-risk population.
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Affiliation(s)
- J Ena
- Servicio de Medicina Interna, Hospital Marina Baixa, Villajoyosa, Alicante, España.
| | - J Carretero-Gómez
- Servicio de Medicina Interna, Hospital de Zafra, Zafra, Badajoz, España
| | - A Zapatero-Gaviria
- Servicio de Medicina Interna, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, España
| | - F J Carrasco Sánchez
- Servicio de Medicina Interna, Hospital Universitario Juan Ramón Jiménez, Huelva, España
| | - M Del Romero-Sánchez
- Servicio de Medicina Interna, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, España
| | - C González-Becerra
- Servicio de Medicina Interna, Hospital San Juan de Dios, Tenerife, España
| | - J C Blazquez-Encinar
- Servicio de Medicina Interna, Hospital Universitario de Torrevieja, Torrevieja, Alicante, España
| | | | | | - R Gómez-Huelgas
- Servicio de Medicina Interna, Hospital Regional Universitario de Málaga, Málaga, España
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Kravchenko MI, Tate JM, Clerc PG, Forbes WL, Gettle MC, Wardian JL, Colburn JA. IMPACT OF STRUCTURED INSULIN ORDER SETS ON INPATIENT HYPOGLYCEMIA AND GLYCEMIC CONTROL. Endocr Pract 2020; 26:523-528. [PMID: 31968189 DOI: 10.4158/ep-2019-0341] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Objective: In hospitalized patients, glycemic excursions outside recommended glycemic targets have been associated with increased morbidity and mortality. Despite recommendations to avoid use of correctional insulin alone for managing hyperglycemia, this approach remains common. We performed a quality improvement project aimed at both reducing hypoglycemic events and promoting increased use of basal insulin by updating our insulin order sets to reflect clinical practice guideline recommendations. Methods: Brooke Army Medical Center correctional insulin order sets were modified to reflect higher treatment thresholds and targets, and a basal insulin order was added with a recommended weight-based starting dose. Pre- and postintervention analyses were performed. Patients were included if they were prescribed subcutaneous insulin during their hospital stay. The following outcomes were measured: (1) glucose levels, and (2) prescriptions for basal insulin. Results: A significant reduction in hypoglycemia events was noted following the intervention (glucose <70 mg/dL: 9.2% pre-intervention vs. 8.8% postintervention; glucose <55 mg/dL: 4.2% pre-intervention vs. 2.2% postintervention). When excluding patients that were ordered correctional insulin alone but did not receive a dose, an increase in basal insulin use was seen (50% pre-intervention vs. 61% postintervention). Rates and severity of hyperglycemia (glucose >180 mg/dL) remained unchanged. Conclusion: The alteration in insulin order set parameters resulted in a significant reduction in hypoglycemia without significant increases in hyperglycemia. Although basal insulin use increased, optimal dosing recommendations were not often utilized. Further interventions are necessary to reduce hyperglycemia. Abbreviations: CPOE = computerized provider order entry; EMR = electronic medical record; HbA1c = hemoglobin A1c; LOS = length of stay; QI = quality improvement; SSI = sliding scale insulin.
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Sheen YJ, Huang CC, Huang SC, Huang MD, Lin CH, Lee IT, Lin SY, Sheu WHH. IMPLEMENTATION OF AN ELECTRONIC DASHBOARD WITH A REMOTE MANAGEMENT SYSTEM TO IMPROVE GLYCEMIC MANAGEMENT AMONG HOSPITALIZED ADULTS. Endocr Pract 2019; 26:179-191. [PMID: 31557078 DOI: 10.4158/ep-2019-0264] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Objective: Better glycemic control for hospitalized diabetic patients significantly reduces health expenditures and improves disease outcomes. We developed a dynamic dashboard with a remote management system and evaluated its impact on inpatient glycemic control. Methods: This was an observational institution-wide study; study participants were enrolled from a 1,500-bed public medical center from 2016 to 2018. We evaluated the impact of a dynamic dashboard system, which analyzed and monitored all glucose data with virtual glycemic management recommendation by a team of endocrinologists, over 3 × 1-year periods: 2016 (pre-implementation), 2017 (development), and 2018 (implementation). Results: A total of 51,641 discharges with 878,159 blood glucose measurements were obtained during the 3-year period. After implementation of the dashboard system, the proportion of patients with poor glycemic control (hyperglycemia or hypoglycemia) was reduced by 31% (from 10.2 to 7.0 per day per 100 patients with glucose monitoring; P<.001); hyperglycemia decreased by 25% (from 6.1 to 4.6 per day per 100 patients with glucose monitoring; P<.001), and hypoglycemia decreased by 45% (from 4.2 to 2.3 per day per 100 patients with glucose monitoring; P<.001). Furthermore, the trend in the proportion of patients within the treat-to-target range showed significant improvement (P<.001) during the development period, with effectiveness maintained throughout the implementation period. Conclusion: We successfully installed a dynamic, electronic medical records-based dashboard monitoring system to improve inpatient glycemic control. The system, supported by a team of endocrinologists via remote recommendations, could efficiently fill an important need for improved glycemic management among hospitalized adults. Abbreviations: CDE = certified diabetes educator; DM = diabetes mellitus; EMR = electronic medical record; POC = point-of-care; TCVGH = Taichung Veterans General Hospital; UCSF = University of California, San Francisco; U.S. = United States; vGMS = virtual glucose management service.
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Zapatero-Gaviria A, Gómez-Huelgas R, Canora-Lebrato J, Ena-Muñoz J, Romero-Sánchez M, Mendez-Bailón M, Marco-Martínez J, Barba-Martín R. Analysis of hospitalizations by cardiovascular disease in the population with diabetes in Spain. Rev Clin Esp 2019. [DOI: 10.1016/j.rceng.2018.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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15
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Zapatero-Gaviria A, Gómez-Huelgas R, Canora-Lebrato J, Ena-Muñoz J, Romero-Sánchez M, Mendez-Bailón M, Marco-Martínez J, Barba-Martín R. Análisis de las hospitalizaciones por enfermedad cardiovascular en población diabética en España. Rev Clin Esp 2019; 219:124-129. [DOI: 10.1016/j.rce.2018.09.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 09/11/2018] [Accepted: 09/18/2018] [Indexed: 12/24/2022]
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16
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Ena J. Health services research for hospitalized patients with diabetes mellitus. Rev Clin Esp 2019. [DOI: 10.1016/j.rceng.2018.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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17
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Ena J. Health services research for hospitalized patients with diabetes mellitus. Rev Clin Esp 2018; 219:30-31. [PMID: 30583801 DOI: 10.1016/j.rce.2018.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 12/07/2018] [Indexed: 12/01/2022]
Affiliation(s)
- J Ena
- Servicio de Medicina Interna, Hospital Marina Baixa, La Vila Joiosa, Alicante, España.
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18
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Ena J, Gómez-Huelgas R, Gracia-Tello B, Vázquez-Rodríguez P, Alcalá-Pedrajas J, Carrasco-Sánchez F, Murcia-Casas B, Romero-Sánchez M, Segura-Heras J, Carretero J. Derivation and validation of a predictive model for the readmission of patients with diabetes mellitus treated in internal medicine departments. Rev Clin Esp 2018. [DOI: 10.1016/j.rceng.2018.03.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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19
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Ena J, Gómez-Huelgas R, Gracia-Tello BC, Vázquez-Rodríguez P, Alcalá-Pedrajas JN, Carrasco-Sánchez FJ, Murcia-Casas B, Romero-Sánchez M, Segura-Heras JV, Carretero J. Derivation and validation of a predictive model for the readmission of patients with diabetes mellitus treated in internal medicine departments. Rev Clin Esp 2018; 218:271-278. [PMID: 29731294 DOI: 10.1016/j.rce.2018.03.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Revised: 03/15/2018] [Accepted: 03/16/2018] [Indexed: 10/17/2022]
Abstract
OBJECTIVES We developed a predictive model for the hospital readmission of patients with diabetes. The objective was to identify the frail population that requires additional strategies to prevent readmissions at 90 days. METHODS Using data collected from 1977 patients in 3 studies on the national prevalence of diabetes (2015-2017), we developed and validated a predictive model of readmission at 90 days for patients with diabetes. RESULTS A total of 704 (36%) readmissions were recorded. There were no differences in the readmission rates over the course of the 3 studies. The hospitals with more than 500 beds showed significantly (p=.02) higher readmission rates than those with fewer beds. The main reasons for readmission were infectious diseases (29%), cardiovascular diseases (24) and respiratory diseases (14%). Readmissions directly related to diabetic decompensations accounted for only 2% of all readmissions. The independent variables associated with hospital readmission were patient's age, degree of comorbidity, estimated glomerular filtration rate, degree of disability, presence of previous episodes of hypoglycaemia, use of insulin in treating diabetes and the use of systemic glucocorticoids. The predictive model showed an area under the ROC curve (AUC) of 0.676 (95% confidence interval [95% CI] 0.642-0.709; p=.001) in the referral cohort. In the validation cohort, the model showed an AUC of 0.661 (95% CI 0.612-0.710; p=.001). CONCLUSION The model we developed for predicting readmissions for hospitalised patients with type 2 diabetes helps identify a subgroup of frail patients with a high risk of readmission.
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Affiliation(s)
- J Ena
- Servicio de Medicina Interna, Hospital Marina Baixa, Villajoyosa, Alicante, España.
| | - R Gómez-Huelgas
- Servicio de Medicina Interna, Hospital Regional Universitario de Málaga, Málaga, España
| | - B C Gracia-Tello
- Servicio de Medicina Interna, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España
| | - P Vázquez-Rodríguez
- Servicio de Medicina Interna, Complexo Hospitalario Universitario A Coruña, A Coruña, España
| | - J N Alcalá-Pedrajas
- Servicio de Medicina Interna, Hospital Comarcal de Pozoblanco, Pozoblanco, Córdoba, España
| | | | - B Murcia-Casas
- Servicio de Medicina Interna, Hospital Clínico Universitario Virgen de la Victoria, Málaga, España
| | - M Romero-Sánchez
- Servicio de Medicina Interna, Hospital de Fuenlabrada, Fuenlabrada, Madrid, España
| | - J V Segura-Heras
- Centro de Investigación Operativa, Universidad Miguel Hernández, Elche, Alicante, España
| | - J Carretero
- Servicio de Medicina Interna, Hospital Comarcal de Zafra, Zafra, Badajoz, España
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20
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Abstract
Diabetes and hyperglycemia are present in over one-third of inpatients in internal medicine units and are associated with worse prognosis in multiple morbidities. Treatment of inpatient hyperglycemia is usually with basal bolus insulin in a dose calculated by the patient's weight, with lower doses recommended in patients who are at a higher risk for hypoglycemia. Other antihyperglycemic medications and insulin regimens can be used in selected patients. There are no adequately powered studies on the effect of improving glycemic control on hospitalization outcomes in non-critically ill patients in internal medicine units, and in most patients a modest glucose target of 140-180 mg/dL is recommended. A structured discharge plan should intensify antihyperglycemic treatment as needed and include an outpatient follow-up appointment shortly after discharge.
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Affiliation(s)
- Irit Hochberg
- Institute of Endocrinology, Diabetes and Metabolism, Rambam Health Care Campus, Haifa, Israel
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21
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Ena J, Gaviria AZ, Romero-Sánchez M, Carretero-Gómez J, Carrasco-Sánchez FJ, Segura-Heras JV, Porto-Perez AB, Vázquez-Rodriguez P, González-Becerra C, Gómez-Huelgas R. Derivation and validation model for hospital hypoglycemia. Eur J Intern Med 2018; 47:43-48. [PMID: 28882417 DOI: 10.1016/j.ejim.2017.08.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Revised: 08/26/2017] [Accepted: 08/27/2017] [Indexed: 01/19/2023]
Abstract
BACKGROUND An objective and simple prognostic model for hospitalized patients with hypoglycemia could be helpful in guiding initial intensity of treatment. METHODS We carried out a derivation rule for hypoglycemia using data from a nationwide retrospective cohort study of patients with diabetes or hyperglycemia carried out in 2014 (n=839 patients). The rule for hypoglycemia was validated using a second data set from a nationwide retrospective cohort study carried out in 2016 (n=561 patients). We derived our prediction rule using logistic regression with hypoglycemia (glucose less than 70mg/dL) as the primary outcome. RESULTS The incidence of hypoglycemia in the derivation cohort was 10.3%. Patient's characteristics independently associated with hypoglycemia included episodes of hypoglycemia during the previous three months (odds ratio [OR]: 6.29, 95% confidence interval [95%CI]: 3.37-11.79, p<0.001) estimated glomerular filtration rate lower than 30mL/min/1.73m2 (OR: 2.32, 95%CI: 1.23-4.35, p=0.009), daily insulin dose greater than 0.3units per Kg (OR: 1.74, 95%CI: 1.06-2.85, p=0.028), and days of hospitalization (OR: 1.03, 95%CI: 1.01-1.04, p=0.001). The model showed an area under the curve (AUC): 0.72 (95%CI: 0.66-0.78, p<0.001). The AUC in the validation cohort was: 0.71 (95%CI: 0.63-0.79, p<0.001). CONCLUSIONS The rule showed fair accuracy to predict hypoglycemia. Implementation of the rule into computer systems could be used in guiding initial insulin therapy.
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Affiliation(s)
- Javier Ena
- Internal Medicine Department, Hospital Marina Baixa, Alicante, Spain.
| | | | | | | | | | - José Vicente Segura-Heras
- Centro de Investigación Operativa, Universidad Miguel Hernández, Sant Joan D'Alacant, Alicante, Spain
| | - Ana Belkis Porto-Perez
- Internal Medicine Department, Complexo Hospitalario Universitario de A Coruña, A Coruña, Spain
| | | | | | - Ricardo Gómez-Huelgas
- Internal Medicine Department, Hospital Regional Universitario, FIMABIS, Málaga, Spain
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22
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Díez-Manglano J, Recio Iglesias J, Varela Aguilar JM, Almagro Mena P, Zubillaga Garmendia G. Effectiveness of a simple intervention on management of acute exacerbations of chronic obstructive pulmonary disease and its cardiovascular comorbidities: COREPOC study. Med Clin (Barc) 2017; 149:240-247. [PMID: 28396131 DOI: 10.1016/j.medcli.2017.02.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 02/15/2017] [Accepted: 02/16/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND AND OBJECTIVE To determine the effectiveness of a simple educational intervention to improve the management of cardiovascular comorbidities in patients hospitalized with an acute exacerbation of chronic obstructive pulmonary disease (COPD). MATERIAL AND METHODS Multicenter study participated in by 26 hospital centers. A panel of experts elaborated a set of recommendations about diagnostic and therapeutic management of acute exacerbation of COPD and cardiovascular comorbidities (coronary artery disease, atrial fibrillation, heart failure and diabetes). The recommendations were graduated as indispensable, advisable and outstanding. Compliance with recommendations were assessed in the discharge letter for COPD patients hospitalized with acute exacerbation in Internal Medicine departments. The protocols to treat the comorbidities in COPD were explained in a clinical session. After 6 months' compliance with recommendations they were reassessed. RESULTS A total of 390 cases before and after the intervention were assessed. There was significant progress in 53% of cases. The improvement was greater in cases referred to general management and COPD management (66.7 and 76.9%, respectively), and lower in cases referred to ischemic heart disease (11.1%) and none in those referred to coronary artery disease. After the intervention, the adherence to overall and indispensable recommendations was higher (P=.020 and P=.017, respectively) and a trend to improve was observed in advisable (P=.058) and outstanding recommendations (P=.063). CONCLUSIONS A simple intervention can improve the management of lung disease in COPD patients with an acute exacerbation, but has less effect on the management of comorbidities.
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Affiliation(s)
- Jesús Díez-Manglano
- Servicio de Medicina Interna, Hospital Universitario Miguel Servet, Zaragoza, España; Grupo de investigación en Comorbilidad y Pluripatología en Aragón, Instituto Aragonés de Ciencias de la Salud, Zaragoza, España; Departamento de Medicina, Dermatología y Psiquiatría, Universidad de Zaragoza, Zaragoza, España.
| | - Jesús Recio Iglesias
- Servicio de Medicina Interna, Hospital Vall d'Hebron, Barcelona, España; Departamento de Medicina, Universitat Autònoma de Barcelona, Barcelona, España
| | - José Manuel Varela Aguilar
- Servicio de Medicina Interna, Hospital Universitario Virgen del Rocío, Sevilla, España; Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública, Instituto de Biomedicina de Sevilla, Sevilla, España
| | - Pere Almagro Mena
- Servicio de Medicina Interna, Hospital Universitario Mutua de Terrassa, Terrassa, Barcelona, España
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Núñez-Sánchez MÁ, Cervantes-Cuesta MÁ, Brocal-Ibañez P, Salmeron-Arjona E, León-Martínez LP, Cerezo-Sanmartin M. [Introduction of capillary glycosylated haemoglobin determination in a Primary Care Health Area: Multicentre study of the evolution of patients with type 2 diabetes mellitus]. REVISTA DE CALIDAD ASISTENCIAL : ORGANO DE LA SOCIEDAD ESPANOLA DE CALIDAD ASISTENCIAL 2017; 32:66-72. [PMID: 27836420 DOI: 10.1016/j.cali.2016.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 09/08/2016] [Accepted: 09/11/2016] [Indexed: 06/06/2023]
Abstract
PURPOSE The aim of this study was to evaluate the efficiency of a joint intervention that included educational components, self-assessment, and information to optimise diabetes control through the introduction of instant capillary glycosylated haemoglobin (HbA1c) determination in Primary Care. MATERIALS AND METHODS A multicentre prospective descriptive study was carried out over 3years in 10Primary Care Centres of the Area VII Murcia East. At the end of the study there were 804 patients with type 2 diabetes (DM2). Patients were divided into 4 groups based on initial values of HbA1c, and if changes in their treatment were needed. HbA1c, body mass index, and blood pressure were monitored. A financial assessment was also performed on the impact of the implementation of a protocol to measure instant capillary RESULTS: A significant reduction was observed in HbA1c values. The initial HbA1c mean value was 7.4±1.4%, which decreased to a final value of 6.9±1.0% (P<.001). At the end of the study, 71.4% of patients included reached diabetic control objectives. In addition, the financial assessment demonstrated that the implementation of this diabetes control system led to a decrease of the 24.7% in spending on glucose strips after the first year of study in Area VII Murcia Health Service. CONCLUSIONS The introduction of capillary HbA1c determination in Primary Care has demonstrated to improve diabetes control and the efficiency of the health personnel. Furthermore, a reduction in the health costs of patients with DM2 was also shown.
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Affiliation(s)
- M Á Núñez-Sánchez
- Unidad de Diabetes, Hospital General Universitario Reina Sofía, Murcia, España.
| | | | - P Brocal-Ibañez
- Centro de Salud de Atención Primaria El Carmen, Murcia, España
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Makuc J, Ravber K, Keber T. Glycemia management in a Slovenian general hospital. Wien Klin Wochenschr 2016; 129:16-20. [PMID: 27848073 DOI: 10.1007/s00508-016-1119-1] [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: 05/08/2016] [Accepted: 10/19/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND In-hospital hyperglycemia is common and associated with an increased risk of in-hospital mortality and extensive length of stay but there are only few studies on real-life hyperglycemia and diabetes management. METHODS In this cross-sectional, non-interventional, prospective study we analyzed medical charts on glycemia status at our internal medicine department for 5 consecutive months. Patients were grouped by departments and divided into subgroups by diabetes type, etiology and duration. Physicians answered a questionnaire regarding knowledge on national guidelines and personal opinions on the subject. RESULTS A total of 7080 capillary blood glucose measurements from 308 patients were included in the study. Patients were of Caucasian origin with a mean age 72.7 ± 10.7 years and 50.3% were male. Of the measurements 63.3% were within glycemia goals, 2.7% in the range of hypoglycemia and 0.3% of hyperglycemic syndromes. The mean value was 8.88 ± 3.5 mmol/l (159.84 ± 63 mg/dl). There were no differences in mean glucose measurements but significant differences in reaching glycemia target goals and frequency of acute complications between intensive care, general ward and palliative care patients. Subgroup analysis confirmed the association between glycemia management and newly discovered diabetes, type 1 diabetes, steroid use and disrupted food intake (p < 0.05 for all). CONCLUSIONS Our results on in-hospital glycemia management seem comparable to previously published data. Patients with newly discovered diabetes, type 1 diabetes, treated with steroids and those eating improperly should be closely monitored. Additional education on guidelines and steroid-induced hyperglycemia accompanied by updated medical charts represent possible improvements. Quality standards for in-hospital glycemia management should be established.
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Affiliation(s)
- Jana Makuc
- General Hospital Slovenj Gradec, Gosposvetska cesta 1, 2380, Slovenj Gradec, Slovenia.
| | - Katja Ravber
- General Hospital Slovenj Gradec, Gosposvetska cesta 1, 2380, Slovenj Gradec, Slovenia
| | - Tajda Keber
- General Hospital Slovenj Gradec, Gosposvetska cesta 1, 2380, Slovenj Gradec, Slovenia
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25
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Efecto de una intervención sobre indicadores de calidad para mejorar el tratamiento de la hiperglucemia en pacientes hospitalizados en áreas no críticas. Rev Clin Esp 2016; 216:352-360. [DOI: 10.1016/j.rce.2016.05.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 05/05/2016] [Accepted: 05/08/2016] [Indexed: 11/20/2022]
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Ena J, Gómez-Huelgas R, Zapatero-Gaviria A, Vázquez-Rodriguez P, González-Becerra C, Romero-Sánchez M, Igúzquiza-Pellejero M, Artero-Mora A, Varela-Aguilar J. Effect of an intervention on quality indicators for improving the treatment of hyperglycemia in patients hospitalized in noncritical areas. Rev Clin Esp 2016. [DOI: 10.1016/j.rceng.2016.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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de los Santos Moreno A, Ruiz Blasco E, López Alonso B, Girón-González JA. Determination of glycosylated hemoglobin during hospitalization as an opportunity to assess and optimize glycemic control in our patients: An unresolved matter. ENDOCRINOLOGIA Y NUTRICION : ORGANO DE LA SOCIEDAD ESPANOLA DE ENDOCRINOLOGIA Y NUTRICION 2015; 63:101-2. [PMID: 26547750 DOI: 10.1016/j.endonu.2015.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/12/2015] [Revised: 09/05/2015] [Accepted: 09/07/2015] [Indexed: 11/15/2022]
Affiliation(s)
| | - Elvira Ruiz Blasco
- Unidad de Gestión Clínica, Hospital Universitario Puerta del Mar, Cádiz, España
| | | | - José Antonio Girón-González
- Unidad de Gestión Clínica, Hospital Universitario Puerta del Mar, Cádiz, España; Departamento de Medicina, Universidad de Cádiz, Cádiz, España
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Sternthal E, Underwood P, Mantzoros CS. Slip sliding away: the need for continued discussion of the use of insulin sliding scale in hospitalized patients. Metabolism 2015; 64:935-6. [PMID: 26159821 DOI: 10.1016/j.metabol.2015.06.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 06/16/2015] [Indexed: 10/23/2022]
Affiliation(s)
- Elliot Sternthal
- Section of Endocrinology, Boston VA Healthcare System, 150 S Huntington Ave, Jamaica Plain, MA 02130; Section of Endocrinology, Diabetes and Nutrition, Boston University Medical Center, 88 East Newton Street, Boston, MA 02118.
| | - Patricia Underwood
- Section of Endocrinology, Boston VA Healthcare System, 150 S Huntington Ave, Jamaica Plain, MA 02130
| | - Christos S Mantzoros
- Section of Endocrinology, Boston VA Healthcare System, 150 S Huntington Ave, Jamaica Plain, MA 02130; Division of Endocrinology, Diabetes and Metabolism, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA, 02215
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